Aortic valve replacement through conventional sternotomy still represents the gold-standard surgical approach for aortic valve disease. However, given the increasing number of patients with comorbidities, strategies that can improve operative results are always sought. Minimally invasive aortic valve surgery, although related to a steep learning curve, might be associated with improved postoperative outcomes. The main aim of this study was to assess whether significant differences exist in terms of operative and early results between a mini-sternotomy and a right mini-thoracotomy approach for isolated aortic valve replacement without sutureless technologies. This is an observational retrospective multicentre study from nine Italian cardiac centres that analyses prospectively collected data of patients who underwent isolated minimally invasive aortic valve replacement between January 2010 and December 2014. Two approaches are considered (mini-sternotomy and mini-thoracotomy) and compared in terms of operative and early outcomes. After interrogation of the centralized database, a total of 1130 patients were retrieved (854 mini-sternotomy and 276 mini-thoracotomy). Patients in the mini-sternotomy group had a higher risk profile. There was no difference in terms of early mortality; cardiopulmonary bypass and cross-clamp time did not differ significantly between the groups; and a significantly higher number of reoperations for bleeding was observed in the right mini-thoracotomy group. Both mini-sternotomy and mini-thoracotomy could be performed safely, with low mortality and postoperative morbidity. The mini-thoracotomy approach was associated with a significantly higher rate of reoperation for bleeding. Uptake among cardiac centres was low. Sutureless technologies could potentially increase surgical volume by simplifying the mini-thoracotomy procedure.
Abstract Background Mitral regurgitation is a frequent valvular disease, with an increasing prevalence. We analyzed the short-term outcomes of mitral valve repair procedures conducted in our clinic using a new semirigid annuloplasty ring featuring a gradual saddle shape design. Methods We retrospectively analyzed mitral valve repair surgeries performed at our Institution between December 2019 and November 2021 with the MEMO 4D semirigid annuloplasty ring. Results In total, 53 patients were included in the study. Mean patient age was 63.6 ± 11.7 years. Most patients presented with degenerative mitral valve regurgitation ( N = 44; 83%). The grade of mitral regurgitation was equal or more than 3 + in 98.1% of the patients ( N = 52). The most used ring size was size 34 mm ( N = 30, 56.6%). There was no intraoperative or hospital mortality. No cases of stroke, bleeding, endocarditis or other major complications occurred. At discharge, most patients were in NYHA class I. Postoperative echocardiographic results showed no (90.6%) or 1+ (5.7%) mitral valve regurgitation. Only 1 patient (1.9%) presented with mitral valve regurgitation grade 2+. Mean postoperative transvalvular gradient was low (mean = 3.3 ± 1.2 mmHg). No cases of LVOT obstruction or systolic anterior motion occurred. Conclusions Our series showed excellent mitral valve competency and very satisfactory early clinical outcomes. The transesophageal echocardiographic follow-up, despite obtained in a limited number of patients, further confirmed the effectiveness of findings of this preliminary experience.
Healthcare organizations today are facing a series of problems due to two main factors: increasing difficulty in satisfying a progressively more ‘aware’ and demanding user, and the need to change their internal organization to keep pace with the very rapid changes taking place in technology and approach. A continuous increase of complexity and the capacity of physicians will not ensure the fundamental requirement of any business: to really deliver what its customers need. Hence, it is time for a revolutionary strategy focused on: (i) maximizing value for patients by obtaining the best outcomes at lowest cost and (ii) moving from a physician-centred organization to an ‘organization-driven’ care process.
However, complex systems are typically conservative and rather resistant to change, and the healthcare system is no exception to this rule. The challenge is that doctors have to be central players in the healthcare revolution and any strategy that they do not embrace will fail. Certainly, a piecemeal approach will not work. Engaging doctors in transforming the system requires focusing on shared goals, by using motivational tools: shared purpose, peer pressure, measuring performance, and enhancing a patient-centred approach.
