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Background and Objective. Renal Doppler resistive index (RDRI) is a noninvasive index considered to reflect renal vascular perfusion. The aim of this study was to identify the independent hemodynamic determinants of RDRI in mechanically ventilated patients after cardiac surgery. Methods. RDRI was determined in 61 patients by color and pulse Doppler ultrasonography of the interlobar renal arteries. Intermittent thermodilution cardiac output measurements were obtained and blood samples taken from the tip of pulmonary artery catheter to measure hemodynamics and mixed venous oxygen saturation (SvO2). Results. By univariate analysis, RDRI was significantly correlated with SvO2, oxygen extraction ratio, left ventricular stroke work index, and cardiac index, but not heart rate, central venous pressure, mean artery pressure, pulmonary capillary wedge pressure, systemic vascular resistance index, oxygen delivery index, oxygen consumption index, arterial lactate concentration, and age. However, by multivariate analysis RDRI was significantly correlated with SvO2 only. Conclusions. The present data suggests that, in mechanically ventilated patients after cardiac surgery, RDRI increases proportionally to the decrease in SvO2, thus reflecting an early vascular response to tissue hypoxia.

There is an increasing number of patients with mitral regurgitation secondary to dilated cardiomyopathy. Recent data suggest that mitral regurgitation (MR) can be surgically corrected in heart failure with symptomatic improvements and favourable reverse left ventricular remodeling. However, several questions remain to be answered, regarding the optimal management of functional mitral regurgitation, the correct timing of surgery and the choice of the surgical technique to perform in patients affected by dilated cardiomyopathy. In the setting of ischemic chronic cardiomyopathy, data derived from the recent literature suggest that concomitant severe ischemic MR should be addressed during CABG to improve survival and quality of life. Most surgeons perform concomitant CABG and mitral valve surgery in patients with ischemic chronic cardiomyopathy and moderate to severe MR. In the setting of chronic dilated cardiomyopathy, most clinicians would agree that correction of severe MR in heart failure is warranted, mostly due to a symptomatic benefit and reduction of number of re-hospitalizations. Moreover, reverse ventricular remodeling has been demonstrated with undersized annuloplasty rings and correction of MR: this could lead to improved contractility, reduction in left ventricular end-diastolic and end-systolic volumes, and finally to improved NYHA functional class. Recent large studies suggest that patients undergoing mitral valve repair had improved perioperative survival, shorter length of stay, and improved long-term survival than those undergoing mitral valve replacement because the preservation of the subvalvular apparatus seems to result in superior left ventricular remodelling and in greater improvement in NYHA class. In the near future, data from multi-institutional, randomized prospective trials will help to elucidate many of the questions and concerns regarding repair of severe functional mitral regurgitation. Finally, technology applied to heart surgery is continually evolving and will allow more exciting cellular and novel device therapies for the treatment of functional mitral regurgitation secondary to dilated cardiomyopathy.

On computed tomography (CT) imaging, a peri-vascular adipose tissue attenuation (pVAT) measure has been proposed as a non-invasive correlate of inflammation in the coronary artery vessels, and a single research group provided histopathological demonstration of this radiological/pathological correspondence. Our group has shown that patients with surgical-grade ascending aorta (AA) aneurysm display higher pVAT compared with patients with smaller aneurysms or normal AA. Based on histopathological studies on coronary arteries, we speculated that this correlation may be related to a non-otherwise specified aortic inflammatory process. However, since adipose tissue around the AA is often scant, and there are no histopathological studies confirming such hypothesized association between higher pVAT and inflammation around the AA, we cannot exclude that this pVAT change is secondary to different mechanisms, unrelated to the actual presence of peri-vascular inflammation. We performed a retrospective clinical/radiological/pathological study in 78 patients who underwent AA surgery with the aim to correlate pre-operatory pVAT on CT with histopathological findings from the surgical specimens. Histopathological review and immunohistochemistry were performed on the surgical aortic samples. The AA adventitial/periadventitial adipose tissue had higher pVAT by an increasing collagen fiber deposition, which progressively makes the fat hypotrophic and, in the late stages of this process, it replaces the normal soft tissue composition in this location. In the ascending aorta, pVAT on CT imaging is probably not a proxy for the presence of current vascular inflammation, although it may track changes involving the progressive substitution of perivascular adipose cells by higher-pVAT tissues, mainly fibrotic replacement.

Ever since the first hybrid prosthesis was used for a total aortic arch replacement, many other techniques have been developed to comply with the need for the treatment of a wide spectrum of patients and their clinical pictures. We hereby provide an overview of the most popular surgical techniques to perform a frozen elephant trunk, including our tailored approach revolving around the antegrade deployment of a Gore C-TAG endovascular stent graft sutured to a four-branched vascular prosthesis. This technique was applied to three cases of acute type A aortic dissection. Although our small series of patients consists of acute aortic dissections only, this technique could be applied to any other aortic arch pathology, such as chronic dissections or aneurysms. Moreover, we believe that, because of the individually tailored approach and widespread availability of the necessary materials, this technique can reveal itself useful in many different operative scenarios.

Objective: Our aim was to perform antegrade selective cerebral perfusion with a different surgical technique using a new type of cannula.Methods: This cannula has been designed to be introduced in the supra-aortic vessels directly using a standard guidewire technique (Seldinger technique). The cannula can also be inserted from the ostia of a vessel if preferred. Furthermore, this device can be introduced before the institution of hypothermic circulatory arrest and opening the aortic arch.Results: We have performed operations on 5 patients so far using this cannula. No stroke or spinal cord injuries were detected. At the moment, both intraoperatively and at computed tomography scan follow-up, no significant stenosis of the cannulation sites were noted. Follow-up at 2 years found that patients are alive and free from new major neurological events.Conclusions: Transarterial introduction using the Seldinger technique of our cannula (AV Flow; MedEurope Srl, Bologna, Italy) represents an alternative to the current well-established techniques. The major advantages we describe are complete cerebral protection throughout the hypothermic circulatory arrest and easier arch vessels reimplantation or hemiarch operations. (JTCVS Techniques 2020;4:10-3) AV Flow cannula (MedEurope Srl, Bologna, Italy) with guidewire.

Since the advent of TAVR (transcatheter aortic valve replacement), the transapical surgical approach has been affirmed as a safe and effective alternative access for patients with unsuitable peripheral arteries. With the improvement of devices for transfemoral approach and the development of other alternative accesses, the number of transapical procedures has decreased significantly worldwide. The left ventricular apex, however, has proved to be a safe and valid alternative access for various other structural heart procedures such as mitral valve repair, mitral valve-in-valve or valve-in-ring replacement, transcatheter mitral valve replacement (TMVR), transcatheter mitral paravalvular leak repair, and thoracic aorta endovascular repair (TEVAR). We review the literature and our experience of various hybrid transcatheter structural heart procedures using the transapical surgical approach and discuss pros and cons.