Publications by authors named "Piergiorgio Bruno"

47 Publications

Bicuspidized De Vega for functional tricuspid valve regurgitation: "De-Kay repair".

Ann Thorac Surg 2021 Apr 27. Epub 2021 Apr 27.

Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome.

Functional tricuspid valve regurgitation in the contest of mitral valve disease is a highly prevalent disease. We describe a ring-less technique that combines restrictive annuloplasty (De Vega) with posterior tricuspid leaflet obliteration (Kay) used for patients with less-than-severe functional tricuspid valve regurgitation undergoing mitral valve surgery. The technique has been in use at our centre since 2012, showing promising long-term echocardiographic results, with stable reduction of the annulus size and stable reduction of the degree of regurgitation.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.038DOI Listing
April 2021

Telemedicine for adult congenital heart disease patients during the first wave of COVID-19 era: a single center experience.

J Cardiovasc Med (Hagerstown) 2021 Apr 20. Epub 2021 Apr 20.

Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario A. Gemelli IRCCS Catholic University of the Sacred Heart Department of Pediatric Cardiology and Cardiac Surgery - Bambino Gesù Hospital, Rome, Italy.

Aim: To summarize our experience on the implementation of a telemedicine service dedicated to adult congenital heart disease (ACHD) patients during the lockdown for the first wave of COVID-19.

Methods: This is a prospective study enrolling all ACHD patients who answered a questionnaire dedicated telematic cardiovascular examination.

Results: A total of 289 patients were enrolled, 133 (47%) were male, 25 (9%) were affected by a genetic syndrome. The median age was 38 (29-51) years, whereas the median time interval between the last visit and the telematic follow-up was 9.5 (7.5-11.5) months. Overall, 35 patients (12%) reported a worsening of fatigue in daily life activity, 17 (6%) experienced chest pain, 42 (15%) had presyncope and 2 (1%) syncope; in addition, 28 patients (10%) presented peripheral edema and 14 (5%) were orthopneic. A total of 116 (40%) patients reported palpitations and 12 had at least one episode of atrial fibrillation and underwent successful electrical (8) or pharmacological (4) cardioversion. One patient was admitted to the emergency department for uncontrolled arterial hypertension, five for chest pain, and one for heart failure. Two patients presented fever but both had negative COVID-19 nasal swab.

Conclusion: During the COVID-19 pandemic, the use of telemedicine dramatically increased and here we report a positive experience in ACHD patients. The postpandemic role of telemedicine will depend on permanent regulatory solutions and this early study might encourage a more systematic telematic approach for ACHD patients.
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http://dx.doi.org/10.2459/JCM.0000000000001195DOI Listing
April 2021

Heart valve critical pathway and heart valve clinic: novel benchmarks for modern management of valvular heart disease.

Crit Pathw Cardiol 2021 Mar 31. Epub 2021 Mar 31.

Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia Università Cattolica del Sacro Cuore, Roma, Italia.

The growing burden of Valvular Heart Disease (VHD) in Western countries represents a challenge for the daily clinical practice, especially in the light of the ever-increasing number of therapeutic options. The Euro Heart Survey showed that, among elderly subjects with severe, symptomatic valve dysfunction, surgery is denied for 33% of patients with aortic stenosis and for 50% of patients with mitral regurgitation. Current management (from diagnosis to follow-up) is often fragmented in multiple - sometimes unnecessary- steps. Such a "patchy" approach may translate into a suboptimal management, especially in the geriatric population. New healthcare models exist, that can coordinate care, reduce fragmentation, limit costs and, ultimately, improve outcomes: the clinical pathways.
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http://dx.doi.org/10.1097/HPC.0000000000000260DOI Listing
March 2021

The treatment of mitral insufficiency in refractory heart failure.

Eur Heart J Suppl 2020 Nov 18;22(Suppl L):L93-L96. Epub 2020 Nov 18.

Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.

Secondary mitral insufficiency (SMI) is caused by dilatation and left ventricular dysfunction and is a frequent finding in patients with heart failure (HF). It is associated with a mortality of between 40% and 50% at 3 years. The first-line treatment is represented by medical therapy, possibly associated, when indicated, with cardiac re-synchronization. If the patient remains symptomatic, corrective action should be considered. Surgery is indicated in cases of severe SMI with ejection fraction >30% and the need for myocardial revascularization. The management of patients in whom revascularization is not an option remains extremely complex and the evidence in this field is extremely limited. Percutaneous transcatheter therapies, reparative or replacement, are rapidly emerging as valid alternatives in cases of patients at high surgical risk. In particular, edge-to-edge repair (MitraClip) has proven effective in improving symptoms and reducing hospitalizations for HF. However, neither transcatheter nor surgical mitral repair or replacement has been shown to significantly improve prognosis, with mortality remaining high (14-20% at 1 year). Randomized trials aimed at assessing the effect of these treatments and establishing their long-term outcomes are urgently required.
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http://dx.doi.org/10.1093/eurheartj/suaa143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904083PMC
November 2020

An "orthotopic" snorkel-stenting technique to maintain coronary patency during transcatheter aortic valve replacement.

