To report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period. From September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT. The mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %. Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

Background: Sutureless aortic bioprostheses are increasingly being used to provide shorter cross-clamp time and facilitate minimally invasive aortic valve replacement. As the use of sutureless valves has increased over the past decade, we begin to encounter their degeneration. We describe clinical outcomes and technical aspects in patients with degenerated sutureless Perceval (CorCym, Italy) aortic bioprosthesis treated with valve-in-valve transcatheter aortic valve replacement (VIV-TAVR). Methods: Between March 2011 and March 2023, 1310 patients underwent aortic valve replacement (AVR) with Perceval bioprosthesis implantation. Severe bioprosthesis degeneration treated with VIV-TAVR occurred in 32 patients with a mean of 6.4 ± 1.9 years (range: 2–10 years) after first implantation. Mean EuroSCORE II was 9.5 ± 6.4% (range: 1.9–35.1%). Results: Thirty of thirty-two (94%) VIV-TAVR were performed via transfemoral and two (6%) via transapical approach. Vascular complications occurred in two patients (6%), and mean hospital stay was 4.6 ± 2.4 days. At mean follow-up of 16.7 ± 15.2 months (range: 1–50 months), survival was 100%, and mean transvalvular pressure gradient was 18.7 ± 5.3 mmHg. Conclusion: VIV-TAVR is a useful option for degenerated Perceval and appears safe and effective. This procedure is associated with good clinical results and excellent hemodynamic performance in our largest single-center experience.

Minimally invasive aortic valve replacement is performed by mini-sternotomy (MS) or less invasive right anterior mini-thoracotomy (RT). The possibility of adopting RT is assessed by anatomical criteria derived from manual 2D image analysis. We developed a semi-automatic tool (RT-PLAN) to assess the criteria of RT, extract other parameters of surgical interest and generate a view of the anatomical region in a 3D space. Twenty-five 3D CT images from a dataset were retrospectively evaluated. The methodology starts with segmentation to reconstruct 3D surface models of the aorta and anterior rib cage. Secondly, the RT criteria and geometric information from these models are automatically and quantitatively evaluated. A comparison is made between the values of the parameters measured by the standard manual 2D procedure and our tool. The RT-PLAN procedure was feasible in all cases. Strong agreement was found between RT-PLAN and the standard manual 2D procedure. There was no difference between the RT-PLAN and the standard procedure when selecting patients for the RT technique. The tool developed is able to effectively perform the assessment of the RT criteria, with the addition of a realistic visualisation of the surgical field through virtual reality technology.

The management of patients with aortic disease that involves the ascending aorta, the aortic arch, and the descending aorta represent a surgical challenge. Open surgical repair remains the gold standard for aortic arch pathologies. However, this operation requires a cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest, which carries a substantial rate of mortality and morbidity. For these reasons, hybrid arch repair that involves a combination of open surgery with endovascular aortic stent graft placement has been introduced as a therapeutic alternative for those patients deemed unfit for open surgical procedures. Hybrid repair requires varying degrees of invasiveness and can be performed as a single-stage procedure or as a two-stage procedure. The choice of the technique is multifactorial, depending on the characteristics of the diseased arch with regard to position of the stent graft proximal landing zone, patient fitness and comorbid status, as well as surgical expertise and hospital facilities. Among the evolving hybrid procedures is the so-called “frozen” or stented elephant trunk technique. Adapted from the classical elephant trunk technique, this approach facilitates the repair of a concomitant aortic arch and proximal descending aortic aneurysms in a single stage under circulatory arrest. This technique is increasingly being used to treat extensive thoracic aortic disease and has shown promising results.

Background: Several blood biomarkers have shown a major role in predicting major adverse complications (MACs) in patients who have undergone cardiac surgery. Here, we aimed to investigate the possible role of the blood urea nitrogen (BUN) to serum albumin ratio (BAR) and the inflammatory prognostic index (IPI) in predicting major adverse complication after surgical aorta valve replacement (SAVR). Methods: The clinical, echocardiographic, and clinical-chemistry laboratory data of 195 patients who underwent SAVR were evaluated. The post-surgical MACs (death, surgical re-exploration, myocardial infarction and cerebral ischemia) during the hospitalization were recorded. Univariate and multivariate logistic regression analyses were studied by comparing the basic clinical features, echocardiographic parameters, and patients’ hematological indices between patients with or without MACs. Results: The mean age was 66.1 years, and 62.5% were males. Logistic regression analysis showed that the left atrium volume (LAV), BAR, and IPI as either continuous or categorical variables were independently associated with MACs. Moreover, we found a combined effect of higher LAV with a higher value of BAR or IPI. Combined higher levels of LAV and BAR increased the risk of developing MACs by 9.8 (CI 95% = 2.8–34.3, p = 0.0003), while higher values of LAV and IPI increased the risk of developing MACs by 4.5. Conclusions: Higher levels of BAR and IPI, alone or in combination with higher LAVs, showed an independent predictive value of MACs after SAVR. These findings strongly support the importance of evaluating easily available biomarkers of the pre-operative status of patients in order to predict adverse outcomes.

Background: New-onset postoperative atrial fibrillation (NOAF) is the most prevalent arrythmia after cardiac surgery with a significant clinical and economic impact. Therefore, simple and practical biomarkers for NOAF prediction remain a clinical priority. Increasing evidence indicates that malnutrition is linked to postoperative complications, including the onset of atrial fibrillation. The Prognostic Nutritional Index (PNI), which reflects the immunonutritional and inflammatory status through serum albumin concentration and lymphocyte count, has emerged as a reliable prognostic indicator in cardiovascular disease. The present study aimed to investigate the association between PNI and the development of NOAF in patients undergoing surgical aortic valve replacement (SAVR). Methods: A total of 241 consecutive patients who underwent AVR for severe aortic stenosis or regurgitation were enrolled in this study. The population was stratified into two groups according to the development of NOAF (NOAF group) or the lack thereof (no NOAF group). Results: In both univariate and multivariate logistic regression analyses adjusted for several established NOAF determinants, age and PNI, both as continuous variables, were independently associated with NOAF in both univariate (OR = 1.03; CI 95% = 1.01–1.06, p = 0.009, and OR = 0.9; CI 95% = 0.8–0.9, p = 0.01, respectively) and multivariate models (OR = 1.02; CI 95% = 1.01–1.06, p = 0.05, and OR = 0.9; CI 95% = 0.8–0.9, p = 0.03, respectively). When PNI was analyzed by tertiles, patients in the lowest tertile (PNI < 41.5) showed a significantly higher risk of developing NOAF at both univariate (OR = 1.9; CI 95% = 1.2–2.8, p = 0.004) and multivariate analysis (OR = 1.6; CI 95% = 1–2.6, p = 0.03), whereas age lost statistical significance (OR = 1.0; 95% CI = 0.9–1.05; p = 0.06). Furthermore, when the study population was divided into two groups based on the median age (70 years), PNI values differed significantly between NOAF and no NOAF patients only in patients under 70 years (p = 0.01). In this younger subgroup, PNI remained an independent predictor of NOAF, both when considered as a continuous variable (OR = 0.86; CI 95% = 0.74–0.98, p = 0.02), and nominal variable (PNI < 41.5, OR = 0.88; CI 95% = 0.80–0.97, p = 0.01). Conclusions: Overall, these findings identify PNI as an independent predictor of NOAF following SAVR, particularly in patients younger than 70 years. This study underlines the potential clinical value of preoperative nutritional assessment for risk stratification. Incorporating nutritional parameters such as PNI into current predictive models may enhance the accuracy of prognostic evaluation and support targeted perioperative management strategies.