Medical therapy often fails to control symptoms of severe heart failure. The possibility of modifying to some degree the global ventricular performance with the implantation of a physiological dual chamber pacemaker, set with a short atrioventricular delay (100 msec), has been adopted in two patients with severe heart failure due to coronary artery disease. The baseline clinical condition of both patients was characterized by leg edema, ascites, dyspnea at rest, or even orthopnea with a functional New York Heart Association (NYHA) class III-IV. Acute measurements of hemodynamic and echocardiographic parameters during stepwise shortening of AV interval guided the pacemaker implantation and setting of AV delay in the chronic phase. Within a few days after pacemaker implantation, both patients considerably improved their clinical status as well as their functional NYHA class, improving to class II in one patient and to class II-III in the other patient. In addition, modification of systolic and diastolic parameters paralleled these improvements functional class and clinical condition. Pacemaker therapy in severe heart failure refractory to medical therapy can be of considerable benefit in patients whose quality-of-life is severely compromised when pharmacological therapy is no longer effective. Acute hemodynamic and echocardiographic testing is useful in assessing the most appropriate AV delay and pacing mode.

The indexed effective orifice area of the sutureless group was significantly larger than in the sutured one. The incidence of PPM with the conventional sutured biprosthesis was 61.3%, while it decreases to 0% in the sutureless group. No PPM was reported in the sutureless valve group. Therefore, the Perceval sutureless valve provides larger effective orifice areas compared to the sutured conventional bioprosthesis and could be considered as a good option to reduce the risk of a PPM.

Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.

T he surgical mortality rate for type A acute aortic dissection (AAD) still remains high (8%-34%), despite improvements in perioperative and postoperative management during the last decade.1-3 Complete resection of the intimal tear and prosthetic replacement of the ascending aorta are still considered the standard of care for type A dissection surgery. Because the residual dissection flap in the aortic arch and descending aorta carries risks of progressive aortic dilation and rupture and the need for secondary intervention, several groups have suggested immediate extensive surgery that involves the aortic arch, although concomitant distal aortic manipulation has been associated with an increased risk of morbidity and death. [4][5][6][7][8][9][10][11][12][13] In this situation, 2 different surgical strategies have been proposed: total arch replacement or hemiarch replacement (a more conservative repair limited to the ascending aorta and proximal arch). 4,[9][10][11][12] We evaluated the early and intermediate outcomes of aortic arch surgery in patients with type A AAD, investigating the effect, upon postoperative results, of aortic arch extension. Patients and MethodsWe undertook a retrospective, observational study of prospectively collected data on consecutive patients who had presented with type A AAD at our institution. This cohort study was approved by our local ethics committee, and individual consent was obtained by each patient's physician. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent surgery at our institution. For the purposes of this study, we did not consider 109 AAD patients who underwent isolated replacement of the ascending aorta. We included only the 92 patients who underwent

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To determine whether body mass index ≥30 kg/m2 affects morbidity and mortality rates in patients undergoing surgery for type A acute aortic dissection, we conducted a retrospective study of 201 patients with type A dissection. Patients were divided into 2 groups according to body mass index (BMI): nonobese (BMI, <30 kg/m2; 158 patients) and obese (BMI, ≥30 kg/m2; 43 patients). Propensity score matching was used to reduce selection bias. The overall mortality rate was 19% (38/201 patients). The perioperative mortality rate was higher in the obese group, both in the overall cohort (33% vs 15%; P=0.01) and in the propensity-matched cohort (32% vs 12%; P=0.039). In the propensity-matched cohort, patients with obesity had higher rates of low cardiac output syndrome (26% vs 6%; P=0.045) and pulmonary complications (32% vs 9%; P=0.033) than those without obesity. The overall 5-year survival rates were 52.5% ± 7.8% in the obese group and 70.3% ± 4.4% in the nonobese group (P=0.036). In the propensity-matched cohort, the 5-year survival rates were 54.3% ± 8.9% in the obese group and 81.6% ± 6.8% in the nonobese group (P=0.018). Patients with obesity (BMI, ≥30 kg/m2) who underwent surgery for type A acute aortic dissection had higher operative mortality rates and an increased risk of low cardiac output syndrome, pulmonary complications, and other postoperative morbidities than did patients without obesity. Additional extensive studies are needed to confirm our findings.

Need of permanent pacemaker implantation after aortic valve replacement seems to be related more to preoperative advanced aortic valve disease rather than pre-existing conducting system abnormalities. An accurate surgical technique for aortic valve replacement probably helps to prevent further impairment of conducting system function requiring early postoperative permanent pacemaker implantation.