Cardiovasc Revasc Med 2020 Dec 11. Epub 2020 Dec 11.

Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.

Coronary artery obstruction (CAO) during transcatheter-aortic-valve replacement (TAVR) represents a main concern for TAVR safety in patients with low coronary take-off. To date, "snorkel" (also called chimney) technique, consisting of stent implantation from the coronary ostium to the aorta within the space between the valve frame and the aortic wall, is the most adopted strategy to prevent CAO. This technique is associated with the creation of complex valve/stent configuration that can hinder repeat coronary interventions. Due to this concern, we set up an original sequence for coronary protection aiming to ensure a more physiological TAVR frame/stent configuration. According to this technique, TAVR prosthesis is released with a "protection" system consisting of guiding catheter (GC), wire and stent inside the coronary artery with high CAO risk. In the case of CAO occurrence, the stent is released according to the snorkel technique. In the absence of complete CAO, a new GC is advanced inside the implanted TAVR prosthesis and the stent is deployed from the coronary artery up to the prosthesis. We herein report two cases of very high CAO risk where this technique was successfully used during last-generation self-expandable prostheses implantation (in a native aortic valve and in one prosthetic aortic valve). In conclusion, this "orthotopic snorkel-stenting in TAVR" (OST) technique represents a novel option for treating impeding CAO during TAVR. As compared with the "classic" snorkel technique, it allows avoiding stent implantation in some patients (who do not experience CAO) and may provide a more predictable and physiologic TAVR prosthesis/stent configuration in the case of stent implantation need.
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http://dx.doi.org/10.1016/j.carrev.2020.12.013DOI Listing
December 2020

Minimally Invasive Aortic Valve Surgery in Octogenarians: Reliable Option or Fallback Solution?

Innovations (Phila) 2021 Jan-Feb;16(1):34-42. Epub 2020 Dec 15.

60234 Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.

Objective: Aortic valve disease is more and more common in western countries. While percutaneous approaches should be preferred in older adults, previous reports have shown good outcomes after surgery. Moreover, advantages of minimally invasive approaches may be valuable for octogenarians. We sought to compare outcomes of conventional aortic valve replacement (CAVR) versus minimally invasive aortic valve replacement (MIAVR) in octogenarians.

Methods: We retrospectively collected data of 75 consecutive octogenarians who underwent primary, elective, isolated aortic valve surgery through conventional approach (41 patients, group CAVR) or partial upper sternotomy (34 patients, group MIAVR).

Results: Mean age was 81.9 ± 0.9 and 82.3 ± 1.1 years in CAVR and MIAVR patients, respectively ( = 0.09). MIAVR patients had lower 24-hour chest drain output (353.4 ± 207.1 vs 501.7 ± 229.9 mL, < 0.01), shorter mechanical ventilation (9.6 ± 2.4 vs 11.3 ± 2.3 hours, < 0.01), lower need for blood transfusions (35.3% vs 63.4%, = 0.02), and shorter hospital stay (6.8 ± 1.6 vs 8.3 ± 4.3 days, < 0.01). Thirty-day mortality was zero in both groups. Survival at 1, 3, and 5 years was 89.9%, 80%, and 47%, respectively, in the CAVR group, and 93.2%, 82.4%, and 61.8% in the MIAVR group, with no statistically significant differences (log-rank test, = 0.35).

Conclusions: Aortic valve surgery in older patients provided excellent results, as long as appropriate candidates were selected. MIAVR was associated with shorter mechanical ventilation, reduced blood transfusions, and reduced hospitalization length, without affecting perioperative complications or mid-term survival.
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http://dx.doi.org/10.1177/1556984520974467DOI Listing
December 2020

Cardiovascular Disease and SARS-CoV-2: the Role of Host Immune Response Versus Direct Viral Injury.

Int J Mol Sci 2020 Oct 30;21(21). Epub 2020 Oct 30.

Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy.

The 2019 novel coronavirus [2019-nCoV], which started to spread from December 2019 onwards, caused a global pandemic. Besides being responsible for the severe acute respiratory syndrome 2 [SARS-CoV-2], the virus can affect other organs causing various symptoms. A close relationship between SARS-CoV-2 and the cardiovascular system has been shown, demonstrating an epidemiological linkage between SARS-CoV-2 and cardiac injury. There are emerging data regarding possible direct myocardial damage by 2019-nCoV. In this review, the most important available evidences will be discussed to clarify the precise mechanisms of cardiovascular injury in SARS-CoV-2 patients, even if further researches are needed.
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http://dx.doi.org/10.3390/ijms21218141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7663579PMC
October 2020

Unexpected diagnosis following screening breast ultrasound.

Clin Case Rep 2020 Oct 1;8(10):2073-2075. Epub 2020 Jun 1.

