Background: Antegrade root cardioplegia remains the most popular strategy for myocardial protection during coronary artery bypass graft (CABG) performed with cardiopulmonary bypass (CPB) and aortic cross clamp. In patients with depressed left ventricular function, however, especially if associated with severe multiple coronary stenosis, increased pharmacological and/or mechanical support in the early post-CPB period is often required to support left ventricular recovery. In this study, we analyzed the results of a myocardial protection strategy that includes selective infusion of cardioplegia through each venous graft followed by warm reperfusion distal to each coronary anastomosis until complete removal of the aortic clamp (total antegrade cardioplegia infusion and warm reperfusion = TAWR) to improve early postoperative recovery in patients with depressed left ventricular function undergoing multi-vessel CABG. Methods: Out of 97 patients undergoing CABG using the TAWR strategy for myocardial protection, 32 patients presented with depressed left ventricle function (EF < 40%) and multi-vessel coronary diseases requiring ≥2 vein grafts and were enrolled as Group A. Combined primary outcomes and postoperative early and late left ventricle recovery (including spontaneous rhythm recovery, inotropic support and postoperative troponin release) were analyzed and compared with those of 32 matched patients operated on using standard antegrade root cardioplegia and limited warm reperfusion through LIMA graft (SAWR) enrolled as Group B. Results: Two patient died in hospital (in-hospital mortality 3.1%) with no statistical differences between the two groups. In Group A 27 patients (90%) had spontaneous recovery of idiopathic rhythm compared to 17 (53%) in group B (p = 0.001). Early inotropic support was required in nine patients (28%) of group A and seventeen patients (53%) of group B (p = 0.041). Furthermore, in eight patients (25%) of group A and seventeen (53%) of group B (p = 0.039) inotropic support was continued for >48 h. Conclusions: The TAWR strategy seems to significantly improve early postoperative cardiac recovery in patients with left ventricle depression undergoing multi-vessel CABG, when compared with SAWR strategy and could therefore be considered the strategy of choice in this subset of patients.

Background: In this study, we examined and compared ex vivo mechanical properties of aortic walls in patients with bicuspid (BAV) and tricuspid (TAV) aortic valve aortopathy to investigate if the anatomical peculiarities in the BAV group are related to an increased frailty of the aortic wall and, therefore, if a different surgical cutoff point for ascending aortic replacement could be reasonable in such patients. Methods: Ultimate stress tests were performed on fresh aortic wall specimens harvested during elective aortic surgery in BAV (n. 33) and TAV (n. 77) patients. Three mechanical parameters were evaluated at the failure point, under both longitudinal and circumferential forces: the peak strain (Pstr), peak stress (PS), and maximum elastic modulus (EM). The relationships between the three mechanical parameters and preoperative characteristics were evaluated, with a special focus on evaluating potential risk factors for severely impaired mechanical properties, cumulatively and comparatively (BAV vs. TAV groups). Results: The patient populations were inhomogeneous, as BAV patients reached surgical indication, according to the maximum aortic dilatation, at a younger age (58 ± 15 vs. 64 ± 13; p = 0.0294). The extent of the maximum aortic dilatation was, conversely, similar in the two groups (52 ± 4 vs. 54 ± 7; p = 0.2331), as well as the incidences of different phenotypes of aortic dilatation (with the ascending aorta phenotype being the most frequent in 81% and 66% of the BAV and TAV patients, respectively (p = 0.1134). Cumulatively, the mechanical properties of the aortic wall were influenced mainly by the orientation of the force applied, as both PS and EM were impaired under longitudinal stress. An age of >66 and a maximum dilatation of >52 mm were shown to predict severe Pstr reduction in the overall population. Comparative analysis revealed a trend of increased mechanical properties in the BAV group, regardless of the position, the force orientation, and the phenotype of the aortic dilatation. Conclusions: BAV aortopathy is not correlated with impaired mechanical properties of the aortic wall as such. Different surgical cutoff points for BAV aortopathy, therefore, seem to be unjustified. An age of >66 and a maximum aortic dilatation of >52 mm, however, seem to significantly influence the mechanical properties of the aortic wall in both groups. These findings, therefore, could suggest the need for more accurate monitoring and evaluation in such conditions.

