Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support in patients with refractory cardiogenic shock, allowing time for cardiac recovery. Levosimendan is a calcium sensitizer with inotropic and vasodilatory effects used in the treatment of severe heart failure. It does not increase myocardial oxygen consumption. Its maximum hemodynamic response is seen 24-48 h after stopping infusion, but its effects can persist for 7-9 d owing to active metabolites. We sought to investigate whether the use of levosimendan improves weaning outcomes in patients on VA-ECMO. Six consecutive patients with cardiogenic shock were placed on femorofemoral VA-ECMO support and received levosimendan 24 h before the planned weaning (group A). As control group (group B), we retrospectively reviewed the VA-ECMO implanted at our institution before the introduction of the levosimendan protocol. These patients received only traditional inotropes. The weaning rate was 83.33% in group A and 27.3% in group B. The survival rate was 66.66% and 36.4%, respectively. In group A, three of six patients (50%) required inotropic/vasopressor support after ECMO cessation, while in group B 11 of 11 patients (100%) required support. In our case series, pretreatment with levosimendan seems to facilitate weaning from VA-ECMO, reducing the need for high-dose inotropes.

Abdominal aortic aneurysm (AAA) is defined as a permanent dilatation of the abdominal aorta that exceeds 3 cm. Most AAAs arise in the portion of abdominal aorta distal to the renal arteries and are defined as infrarenal. Most AAAs are totally asymptomatic until catastrophic rupture. The strongest predictor of AAA rupture is the diameter. Surgery is indicated to prevent rupture when the risk of rupture exceeds the risk of surgery. In this review, we aim to analyze this disease comprehensively, starting from an epidemiological perspective, exploring etiology and pathophysiology, and concluding with surgical controversies. We will pursue these goals by addressing eight specific questions regarding AAA: (1) Is the incidence of AAA increasing? (2) Are ultrasound screening programs for AAA effective? (3) What causes AAA: Genes versus environment? (4) Animal models: Are they really relevant? (5) What pathophysiology leads to AAA? (6) Indications for AAA surgery: Are surgeons over-eager to operate? (7) Elective AAA repair: Open or endovascular? (8) Emergency AAA repair: Open or endovascular?

Aortic surgery with DHCA can be performed with favorable late survival, with the duration of DHCA period having only a limited impact. However, these results cannot be generalized for very long durations of DHCA (>50 minutes), when perfusion methods may be preferable. In elective, nondissection first-time surgeries, a late survival comparable to that in a reference population can be achieved. Early survival is adversely affected by aortic dissection, redo status, and disease extent.

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OBJECTIVES The EuroSCORE II is widely used to predict 30-day mortality in patients undergoing open and transcatheter cardiac surgery. The aim of this study is to evaluate the discriminatory ability of the EuroSCORE II in predicting 30-day mortality in a large cohort of patients undergoing surgical mitral valve repair in a high-volume centre. METHODS A retrospective review of our institutional database was carried on to find all patients who underwent mitral valve repair in our department from January 2012 to December 2019. Discrimination of the EuroSCORE II was assessed using receiver operating characteristic curves. The maximum Youden’s Index was employed to define the optimal cut-point. Calibration was assessed by generating calibration plot that visually compares the predicted mortality with the observed mortality. Calibration was also tested with the Hosmer–Lemeshow goodness-of-fit test. Finally, the accuracy of the models was tested calculating the Brier score. RESULTS A total of 2645 patients were identified, and the median EuroSCORE II was 1.3% (0.6–2.0%). In patients with degenerative mitral regurgitation (MR), the EuroSCORE II showed low discrimination (area under the curve 0.68), low accuracy (Brier score 0.27) and low calibration with overestimation of the 30-day mortality. In patients with secondary MR, the EuroSCORE II showed a good overall performance estimating the 30-day mortality with good discrimination (area under the curve 0.88), good accuracy (Brier score 0.003) and good calibration. CONCLUSIONS In patients with degenerative MR operated on in a high-volume centre with a high level of expertise in mitral valve repair, the EuroSCORE II significantly overestimates the 30-day mortality.