Department of Cardiovascular Sciences Cardiac Surgery Unit Fondazione Policlinico Universitario "A. Gemelli" IRCCS Rome Italy.

Any instrumental examination may lead to unexpected diagnosis that in turn can radically change the clinical pathway of a patient.
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http://dx.doi.org/10.1002/ccr3.3014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7562835PMC
October 2020

Psychological Effects of Skin Incision Size in Minimally Invasive Valve Surgery Patients.

Innovations (Phila) 2020 Nov/Dec;15(6):532-540. Epub 2020 Sep 28.

Cardiovascular Sciences Department, Agostino Gemelli Polyclinic Foundation IRCSS, Rome, Italy.

Objective: Clinical benefits of minimally invasive cardiac valve surgery (MIVS) have been reported. Improved postoperative mental status was never analyzed with dedicated psychological tests. In the present study we intend to investigate potential benefits of MIVS for patient psychological well-being, with special attention to the relevance of the patient perception of the chest surgical scar, of the self body image and cosmetic aspects.

Methods: Between 2016 and 2017, 87 eligible patients, age 66.5 ± 14.5 years, operated on for heart valve surgery, underwent either conventional full sternotomy (CS; = 48) or MIVS by V-shape hemi-sternotomy approach ( = 39). Before selection of the surgical approach, patients had undergone preoperative evaluation of their psychological status using Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory Form Y (STAI-Y), and EuroQol-5D (EQ-5D) psychological tests. Six months postoperatively, patients filled in dedicated questionnaires to assess their psychological status, quality of life, and subjective perception, thus repeating the above-mentioned tests and adding the Body Image Questionnaire (BIQ) and Patient and Observer Scar Assessment Scale (POSAS) v2.0 tests for scar-healing process evaluation.

Results: No patient died during the study.The 4 post-test scales of psychological well-being (BDI-II = 0.04, STAI-Y = 0.04, 2 indices of EQ-5D = 0.03, = 0.01) showed significant differences between the MIVS group and CS group, with MIVS-small incision patients having lower level of depression and anxiety symptoms and better quality of life. Mean score differences of scar perception (BIQ and POSAS v2.0) were significant, with MIVS patients having evaluated the scar quality significantly better than CS patients.

Conclusions: MIVS appears associated with significant esthetical and related psychological benefits, as documented by technical tests. These findings should be considered when selecting the most appropriate technique for heart valve surgery.
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http://dx.doi.org/10.1177/1556984520956980DOI Listing
September 2020

Sortilin levels correlate with major cardiovascular events of diabetic patients with peripheral artery disease following revascularization: a prospective study.

Cardiovasc Diabetol 2020 09 25;19(1):147. Epub 2020 Sep 25.

Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italia.

Background: Peripheral artery disease (PAD) represents one of the most relevant vascular complications of type 2 diabetes mellitus (T2DM). Moreover, T2DM patients suffering from PAD have an increased risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Sortilin, a protein involved in apolipoproteins trafficking, is associated with lower limb PAD in T2DM patients.

Objective: To evaluate the relationship between baseline serum levels of sortilin, MACE and MALE occurrence after revascularization of T2DM patients with PAD and chronic limb-threatening ischemia (CLTI).

Research Design And Methods: We performed a prospective non-randomized study including 230 statin-free T2DM patients with PAD and CLTI. Sortilin levels were measured before the endovascular intervention and incident outcomes were assessed during a 12 month follow-up.

Results: Sortilin levels were significantly increased in individuals with more aggressive PAD (2.25 ± 0.51 ng/mL vs 1.44 ± 0.47 ng/mL, p < 0.001). During follow-up, 83 MACE and 116 MALE occurred. In patients, who then developed MACE and MALE, sortilin was higher. In particular, 2.46 ± 0.53 ng/mL vs 1.55 ± 0.42 ng/mL, p < 0.001 for MACE and 2.10 ± 0.54 ng/mL vs 1.65 ± 0.65 ng/mL, p < 0.001 for MALE. After adjusting for traditional atherosclerosis risk factors, the association between sortilin and vascular outcomes remained significant in a multivariate analysis. In our receiver operating characteristics (ROC) curve analysis using sortilin levels the prediction of MACE incidence improved (area under the curve [AUC] = 0.94) and MALE (AUC = 0.72).

Conclusions: This study demonstrates that sortilin correlates with incidence of MACE and MALE after endovascular revascularization in a diabetic population with PAD and CLTI.
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http://dx.doi.org/10.1186/s12933-020-01123-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519536PMC
September 2020

Blood lactate predicts survival after percutaneous implantation of extracorporeal life support for refractory cardiac arrest or cardiogenic shock complicating acute coronary syndrome: insights from the CareGem registry.

Intern Emerg Med 2021 Mar 9;16(2):463-470. Epub 2020 Aug 9.

Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy, Italian IRCCS Cardiovascular Network and Università Cattolica del Sacro Cuore, Largo A. Gemelli, 00168, Rome, Italy.

