Background. Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (ACP) or retrograde. In recent years nadir temperature progressively increased to 26-28 °C (moderately hypothermic circulatory arrest, MHCA), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10-minute of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming, DR) can provide a neuroprotection and a lower body protection similar to that provided by MHCA+ACP. Methods. Two-hundred-ten patients were included in the study. DHCA+DR was used in 59 patients and MHCA+ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE) or permanent (permanent neurologic deficit, PND), and need of renal replacement therapy (RRT). Results. Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%) and PNDs in 10 (4.8%). Twenty-three patients (10.9%) needed RRT. Death+PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs and death+PND, but need of RRT (OR 7.39, CI 1.37-79.1) and composite endpoint (OR 8.97, CI 1.95-35.3) were significantly lower in DHCA+DR group compared with MHCA+ACP group. Conclusions. The results of our study demonstrate that DHCA+DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA+ACP. However, the data suggests that DHCA+DR when compared with MHCA+ACP provides better renal protection and reduced prevalence of composite endpoint.

ARTIFICIAL CHORDAE FOR ANTERIOR LEAFLET PROLAPSE: ARE ALL THE ROADS LEADING TO ROME?Antonio Maria Calafiore (a), MD, Antonio Totaro (a), MD, Sotirios Prapas (b), MD, Diego Magnano, MD (a), Stefano Guarracini (c), PhD, Massimo Di Marco (d), MD, Michele Di Mauro (c,e), PhDDepartment of Cardiovascular Diseases, Gemelli Molise, Campobasso, ItalyDivision of Cardiac Surgery A, Henry Dunant Hospital, Athens, GreeceDepartment of Cardiology, “Pierangeli” Hospital, Pescara, ItalyDepartment of Cardiology, “S Spirito” Hospital, Pescara, ItalyCardio‐Thoracic Surgery Department, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands

Based on Carpentier’s classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morpho-functional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets, but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.

Mitral valve repair is the procedure of choice to correct mitral regurgitation. However, some dangerous complications, correlated to the surgical technique, can occur in the operating theatre, at the end of the procedure. The most frequent is the systolic anterior motion. Due to a systolic dislocation of the anterior leaflet toward the outflow tract, it causes both obstruction of the outflow tract and mitral regurgitation. Often it is due to excess of catecholamines or to reduced filling of the left ventricle, but sometimes needs further surgical maneuvers, focused on moving posteriorly the coaptation line. It can be obtained by shortening the posterior leaflet or increasing the size of the ring or applying an Alfieri stitch to limit the movements of the anterior leaflet. Another complication, often underdiagnosed and potentially lethal, is the injury of the circumflex artery that happens at the level of the anterolateral commissure or P1 zone. Two mechanisms are involved. The first one is direct injury of the artery by a stitch (roughly 25% of the patients present a distance artery-annulus<3 mm). The second one the distortion of the artery, attracted toward the annulus by a misplaced stitch. The attraction causes kinking with stenosis of different degrees till functional occlusion. However, the artery has to be far from the annulus and the atrial tissue has to be stiff and resistant, as after an infective process, to move the CX toward the annulus without tearing. Positioning the stitches very close to the mitral leaflets in the dangerous area is the only prevention to the complication. The treatment in the operating theatre is partial or total removal/re-implantation of the annular sutures or coronary artery bypass grafting to the circumflex area. If the injury is demonstrated only after a coronary angiography, percutaneous revascularization can be attempted before further surgical treatment.