Background/Objectives: Acute bacterial endocarditis (ABE) is a frequent situation and continues to be a challenge. Mitral valve involvement during acute bacterial endocarditis is often the result of the spread of the endocarditic process from the adjacent aortic valve. Mitral involvement, on the other hand, could also be an expression of the initial localization of the bacteria. The best option for treating mitral ABE is still a matter of debate. Recent reports have shown satisfactory results with mitral reconstructive techniques in the treatment of mitral ABE. In this study, we present a comprehensive review of our 10-year institutional experience in the surgical management of acute mitral endocarditis with a focus on technical considerations, outcomes, and the durability of mitral valve repair in this high-risk population. Methods: We queried the institutional database, cross-referencing patients admitted with a diagnosis of “acute bacterial endocarditis” with patients undergoing surgical procedures for “valvular disease” at our division. Out of 1136 valvular procedures listed in our PACS database, 180 patients were admitted with a diagnosis of active acute endocarditis, and 46 included treatment of the mitral valve. We analyzed and compared short- and long-term follow-up (ranging from 3 to 141 months with a mean of 42 ± 38 months) of these 46 patients, dividing them into two groups: mitral valve repair (MVr) and mitral valve replacement (MVR). Results: 18 (40%) patients underwent reconstructive treatment of the mitral valve, and 28 (60%) underwent mitral valve replacement. Cumulative in-hospital mortality was 10% (5 pts, all from the MVR group), however, with no difference between the two groups. A shorter time gap from diagnosis to surgery (60 years), and urgent surgical procedures. Finally, patients with MVr also experienced a favorable postoperative event-free curve for endocarditis recurrence (p = 0.0260) and time elapsed before recurrence (p = 0.0438). Conclusions: Mitral valve repair in the case of active endocarditis could be a treatment associated with more favorable outcomes, providing that a complete eradication of infective tissue can be accomplished. Conservative treatment, when feasible, seems to offer favorable cumulative long-term outcomes.

Background: The ex vivo evaluation of the aortic wall aims to identify potential risk factors predictive of acute aortic syndrome. The comparison of aortic wall properties in patients with bicuspid aortic disease versus those with tricuspid aortic disease has been the subject of many studies. However, the heterogeneity of aortic wall characteristics in individual patients has never been thoroughly investigated. In this study, we focused on comparing the heterogeneity of aortic wall characteristics in patients with bicuspid (BAV) and tricuspid (TAV) aortic valve disease. Materials and Methods: Out of 113 patients enrolled in our cumulative study on the ex-vivo evaluation of the aortic wall, in patients with dilated ascending aorta, 56 patients with >3 specimens taken from the anterior wall were selected for the present study. The heterogeneity of anatomical characteristics (aortic wall thickness) was assessed by measuring the coefficient of variability (cV). In 35 patients, furthermore, mechanical (uniaxial ultimate stress–strain test) characteristics heterogeneity was also evaluated. Intra-patient mechanical and anatomical variability was then compared between the BAV and TAV groups. Results: Heterogeneity of aortic wall thickness was significantly less important compared to heterogeneity of mechanical properties: peak strain (Pstr p = 0.0042), peak stress (PS p = 0.001) and maximum elastic modulus (EM p = 0.001). Only EM heterogeneity was significantly reverse-correlated to patient’s age (p = 0.0005), and this correlation was peculiar for patients with BAV. In BAV patients, furthermore, age > 66 was associated with a significantly superior EM heterogeneity (p = 0.008). A direct comparison of anatomical and mechanical intra-patient variability between BAV and TAV groups, however, did not show significant differences. Discussion: Our study clearly demonstrates that the anatomical and mechanical characteristics of the aortic wall in patients with aortic dilation are not homogeneous. The heterogeneity of aortic wall thickness appears to be less significant than that of mechanical properties, thus confirming a limited correlation between anatomical and mechanical characteristics. The comparison between the BAV and TAV groups revealed limited peculiarities, further suggesting a preservation of the mechanical properties of the aortic wall in patients with bicuspid aortic disease and, therefore, without a peculiar mechanical properties-related increased risk of acute aortic syndrome.