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients' condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01-18.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival.
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http://dx.doi.org/10.1007/s11739-020-02459-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952335PMC
March 2021

A less-invasive totally-endovascular (LITE) technique for trans-femoral transcatheter aortic valve replacement.

Catheter Cardiovasc Interv 2020 08 11;96(2):459-470. Epub 2020 Jan 11.

Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.

Objectives: To describe and report the results of an original technique for trans-femoral (TF) transcatheter-aortic-valve-replacement (TAVR).

Background: TF approach represents the commonest TAVR technique. The best technique for TF-TAVR is not recognized.

Methods: We developed a less-invasive totally-endovascular (LITE) technique for TF-TAVR. The key aspects are: precise TAVR access puncture using angiographic-guidewire-ultrasound guidance radial approach as the "secondary access" (to guide valve positioning, to check femoral-access hemostasis and to manage eventual access-site complications) non-invasive pacing (by retrograde left ventricle stimulation or by definitive pace-maker external programmer) The LITE technique has been systematically adopted at our Institution. Procedure details, complications and clinical events occurring during hospitalization were prospectively recorded. Major vascular complications and life-threatening or major bleedings were the primary study end-points.

Results: A total of 153 consecutive patients referred for TF-TAVR were approached using the LITE technique. Mean predicted surgical operative mortality was 4.9% and mean TAVR predicted mortality was 3.9%. In 132 (86.3%) patients, TAVR was completed without the need for additional femoral artery access or transvenous temporary pace-maker implantation. Major vascular complications occurred in 2 (1.3%), life-threatening or major bleedings occurred in 4 (2.6%) patients. All-cause death occurred in 3 patients (2.0%).

Conclusions: TF-TAVR according to LITE technique is feasible and is associated with very low rates of vascular or bleeding complications.
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http://dx.doi.org/10.1002/ccd.28697DOI Listing
August 2020

Delayed massive subcutaneous emphysema following Robicsek closure.

Clin Case Rep 2019 Dec 3;7(12):2588-2589. Epub 2019 Nov 3.

Department of Cardiovascular Sciences Cardiac Surgery Unit Fondazione Policlinico Universitario "A.Gemelli" IRCCS Catholic University of the Sacred Heart Rome Italy.

A surgical procedure may lead to unusual and unexpected clinical scenario. Good medical practice should always keep it in mind. So, a broken sternal steel wire was the rare cause of massive emphysema.
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http://dx.doi.org/10.1002/ccr3.2518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935661PMC
December 2019

Prognostic Value of Right Ventricular Dysfunction and Tricuspid Regurgitation in Patients with Severe Low-Flow Low-Gradient Aortic Stenosis.

Sci Rep 2019 10 10;9(1):14580. Epub 2019 Oct 10.

Department of Cardiology, Medical University of Vienna, Vienna, Austria.

Long and mid-term data in Low-Flow Low-Gradient Aortic Stenosis (LFLG-AS) are scarce. The present study sought to identify predictors of outcome in a sizeable cohort of patients with LFLG-AS. 76 consecutive patients with LFLG-AS (defined by a mean gradient <40 mmHg, an aortic valve area ≤1 cm and an ejection fraction ≤50%) were prospectively enrolled and followed at regular intervals. Events defined as aortic valve replacement (AVR) and death were assessed and overall survival was determined. 44 patients underwent AVR (10 transcatheter and 34 surgical) whilst intervention was not performed in 32 patients, including 9 patients that died during a median waiting time of 4 months. Survival was significantly better after AVR with survival rates of 91.8% (CI 71.1-97.9%), 83.0% (CI 60.7-93.3%) and 56.3% (CI 32.1-74.8%) at 1,2 and 5 years as compared to 84.3% (CI 66.2-93.1%), 52.9% (CI 33.7-69.0%) and 30.3% (CI 14.6-47.5%), respectively, for patients managed conservatively (p = 0.017). The presence of right ventricular dysfunction (HR 3.47 [1.70-7.09]) and significant tricuspid regurgitation (TR) (HR 2.23 [1.13-4.39]) independently predicted overall mortality while the presence of significant TR (HR 3.40[1.38-8.35]) and higher aortic jet velocity (HR 0.91[0.82-1.00]) were independent predictors of mortality and survival after AVR. AVR is associated with improved long-term survival in patients with LFLG-AS. Treatment delays are associated with excessive mortality, warranting urgent treatment in eligible patients. Right ventricular involvement characterized by the presence of TR and/or right ventricular dysfunction, identifies patients at high risk of mortality under both conservative management and after AVR.
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http://dx.doi.org/10.1038/s41598-019-51166-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787042PMC
October 2019

Improved Patient Recovery With Minimally Invasive Aortic Valve Surgery: A Propensity-Matched Study.

Innovations (Phila) 2019 Oct 21;14(5):419-427. Epub 2019 Aug 21.

Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.

