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.

t’s time for a fivesome. Commentary to: “The predictive value of five glomerular filtration rate formulas for long-term mortality in patients undergoing coronary artery bypass grafting” Coronary artery disease is an extremely common condition and coronary artery bypass-grafting is still one of the most important therapeutic strategy to treat it. Chronic kidney disease is often affecting patients with CAD. Nevertheless, the literature is still debating what formula estimate the best the glomerular filtration rate in patients undergoing CABG. Indeed, the formulas used in clinical practice have some differences some are more accurate in patients with diabetes, while there are some bias given by age and body mass index. In cardiac surgery, the choice of the most fitting formula to evaluate GFR has important clinical implication and, up to now, three formulas have been compared at most. Eilon Ram et al. present a retrospective study which compares the 5 most used formulas (CG, MDRD, CKD-EPI, Mayo, and IB) to derive GFR to evaluate the one with the best accuracy in predicting long-term mortality. In order to do so, they divided 3744 patients in three groups according to the estimated GFR by means of all 5 formulas: significant CKD according to all formulas, non-significant CKD according to all formulas and discordant results (meaning that at least one formula gave normal GFR and at least one formula gave abnormal GFR). Patients with the highest mortality were the ones with significant CKD according to all formulas.

It is well known that the left internal mammary artery (LIMA) should be the first conduit of choice. Similarly, especially in patients younger than 70 years, other conduits should be search among arterial grafts such as right internal mammary artery (RIMA) or radial artery (RA). If the RA can be harvested in the meanwhile of LIMA harvesting without time consuming, it is well established that former one has to be grafted only on presence of a good run-off. One of the main criticisms moved to the use of RIMA are linked to technical difficulties in its harvesting it. Edgar Aranda-Michel and coworkers tried to answer to the age-old question is “RIMA has to be used in situ or free-graft?” In a retrospective study on 667 patients (442 had free RIMA and 245 had free RIMA) that were also matched through propensity analysis (202 patients per group), they did not find any differences between the two groups in the major outcomes, including heart failure specific readmissions. This finding is consistent with the literature, hence the take-home message is whatever happens, two mammary is better than one.

Objectives: One of the most severe and devastating complications following coronary artery bypass grafting (CABG) are cerebro-vascular accidents. Atherosclerotic disease of the ascending aorta and epi-aortic trunks has been considered the most probable cause of cerebral embolization during CABG due to aortic manipulation and clamping. The aim of this study is to investigate if single or double aortic clamping may impact the incidence of neurological events. Methods: This is a retrospective study which includes a series of patients who underwent CABG from a single surgeon at our Institution from March 2006 to December 2012. Patients were divided into two homogenous groups based on the surgical technique: single-aortic clamping (SAC) (118 patients) and double aortic clamp (DAC) (133 pt). Results: Median surgical time was longer for the DAC group than for the SAC group (p= 0.015), but no significant differences were found for the primary outcomes of stroke and transient ischemic attack. The two groups presented a similar 30-day survival. The follow-up was completed at 82% (median 11 years). The Kaplan-Meier estimates a survival at 11 years of 81% and 88% for the DAC and SAC group, respectively. Conclusions: Incidence of stroke seems to be independent from cross-clamping technique and we could infer that the global rate of stroke after CABG in low to moderate risk patients is probably more influenced by other factors that further studies need to address. Moreover, the appearance of the aorta at the time of surgery is crucial to analyse to better personalize the strategy.