Although much has been learned about disease of the thoracic aorta, most diagnosis of thoracic aortic aneurysm (TAA) is still incidental. The importance of the genetic aspects in thoracic aortic disease is overwhelming, and today different mutations which cause TAA or alter its natural history have been discovered. Technological advance has made available testing which detects genetic mutations linked to TAA. This article analyses the genetic aspects of TAA and describes the possible role of genetic tests in the clinical setting in preventing devastating complications of TAA.

OBJECTIVES The aim of this study was to assess the long-term outcomes of different surgical strategies in patients with hypertrophic obstructive cardiomyopathy (HOCM) with septal thickness ≤18 mm and systolic anterior motion (SAM)-related moderate-to-severe mitral regurgitation (MR). METHODS Seventy-six HOCM patients with septal thickness 17 [16; 18] mm, resting left ventricle outflow tract gradient 60 [41; 85] mmHg and SAM-related MR ≥2+/4+, underwent septal myectomy alone (54%) or mitral valve (MV) surgery ± myectomy (46%). RESULTS No hospital death and no ventricular septal defect occurred. Patients undergoing MV surgery ± myectomy had longer cardiopulmonary bypass and X-clamp times (77 [60–106] vs 51 [44–62] min, P < 0.001 and 56 [45–77] vs 32 [28–41] min, P < 0.001) and higher incidence of low output syndrome (11% vs 0%, P = 0.04). Follow-up was 98.6% complete, median 8 years [3–11]. There were no statistically significant differences in overall survival (P = 0.069) with survival rates at 9 years of 96 ± 4% in the myectomy alone group and 81 ± 8% in the MV surgery ± myectomy one. At 9 years, cumulative incidence function of cardiac death was 12 ± 6% in the MV surgery ± myectomy group vs 0% in the myectomy one, P = 0.06. Multivariable analysis identified age and previous septal alcoholization as predictors of cardiac death (hazard ratio (HR) = 1.1, 95% confidence interval (CI) 1.0–1.1, P = 0.004 and HR = 2.9, 95% CI 1.0–8.3, P = 0.042). The 9-year cumulative incidence function of recurrence of MR ≥2+, with death as competing risk, was 3 ± 2.8% in the MV surgery ± myectomy group vs 25 ± 6.9% in the myectomy one, P = 0.005. CONCLUSIONS In HOCM patients with moderate septal thickness and SAM-related MR, as the degree of septal hypertrophy decreases, addressing the abnormalities of the MV apparatus may become necessary to provide a durable resolution of left ventricle outflow tract obstruction and SAM-related MR. However, performing myectomy alone, whenever possible, seems to be associated to a better postoperative course and a trend towards lower cardiac mortality at follow-up, despite a higher rate of residual moderate MR.

Objectives: Although the benefits of surgery in infective endocarditis (IE) are clear, an unneglectable proportion of patients do not undergo surgery despite clear operative indication. Outcomes of these patients are poorly reported. With this study, we aim to analyze patient profiles, indication for surgery, decision-making, and outcomes of patients not undergoing surgery despite contemporary surgical indications. Materials and Methods: Retrospective review of single institution database of patients with IE was done to identify patients that, although a clear surgical indication did not receive surgery. We aimed to review the most contemporary practice from June 2014 to December 2018. Only patients who were physically evaluated at our facility were included. Follow up was 100% complete. Kaplan-Meier methods were used to estimate survival and freedom from a composite outcome of death, stroke, and heart failure. Results: Of the 174 patients with surgical indication during the review period, 46 (27%) did not undergo surgery. The reasons for not pursuing surgery were varied and usually multiple, with severe brain injury and end stage liver disease between the most common. The 30-day mortality was 63%, and the estimated survival at 6 months, 1 year, and 2 years was respectively 22%, 15%, and 10%. Conclusion: The mortality of this cohort of patients is extremely high. A multidisciplinary evaluation is of paramount importance in the decision-making process with shared responsibility for denial of operative options. In a perspective of correct healthcare resources allocation an early palliative care consult may need to be considered in some of those patients.