Objective: Despite conflicting evidence available, minimally invasive aortic valve replacement (MIAVR) is increasingly used as an alternative to full sternotomy. We sought to compare early outcomes of aortic valve replacement through a full sternotomy (conventional aortic valve replacement [CAVR]) and upper ministernotomy (MIAVR).

Methods: We analyzed 297 patients having undergone primary, elective, isolated MIAVR or CAVR between January 2014 and June 2018. Following propensity score matching, 120 patients remained in each group.

Results: MIAVR required longer bypass (93 ± 26 vs 81 ± 24 minutes, < 0.01) and operative times (214 ± 39 vs 182 ± 37 minutes, < 0.01). However, aortic cross-clamp times were comparable (57 ± 17 vs 54 ± 14 minutes for MIAVR and CAVR, respectively, = 0.14). MIAVR had less 24-hour blood loss (253 ± 204 vs 323 ± 296 mL, = 0.03), less red blood cells transfusions [1.4 packs (1.1 o 1.9) vs 2.1 packs (1.8 to 2.7), = 0.01], and shorter assisted ventilation time (7.1 ± 3.3 vs 9.7 ± 3.8 hours, < 0.01) when compared to CAVR. These results led to significantly shorter intensive care unit and hospital stays for MIAVR patients (2.5 ± 1.3 vs 3.4 ± 1.1 days, < 0.01 and 6.9 ± 4.1 vs 8.2 ± 4.8 days, = 0.03, respectively). Thirty-day mortality and clinical outcomes did not differ significantly among groups.

Conclusions: MIAVR through upper ministernotomy was shown to be as safe and reliable as CAVR. Patient recovery time was improved by shortening mechanical ventilation and reducing blood loss and transfusions. These results may be significant for high-risk patients undergoing aortic valve surgery.
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http://dx.doi.org/10.1177/1556984519868715DOI Listing
October 2019

Total Surgical Plication of Left Ventricular Aneurysm Using the BioVentrix Revivent Myocardial Anchoring System.

Innovations (Phila) 2019 Aug 27;14(4):369-373. Epub 2019 Jun 27.

1 Cardiovascular Sciences Department, Foundation Polyclinic University A. Gemelli IRCCS, Rome, Italy.

Surgical ventricular reconstruction (SVR) is the therapy of choice for patients with left ventricular dilatation, apical and anterolateral transmural scar, and low ejection fraction. STICH trial did not show that SVR led to improved survival but several observational studies did. However, because of the considerable operative risk, open heart surgery is considered risky in debilitated patients and clinical results are controversial. Alternative less invasive strategies for left ventricular aneurysm repair have been proposed. We present a case of a left ventricular aneurysm repair using the less invasive ventricular enhancement technique (LIVE) with the Revivent TC system (BioVentrix Inc., San Ramon, CA) in a totally surgical approach, instead of a hybrid interventional-surgical one, as previously described.
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http://dx.doi.org/10.1177/1556984519858919DOI Listing
August 2019

The "Heart Valve Clinic" Pathway for the Management of Frail Patients With Valvular Heart Disease: From "One for All" to "All for One".

Crit Pathw Cardiol 2019 06;18(2):61-65

From the Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCSS, Catholic University of The Sacred Heart, Rome, Italy.

Valvular heart disease (VHD) is frequently diagnosed in old patients with clinical evidence of heart failure. This elderly population typically presents a high prevalence of frailty and comorbidities, which are associated with increased operative risk for surgical and percutaneous procedures. Recently, the Euro Heart Survey reported a clear gap between treatment guidelines and their application in the "real world". A more realistic approach to the treatment of older VHD patients treatment, mostly if associated with heart failure, is advocated. A multidisciplinary approach, as obtained with the Heart Valve Clinic methodology (intended to put the patient in the "center" of the scene and the specialists "around him"), has been applied in a group of 79 patients, aged >70 years, with symptomatic VHD, divided in 2 groups according to their frailty status (58 robust and 21 frail). No in-hospital mortality and no difference in late mortality and complications were observed. Infections were more frequent (14.3 vs. 1.7 %; P = 0.02) in frail patients. In patients with postoperative complications, serum levels of interleukin 6 (67.6 vs. 49.6; P = 0.01) and of CAF (C-terminal agrin fragment) as sarcopenia marker (67.9 vs. 62.0; P = 0.04) were higher than that in uncomplicated patients. This study was designed to determine the outcomes of the multidimensional geriatric assessment in the management of older patients with heart failure eligible for heart valve surgery. Geriatric assessment and measurement of inflammatory and sarcopenia markers may represent valid tools for a more realistic evaluation of elderly patients with VHD.
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http://dx.doi.org/10.1097/HPC.0000000000000179DOI Listing
June 2019

Aortic Valve Replacement in Elderly Patients With Small Aortic Annulus: Results With Three Different Bioprostheses.

Innovations (Phila) 2019 Feb 7;14(1):27-36. Epub 2019 Mar 7.