The chordae tendinae connect the papillary muscles to the mitral valve. While the first-order chordae serve to secure the leaflets to maintain valve closure and prevent mitral valve prolapse, the second-order chordae are believed that they play a role in maintaining normal LV size and geometry. The papillary muscles, from where the chordae tendinae originate, function as shock absorbers that compensate for the geometric changes of the left ventricular wall. The second-order chordae connect the PMs to both trigons under tension. The tension distributed towards the second-order chordae has been demonstrate to be more than three-fold that in the first-order counterpart. Cutting the second-order chordae puts all the tension on the first-order chordae, that can go closer to their rupture point. However, it has been experimentally demonstrated that the tension where the first-order chordae break is 6.8 N, by far higher than the maximal tension reached, that is 0.4 N. Even if the clinical reports have been favorable, the importance of cutting the second-order chordae to recover curvature of the anterior leaflet and increasing the coaptation length between the mitral leaflet has been slowly absorbed by the surgical world. Nevertheless, there are progressive demonstrations that chordal tethering affects the anterior leaflet not only in secondary, but also in primary mitral regurgitation, having a not negligeable role in the long-term outcome of mitral repair.

Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the ’60, but in the mid ’80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore-Tex sutures. In the last years, artificial chords have been exploited because of transcatheter techniques such as NeoChord DS 1000 (Neochord, USA) and Harpoon TSD-5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established basing on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real world surgery, summarizing all the tips and tricks.

Choosing to perform mitral valve (MV) repair or replacement remains a hot and highly debated topic. The current guidelines seem to be conflicting in this specific field and the evidences at our disposal are scarce, only one small randomized trial and few larger retrospective studies. The meta-analysis by Gamal and coworkers tries to summarize the current evidences, concluding that MV replacement for the treatment of ischemic mitral regurgitation is at least as safe as repair and certainly offers a more stable result over time than the latter. Obviously, the implantation of a prosthesis, especially a mechanical one, brings with it a series of problems, such as anticoagulation and, above all, a possible lack of ventricular remodeling, especially if a chordal sparing replacement is not performed. It must be said, on the other hand, that isolated annuloplasty cannot act as a counterpart to replacement, because ischemic MR cannot be considered only an annular disease. Therefore, wanting to mimic the nature that, after an infarction, enacts a series of changes involving also the mitral leaflets and chordae, the surgeons are called to act also on these two entities and not only to downsize the annulus. In a nutshell, a procedure should not be opposed in a fundamentalist way to another one, but we must accept the concept of armamentarium where both procedures are present and tail on the single patient, and also on the surgeon’s expertise, the technique guaranteeing the best possible result.

The COVID-19 pandemic has remarkably impacted the hospital management and the profile of patients suffering from acute cardiovascular syndromes. Among them, acute infective endocarditis (AIE) represented a rather frequent part of these urgent/emergent procedures. The paper by Li and colleagues has clearly shown the higher risk features which patients with diagnosis of AIE presented at hospital admission during the first part (first and second waves) of the outbreak, often requiring challenging operations, but fortunately not associated with worse outcome if compared to results obtained prior to the SARS-2 pandemic. The report discussed herein presents several other aspects worth of discussion and comments, particularly in relation to hospital management and post-discharge outcome which certainly deserve to be highlighted, but also further investigations.

Background and aim of the study. Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few mm. Material and Methods. From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69±7 years and ESII 3.5±1.7. Four patients had moderately impaired ejection fraction (35-49%). Results. There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow up of 53±14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2±2.0 to 42.5±4.1 mm, p=0.03. The diameter of the proximal arch remained unchanged, from 37.1±1.6 to 36.3±2.9 mm, p=0.20. Conclusions. In presence of moderately dilated AA wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure.

The meta-analysis by He and collaborators [has the worth to cover, as much as possible, a gap of scientific evidence where conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provide better pooled results, both early and late, with respect to mitral valve replacement (MVR). However, the superiority of MVP is driven by some single large cohort-studies where surgeons had wide experience in the field of MVP for IE. This finding is also confirmed by other studies. But if mitral repair produces such a better short- and long-term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder but to repair or not to repair, is that really the question? The AATS consensus suggests to repair “whenever possible” but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP as to perform in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with very large volume of valve repairing. This decision cannot therefore be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam.

A document by Daniele Ronco. Click on the document to view its contents.

Resection or exclusion of scars following a myocardial infarction on the LAD territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a “revisitation” of what described before. In some case old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.