AVR can be undertaken with excellent results in octogenarians and the current risk is significantly lower than what is predicted with conventional risk-scoring systems. Patients with advanced age should not necessarily be excluded from being candidates for AVR.

Background: Merkel cell carcinoma is a rare but aggressive cutaneous primary small cell carcinoma. It is commonly seen in elderly affecting the head, neck, and extremities. Macroscopically may be difficult to distinguish MCC from other small cells neoplasms especially oat cell carcinoma of the lung.

Purpose: Deep sternal wound complications after cardiac surgery have an incidence of 2 to 8% and carry a significant mortality. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips on the incidence of postoperative deep sternal wound complications. Methods: We retrospectively reviewed 1119 consecutive patients that underwent major cardiac surgery via median sternotomy in our centre. Sternal closure was performed using Nitinol clips in 235 patients (Group I) and standard stainless steel wires in 884 patients (Group II). The risk factors that were identified between the two groups were age, EuroSCORE, body mass index, diabetes and pulmonary comorbidity. Results: The overall incidence of deep sternal wound complications was 2.2% (25/1119). The incidence was higher in Group II (2.3%) compared to Group I (1.7%) (p = 0�8). Mechanical sternal dehiscence occurred in 2 patients in Group II. Mortality related to sternal wound complications was 8% (2/21) in Group II whereas in Group I was 0%. Conclusion: The incidence of sternal wound complications and the mortality related to them were lower in patients undergoing sternal closure with Nitinol clips. A randomized study to further evaluate the possible advantages of Nitinol clips is warranted.Keywords: wound closure, mediastinal infection, wound infection, wound dehiscence, sternum IntroductionMedian sternotomy is the standard approach in cardiothoracic surgery. Closure of this incision is simple and the method of choice worldwide is the use of standard steel wires placed either parasternally or directly through the bone. Healing complications such as osteomyelitis, mediastinitis, dehiscence, sinuses formation and superficial wound infection may occur and have a significant impact on postoperative recovery. The incidence of deep sternal wound complications (DSWC) after cardiac surgery varies from 0.5% to 5% 1-3� but is associated with a significant mortality in all studies. The surgical management of these complications has evolved over recent decades from closed mediastinal antibiotic irrigation, by Mandelbaum and Schumaker in 1963, to the primary use of pectoralis muscle flaps in 1980, by Jurkiewicz and associates. 3�Today, established treatment protocols include aggressive surgical debridement, the application of vacuumassisted closure (VAC) devices, delayed rewiring or plastic reconstruction with muscle and omental flaps, depending on the severity of infection. Apart from well described inherent patient risks, we believe the technique of primary sternal closure is an important risk factor for the subsequent incidence of dehiscence and wound infection. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips (Praesidia, Bologna, Italy) on the incidence of postoperative DSWC (Fig. 1). Purpose: Deep sternal wound complications after cardiac surgery have an incidence of 2 to 8% and carry a significant mortality. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips on the incidence of postoper...

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Background Myocardial fibrosis occurs in end-stage heart failure secondary to mitral regurgitation (MR), but it is not known whether this is present before onset of symptoms or myocardial dysfunction. This study aimed to characterise myocardial fibrosis in chronic severe primary MR on histology, compare this to tissue characterisation on cardiovascular magnetic resonance (CMR) imaging, and investigate associations with symptoms, left ventricular (LV) function, and exercise capacity. Methods Patients with class I or IIa indications for surgery underwent CMR and cardiopulmonary exercise testing. LV biopsies were taken at surgery and the extent of fibrosis was quantified on histology using collagen volume fraction (CVFmean) compared to autopsy controls without cardiac pathology. Results 120 consecutive patients (64 ± 13 years; 71% male) were recruited; 105 patients underwent MV repair while 15 chose conservative management. LV biopsies were obtained in 86 patients (234 biopsy samples in total). MR patients had more fibrosis compared to 8 autopsy controls (median: 14.6% [interquartile range 7.4–20.3] vs. 3.3% [2.6–6.1], P < 0.001); this difference persisted in the asymptomatic patients (CVFmean 13.6% [6.3–18.8], P < 0.001), but severity of fibrosis was not significantly higher in NYHA II-III symptomatic MR (CVFmean 15.7% [9.9–23.1] (P = 0.083). Fibrosis was patchy across biopsy sites (intraclass correlation 0.23, 95% CI 0.08–0.39, P = 0.001). No significant relationships were identified between CVFmean and CMR tissue characterisation [native T1, extracellular volume (ECV) or late gadolinium enhancement] or measures of LV function [LV ejection fraction (LVEF), global longitudinal strain (GLS)]. Although the range of ECV was small (27.3 ± 3.2%), ECV correlated with multiple measures of LV function (LVEF: Rho = − 0.22, P = 0.029, GLS: Rho = 0.29, P = 0.003), as well as NTproBNP (Rho = 0.54, P < 0.001) and exercise capacity (%PredVO2max: R = − 0.22, P = 0.030). Conclusions Patients with chronic primary MR have increased fibrosis before the onset of symptoms. Due to the patchy nature of fibrosis, CMR derived ECV may be a better marker of global myocardial status. Clinical trial registration Mitral FINDER study; Clinical Trials NCT02355418, Registered 4 February 2015, https://clinicaltrials.gov/ct2/show/NCT02355418