1 Cardiovascular Sciences Department, Foundation Polyclinic University A. Gemelli IRCCS, Rome, Italy.

Objectives: Aortic valve replacement (AVR) in patients with small aortic annulus (diameter ≤21 mm) is considered a challenging scenario because of technical aspects and the high risk of patient-prosthesis mismatch (PPM). The choice of the appropriate prosthesis is crucial, and at the moment, an ideal device has yet to be identified. We compare clinical and hemodynamic results after AVR with three bioprostheses with different design and characteristics.

Methods: We retrospectively evaluated 76 consecutive patients from two cardiac surgery centers who underwent AVR (Trifecta = 24; Edwards INTUITY Elite valve system = 26, and Perceval = 26) for severe aortic stenosis between 2013 and 2017. Patients selected were older than 75 years and with an annulus diameter ≤21 mm at preoperative echocardiogram. Reinterventions and combined procedures were excluded. Minimally invasive AVR was performed in 44 (57.8%) patients. Telephonic interview was obtained at 2.9 ± 0.5 years and echocardiographic follow-up at 2.2 ± 0.8 years.

Results: Clinical outcome was similar in the three groups. At follow-up, Trifecta patients presented significantly higher peak and mean transprosthetic pressure gradients ( P = 0.04 and 0.01). Effective orifice area and left ventricular mass regression were comparable, although an advantage was observed in Perceval patients without reaching the statistical significance. Incidence of moderate ( P = 0.2) and severe PPM ( P = 0.7) was comparable.

Conclusions: Despite higher postoperative pressure gradients observed with the Trifecta valve, all three prostheses (Trifecta, Edwards INTUITY Elite, and Perceval) have proven to be reliable when implanted in small aortic annuli, with good clinical outcome and favorable left ventricular mass regression.
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http://dx.doi.org/10.1177/1556984519826430DOI Listing
February 2019

Giant left main coronary artery aneurysm: How to deal with it?

J Thorac Cardiovasc Surg 2019 Mar 29;157(3):e163-e166. Epub 2018 Sep 29.

Cardiovascular Sciences Department, Agostino Gemelli Foundation Policlinic IRCSS, Catholic University of The Sacred Heart, Rome, Italy.

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http://dx.doi.org/10.1016/j.jtcvs.2018.08.099DOI Listing
March 2019

From Cath Lab to Surgery Room.

Circ Cardiovasc Imaging 2018 09;11(9):e008174

Cardiovascular Department, Cardiac Surgery Unit, Fondazione Policlinico A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy (M.M.).

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http://dx.doi.org/10.1161/CIRCIMAGING.118.008174DOI Listing
September 2018

[How to choose between intra-aortic balloon pump, Impella and extracorporeal membrane oxygenation].

G Ital Cardiol (Rome) 2018 06;19(6 Suppl 1):5S-13S

Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Policlinico Universitario A. Gemelli, Roma.

The use of percutaneous mechanical circulatory support systems in the setting of both high-risk percutaneous coronary intervention (PCI) and cardiogenic shock is an emerging, controversial issue in contemporary clinical cardiology. The most common devices are the intra-aortic balloon pump (IABP), the Impella and the extracorporeal membrane oxygenator (ECMO). Technical progress, equipment improvement and growing cath-lab team expertise are allowing to offer critical patients different levels of assistance according to the selected device. Indeed, they are extremely different and the selection of the proper device for each clinical scenario might be tricky. In high-risk PCI, mechanical hemodynamic support serves the purpose of preventing hemodynamic collapse during the procedure. According to baseline risk stratification, IABP or Impella are usually considered whereas ECMO is seldom considered as a third option for highly selected patients.Cardiogenic shock and cardiac arrest are still associated with high mortality rates. In these conditions mechanical support may be promising. The lack of benefit observed with the systematic use of the IABP (combined with the increased mortality associated with higher number of inotropic drugs) is actually prompting to increasingly consider Impella and ECMO use in critically ill patients. The development of multidisciplinary local protocols is considered pivotal to improve management and outcome of those patients requiring percutaneous circulatory support devices.
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http://dx.doi.org/10.1714/2939.29545DOI Listing
June 2018

Acute heart failure related to a large left atrial myxoma.

Proc (Bayl Univ Med Cent) 2018 Jul 9;31(3):331-333. Epub 2018 Apr 9.

Cardiovascular Sciences Department, Catholic University of The Sacred Heart, Agostino Gemelli Policlinic, Rome, Italy.

An association between atrial myxoma and left ventricular failure is rarely described, is not completely understood, and may have multiple etiologies. We present a 49-year-old man with no history of cardiovascular disease who was admitted to our hospital with pulmonary edema. He was in atrial fibrillation with rapid ventricular response. Echocardiography showed a 10.5-cm left atrial myxoma, which had been asymptomatic until the onset of congestive heart failure in the presence of severe left ventricular systolic dysfunction. Left ventricular inflow obstruction associated with the giant atrial mass could not be the only cause for acute heart failure.
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http://dx.doi.org/10.1080/08998280.2018.1446641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5997048PMC
July 2018

CABG for patients with heart dysfunction: when and why to refuse surgery.