GVM Care & Research is a holding operating in the health, pharmaceutical, spa-well-being, research, biomedical industry, company-aimed services, real estate, and financial areas. The core business is the network of highly multi-specialized hospitals and day-hospital outpatient clinics: this complex system, involving specialized facilities and highly qualified professional expertise, is present in numerous Italian regions and extends also to France, Albania, and Poland. GVM is one of the key players in Italy in cardiac surgery (responsible for ∼15% of all cardiac interventions in Italy) and interventional cardiology, with documented excellent outcomes (cf. the Italian National Healthcare Agency and Italian Ministry of Health).
The first step in any strategic transformation is to clarify the institutional mission, …
The results of recent studies regarding the efficacy of Negative Pressure Wound Therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery are not conclusive.
The hybrid approach has become the most effective treatment option for restoring sinus rhythm and reducing the risk of atrial fibrillation (AF) recurrence. However, several issues remain to be clearly defined, including the appropriate timing of the staged procedure and the most effective strategy.Over a 12-year period of activity, we performed 609 AF ablation procedures via a right mini-thoracotomy. From this general population, 60 patients underwent a hybrid procedure with catheter ablation performed at least 4 weeks after the surgical procedure to confirm if effective complete electrical isolation of pulmonary veins was achieved. In 20 patients, the second stage procedure was performed during the same hospitalization due to patient's electrical instability. The results obtained in immediate versus staged patients were compared.All patients were discharged after the first stage procedure in sinus rhythm. The 20 immediate patients had a shorter hospital stay compared with the staged patients, in whom the two hospitalizations resulted in a longer hospital stay (immediate 5.5 ± 1.6 days versus staged 8.7 ± 1.4, P < 0.001). A significantly higher number of immediate patients had an associated ablation of the Bachmann's bundle (n = 16 in the immediate group [80%] versus n = 14 in the staged group [45%]; P = 0.001). After a mean follow-up of 74 months, there was no significant difference in the risk of AF relapse between groups (immediate 1/20 [5%] versus staged 7/40 [17.5%]; P = 0.18).The hybrid approach for the treatment of AF was safe and effective in immediate restoring sinus rhythm and in its maintenance at follow-up. Our preliminary results show that both immediate and staged procedures show similar efficacy but this result is strongly influenced by the concomitant ablation of the Bachmann's bundle, which appears to be the most important component of the treatment strategy in order to reduce the risk of recurrent AF.
Background: Arrhythmias are common after open heart surgery and may be related to hypomagnesaemia due to cardiopulmonary bypass. Although perioperative prophylactic Mg2+ administration may prevent arrhythmias after coronary artery bypass grafting (CABG), clear indications as well as the timing of Mg2+ substitution and dose regimen need to be clarified. Aim of this study was to evaluate the antiarrhythmic effects of Mg2+ infusion in patients who underwent elective CABG. Method: Ninety-seven patients who underwent elective CABG were divided in four Groups. In Group A 1 g of magnesium sulfate was added to the pump prime, Group B received 1 g in the pump prime plus 5 mmol/L in the cardioplegic solution, Group C received 5 mmol/L in the cardioplegic solution, and Group D was a placebo control Group. Groups A, B, and C also received 24 h continuous infusion of magnesium sulfate at 10 mmol/L. Three-channel electrocardiogram (II-V5-V6) continuous monitoring was performed 12 hours preoperatively and 48 hours postoperatively. Blood samples were taken for subsequent Serum magnesium measurements, at five different time points before, during and after CBP. Results: In all Groups serum Mg2+ levels were reduced during CPB (Time 2) and statistically significant differences from pre-anaesthesia levels (Time 1) were noted (p < 0.05). In Groups A, B, and C Serum Mg2+ levels increased progressively from Time 3 to Time 5; in Group D serum Mg2+ levels were still much lower at Time 5. Significant differences (p < 0.05) were noted for Groups B and C vs Groups A and D in atrial ectopics, atrial fibrillation, and ventricular arrhythmic events. Conclusion: Our results demonstrate that Mg2+ sulfate administration regimens used in Group B and C reduce postoperative arrhythmic events in patients undergoing CABG.