Minerva Cardioangiol 2018 Oct 20;66(5):551-561. Epub 2018 Apr 20.

Unit of Cardiac Surgery, Department of Cardiovascular Surgery, A. Gemelli University Hospital, Catholic University of the Sacred Heart, Rome, Italy.

Surgical myocardial revascularization in patients with reduced left ventricular function has been a matter of debate for decades. A recently-published 10-year extension follow-up of the STICH trial has conclusively demonstrated the benefit of surgical myocardial revascularization in patients with significant coronary artery disease and low left ventricular ejection fraction. However, patient selection for surgery remains challenging, and so does the decision to perform percutaneous rather than surgical revascularization in this class of patients. New evidence helped to clarify the role of preoperative patients' characteristics as risk factors for surgery and to identify those patients who may benefit the most from surgery. Focus of this review is to review epidemiology and results of observational and investigational studies on revascularization in patients with reduced left ventricular function with a particular emphasis on relative indication of coronary artery bypass grafting and percutaneous coronary intervention.
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http://dx.doi.org/10.23736/S0026-4725.18.04711-4DOI Listing
October 2018

Impella: pumps overview and access site management.

Minerva Cardioangiol 2018 Oct 20;66(5):606-611. Epub 2018 Apr 20.

Institute of Cardiology, Catholic University of the Sacred Heart, A. Gemelli University Hospital, Rome, Italy.

The Impella left ventricular support system consists of two main components: a family of different ventricular support catheters with a microaxial pump to be placed across the aortic valve and a single external controller which is connected to activate and control the pump function. Four Impella left ventricular support catheters are available: Impella 2.5, Impella CP, Impella 5.0 and Impella LD. Impella 2.5 and Impella CP are designed for percutaneous peripheral insertion, have respectively a 12F and 14F maximal diameter at the pump level and are capable of providing up to 2.5 and 4.1 liters per minute, respectively. Impella 5.0 and Impella LD have 21F maximal diameter at the pump level and are designed for surgical insertion through, respectively, a peripheral artery (femoral or axillary) or the aorta. The Impella CP or 5.0 are commonly selected for cardiogenic shock patients. The femoral approach represents the most adopted access site for percutaneous Impella insertion. Yet, it requires the presence of suitable aorto-iliac-femoral arterial axis for retrograde advancement of the Impella pump. The axillary artery is usually the main alternative approach for surgical insertion in the patients with unfavorable peripheral anatomy or for patients requiring prolonged assistance. When adopting Impella pumps, maximal attention should be paid to the access site management before, during and after cardiac assistance in order to minimize the risk of vascular complications.
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http://dx.doi.org/10.23736/S0026-4725.18.04703-5DOI Listing
October 2018

Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study.

Eur J Cardiothorac Surg 2018 10;54(4):702-707

Department of Cardiovascular Sciences, Catholic University, Rome, Italy.

Objectives: Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting.

Methods: The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients.

Results: After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety.

Conclusions: In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA.
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http://dx.doi.org/10.1093/ejcts/ezy148DOI Listing
October 2018

Outcomes of Surgery for Severe Aortic Regurgitation with Systolic Left Ventricular Dysfunction.

J Heart Valve Dis 2017 07;26(4):372-379

Department of Cardiac Surgery, Fondazione Policlinico Universitario 'A. GemellI', Catholic University of Sacred Heart, Rome, Italy.

Background And Aim Of The Study: Management of patients with aortic regurgitation (AR) and severe impairment of left ventricular (LV) function characterized by an ejection fraction (EF) ≤35% is challenging. Conflicting results regarding perioperative and long-term survival of these patients have been reported. The study aim was to compare in-hospital outcomes and long-term survival of patients with AR and severe LV dysfunction versus moderate dysfunction (35%
Methods: Between January 2006 and December 2013, a retrospective review was conducted of 119 consecutive patients with severe isolated AR who underwent aortic valve replacement at our institution. Overall, 17 patients (14%) had severe LV dysfunction, 26 (22%) had moderate LV dysfunction, and 76 (64%) had a preserved LV function.

Results: Patients with severely depressed EF were older and more severely symptomatic according to NYHA classification. Operative mortality was 0% in all groups. At a median echocardiographic follow up of 21 months, a statistically significant reverse remodelling of the left ventricle and an improvement in EF of the low-EF group were found. Survival for the overall population was 98.3%, 80.7% and 48.1% at one, five, and nine years, respectively. Long-term postoperative survival was not affected by baseline EF (p = 0.635), but age >70 years and NYHA class III/IV symptoms were predictive of survival.

Conclusions: In-hospital and long-term survival was similar in patients with severe LV dysfunction and with preserved or moderately reduced LV function. Positive reverse LV remodelling and improved LV function was evident at the two-year echocardiographic follow up in these patients, who should not be denied aortic valve surgery.
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July 2017

Expect the Unexpected: A Bizarre Lookalike of Left Atrial Tumor.

Ann Thorac Surg 2017 Dec;104(6):e457-e458

Department of Cardiac Surgery, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.

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http://dx.doi.org/10.1016/j.athoracsur.2017.08.007DOI Listing
December 2017

Percutaneous transcatheter aortic valve replacement induces femoral artery shrinkage: angiographic evidence and predictors for a new side effect.

Catheter Cardiovasc Interv 2018 04 25;91(5):938-944. Epub 2017 Oct 25.

Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.

Objectives: We sought to investigate the possible impact of transaortic valve replacement (TAVR) on common femoral artery (CFA) integrity as assessed by angiography.

Background: CFA represents the most adopted access for TAVR but various degrees of vascular damage may be induced by the procedure.

Methods: Patients underwent percutaneous transfemoral TAVR who had both pre- and post-TAVR access-site angiography were retrospectively selected. Clinical and procedural data (including technique and complications) were prospectively recorded into a structured TAVR database. Pre-TAVR and post-TAVR angiograms were analyzed using a quantitative angiographic analysis software to assess reference diameters, minimum luminal diameter (MLD), and percentage of diameter stenosis (DS).

Results: A total of 124 patients entered the study (mean age: 85 years, mean Euroscore II: 10%). ProStar (13.5%) and double ProGlide (82.2%) preclosure were the main hemostatic techniques. CFA exhibited a significant shrinkage with TAVR as assessed by significant MLD reduction (5.6 mm after TAVR vs. 6.8 mm before, P < .001) and DS increase (30.3% after vs. 17.0%, P < .001). Such differences remained statistically significant after exclusion of 18 patients (14.2%) who had (minor or major) vascular complications. At multivariable analysis, pre-TAVR DS (P = .03) and history of peripheral arterial disease (P = .01), were significantly associated with vascular complications.

Conclusions: Percutaneous TAVR induces an angiographically detectable CFA lumen reduction. Such findings call for further studies assessing clinical impact of this phenomenon and open the door for further refinements of the TAVR access management aimed at preserving vessel integrity.
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http://dx.doi.org/10.1002/ccd.27248DOI Listing
April 2018

Fungal Endocarditis Due to Aspergillus oryzae: The First Case Reported in the Literature.

J Heart Valve Dis 2017 03;26(2):205-207

Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Rome, Italy.

Infective endocarditis (IE) is a severe disease with high mortality and morbidity. Prosthetic valve endocarditis is a life-threatening complication which can occur in less than 10% of patients with valve prosthesis. A fungal etiology of IE is rare and accounts for only 2-4% of all case of endocarditis, but is associated with a higher mortality and morbidity. Herein is reported the first case of fungal endocarditis of aortic valve prosthesis due to Aspergillus oryzae in a 67-year-old caucasian man who nine years previously underwent mitral and aortic valve replacement with mechanical prostheses, and tricuspid annuloplasty for acute IE due to Enterococcus spp. Seven months previously, the patient also underwent a redo cardiac procedure to replace a mitral valve prosthesis with a new mechanical device due to a leakage. Aspergillus oryzae showed impressive growth with strong and unexpected virulence in both local and systemic settings.
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March 2017

A current approach to heart failure in Duchenne muscular dystrophy.

Heart 2017 11 1;103(22):1770-1779. Epub 2017 Jul 1.

Department of Cardiovascular Medicine, Catholic University of the Sacred Heart, Rome, Italy.

Duchenne muscular dystrophy (DMD) is a genetic, progressive neuromuscular condition that is marked by the long-term muscle deterioration with significant implications of pulmonary and cardiac dysfunction. As such, end-stage heart failure (HF) in DMD is increasingly becoming the main cause of death in this population. The early detection of cardiomyopathy is often challenging, due to a long subclinical phase of ventricular dysfunction and difficulties in assessment of cardiovascular symptomatology in these patients who usually loose ambulation during the early adolescence. However, an early diagnosis of cardiovascular disease in patients with DMD is decisive since it allows a timely initiation of cardioprotective therapies that can mitigate HF symptoms and delay detrimental heart muscle remodelling. Echocardiography and ECG are standardly used for screening and detection of cardiovascular abnormalities in these patients, although these tools are not always adequate to detect an early, clinically asymptomatic phases of disease progression. In this regard, cardiovascular magnetic resonance (CMR) with late gadolinium enhancement is emerging as a promising method for the detection of early cardiac involvement in patients with DMD. The early detection of cardiac dysfunction allows the therapeutic institution of various classes of drugs such as corticosteroids, beta-blockers, ACE inhibitors, antimineralocorticoid diuretics and novel pharmacological and surgical solutions in the multimodal and multidisciplinary care for this group of patients. This review will focus on these challenges and available options for HF in patients with DMD.
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http://dx.doi.org/10.1136/heartjnl-2017-311269DOI Listing
November 2017