This review focused on whether subvalvular techniques are more effective than isolated restrictive annuloplasty in addressing ischemic mitral regurgitation (MR). Searching identified 445 papers and, following a selection process, we ended up with 10 articles. Two were propensity-matched studies, four retrospective and four prospective, non-randomized studies. The end points of interest were late recurrence of MR, other early echocardiographic outcomes of mitral function and early mortality. All studies focusing on echocardiographic measurements showed improved results in the groups where subvalvular repair techniques were used. In almost all studies, the recurrence of MR postoperatively was less when subvalvular techniques were used. No difference in early or in-hospital mortality was demonstrated in all four studies that included comparisons. We conclude that subvalvular techniques in combination with annuloplasty are safe and may better address ischemic MR than the use of annuloplasty ring alone.
The most performed repair technique for the treatment of chronic ischemic mitral regurgitation in patients referred for bypass grafting remains restricted annuloplasty. However, it is associated with a high rate of failure, especially if severe tenting exists.To understand if adjunctive sub-valvular mitral procedures may provide better repair performance.A systematic literature review identified six studies of which five fulfilled the criteria for meta-analysis. Outcomes for a total of 404 patients (214 had adjunctive sub-valvular procedures and 190 restricted annuloplasty) were meta-analyzed using random effects modeling. Heterogeneity and subgroup sensitivity analysis were assessed. Primary endpoints were: late recurrence of moderate mitral regurgitation, left ventricle remodeling and coaptation depth at follow-up. Secondary endpoints were: early mortality, mid-term survival and operative outcomes.Sub-valvular procedure technique was associated with a significantly lower late recurrence of mitral regurgitation (Odds ratio (OR) 0.34, 95% Confidence Interval (CI) [0.18, 0.65], p=0.0009), smaller left ventricle end-systolic diameter (Weighted Mean Difference (WMD) -4.06, 95% CI [-6.10, -2.03], p=0.0001) and reduced coaptation depth (WMD -2.36, 95% CI [-5.01, -0.71], p=0.009). These findings were consistent, even in studies that included patients at high risk for repair failure (coaptation depth >10 mm and tenting area >2.5 cm2). A low degree of heterogeneity was observed. There was no difference in terms of early mortality and mid-term survival; sub-valvular technique was associated with prolonged cardiopulmonary and cross-clamp time.Adding sub-valvular procedures when repairing ischemic chronic mitral valve regurgitation may be associated with better durability, even in the case of the presence of predictors for late failure.Surgical sub-valvular adjunctive procedures have to be considered in the case of the presence of echocardiographic predictors for late failure.
Abstract Objective We sought to assess whether post-implant transcatheter aortic valve prosthesis multi detector computed characteristics differ between patients with native tricuspid and bicuspid aortic valve stenosis, as well as the effect on valve performance and clinical implications. Methods We analysed 100 consecutive post-implant multi detector computed tomography scans to assess self-expandable prosthesis non-uniform expansion at six pre-specified valvular levels, and other specific parameters, including valvular and perivalvular thrombosis at six months follow-up. Echocardiographic prosthesis performance and clinical outcome was also evaluated. Results Mean eccentricity was significantly higher in the bicuspid group (0.43 (0.09) vs 0.37 (0.08), p = 0.005, bicuspid vs tricuspid); valvular and perivalvular thrombosis were also significantly more frequent in the bicuspid than in the tricuspid group (81% vs. 36.9%, p = 0.031); there was no significant difference in terms of mean prosthetic gradient at follow-up between (7.31 (5.53 mmHg) vs 7.09 (3.05 mmHg), p = 0.825); EOAi was also similar between bicuspid and tricuspid (1.08 (0.12 cm2) vs 1.03 (0.13 cm2), p = 0.101), with no significant changes compared to discharge. However, the bicuspid valve was associated with a significantly higher risk of adverse events (HR:3.72, 95%CI: 1.07-13.4, p = 0.027). Conclusions Higher level of eccentricity, which indicates prosthesis deformation, is often detected in bicuspid valves. Although echocardiographic performance was not affected, this might have led to an increased incidence of thrombosis at valvular and perivalvular levels and worse outcomes.
