Our results indicate that ECG-gated CT has comparable diagnostic performance to TEE and may be a valuable complement in the preoperative evaluation of patients with aortic PVE.

No abstract

Different minimally invasive approaches have been proposed for cardiac surgery. Between those, the ministernotomy finds wide consensus for the treatment of the aortic disease, being both the upper reversed T and the upper J the mostly used type of incisions. The authors review the literature on the use of ministernotomy in the treatment of the ascending aorta and arch pathology. The scientific literature was reviewed by searching Medline, the Cochrane Library and the CINAHL database. A total of 1411 papers were found in Medline, 186 in the Cochrane database and 514 in CINAHL database; 50 papers were used to write the article; of which seven represent the most significant papers on the subject. The authors, journal, date and country of publication, patients group studied, relevant outcomes, and the results of these papers are tabulated. The ministernotomy is gaining consensus among surgeons. The indication to surgery, initially restricted only to selected elective patients, is now extended to more complex surgeries, including both the aortic root and aortic arch, redo-operations and, in minor cases, to emergency patients. Furthermore, the use of ministernotomy in redo aortic surgery with patent left internal mammary artery (LIMA) to left anterior descending (LAD) artery is a promising alternative. However, the use of this technique is still limited to few institutions and there are still a limited number of studies comparing this approach to full sternotomy in a prospective, randomized fashion. Even with those limitations, from the review of the literature, it seems that ministernotomy approach for aortic root and ascending aorta surgery is a feasible alternative, showing some advantages compared to full sternotomy. Those advantages include: reduced postoperative bleeding and pain, lower risk of mediastinitis, better aesthetic results, and faster respiratory function recovery. This is true not only for first time surgery, but also, and especially, for redo cases, where the limited exposure will reduce risks correlated to the surgical dissection of redo surgery. The ministernotomy approach for aortic root and ascending aorta surgery could in the future be more extensively used, offering greater benefits to cardiac surgical patients.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In patients with sewing needle cardiac injuries is the surgical approach the recommended treatment?' The scientific literature was reviewed by searching Medline, using Ovid interface, from 1950 to August 2009. Six hundred and twenty-six papers were found, of which 24 were deemed relevant to this topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The cause of injury may delay the timing of presentation the diagnosis and consequently the therapeutic strategy. In nearly all the cases in the reviewed papers the authors surgically removed the needle from the heart. However, out of the 24 papers, four patients had a conservative treatment. Most of the authors recommend early removal of the needle to prevent migration and further anatomical damage. The early surgical removal of foreign bodies in the heart is considered an effective approach to prevent complications. The heart is more vulnerable to serious injuries when the foreign body is extracardiac than when the foreign body is completely intracardiac. The unceasing motion of the heart against the sharp point of the fixed foreign body will result in repetitive wounding with bleeding and consequent cardiac tamponade. Due to the tendency of the needle to migrate, the preoperative use of computer tomography scan, trans-thoracic and trans-oesophageal echocardiography have been advocated to locate the exact position of the needle and its correlation with the surrounding tissues. The intraoperative use of epicardial ultrasound or fluoroscopy is also recommended. However, in cases of late diagnosis, in previously untreated patients, treatment can be individualized. If the symptoms are less severe it is reasonable to adopt a conservative approach as with time most foreign bodies become safely encysted and do no harm. Patients can remain asymptomatic for many years. However, they may present many years later with complications such as pericarditis, tamponade or endocarditis. Strict follow-up is useful in those patients.

Acute aortic dissection an extremely severe condition having a high risk of mortality. The classic symptom may mimic other conditions such as myocardial ischemia, leading to misdiagnosis. Coronary malperfusion associated with aortic dissection is relatively rare, but when it occurs, it may have a fatal result for the patient. The diagnosis of acute coronary syndrome may lead to the inappropriate administration of thrombolytic or anticoagulant treatment resulting in catastrophic consequences. Emergency imaging techniques help to guide the correct diagnosis. Transthoracic echocardiography is useful as a first imaging test, and may be followed by transesophageal echocardiography, or other imaging techniques. Surgery represents the treatment for these patients. However, with the aim to stabilize the patient and to reduce myocardial damage, initial preoperative endovascular coronary intervention has been reported.

Aortic PVE is associated with a high rate of early complications and substantial early mortality. Patients who survive the immediate postoperative period have satisfactory long-term survival. The risk of recurrent endocarditis is low, especially in patients treated with homografts. The results have improved during the past decade.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with severe active aortic valve endocarditis, is a stentless valve as good as a homograft?' The scientific literature was reviewed by searching Medline, using the OVID interface, from 1950 to March 2010. One hundred and eight papers were found. Twelve papers were used in the writing of the article, of which 10 were deemed relevant to the topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. In the homograft series, literature review reports a reinfection rate from 3.8% to 6.8%. Yankah, in studying 161 patients with endocarditis, reports 91% freedom from reinfection at 10 and 17 years and 70% survival at 17-year follow-up. Sabik, in studying 103 consecutive patients with prosthetic endocarditis, reports a 3.8% reinfection rate and 95% freedom from reinfection at 10 years, with 56% survival at 10 year. In the stentless series: Musci, in studying 255 patients with endocarditis, reports a 8.6% reinfection rate, 83% freedom from reinfection at five years and 46% five-year survival. He finds a non-significant difference between survival and freedom from reinfection in patients with native valve endocarditis compared to those with prosthetic valve endocarditis (PVE) (P=0.1371 and P=0.8356). The same author, in 221 patients treated with a homograft, reports a 5.4% reinfection rate and 10-year freedom from reoperation, with a reinfection rate in native and PVE of 92%. Ten-year survival was better in native than in PVE (P=0.029). Siniawski, comparing two groups of patients treated with stentless valves and homografts, finds an equal reinfection rate of 4% and lower mortality for the stentless group (12% vs. 16%, respectively). He finds the reinfection rate to be lower for the homograft and stentless groups than for the patients treated with standard prostheses, respectively, 5.8%, 3.7% and 33%. The stentless valve offers a reinfection rate and postoperative echocardiographic data comparable to those achieved with homografts. Further follow-up is required to determine the stentless valve durability and long-term freedom from valve-related complications.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing surgical repair of post-infarction ventricular septal defect (VSD), does concomitant revascularization improve prognosis?'. The scientific literature was reviewed by searching Medline, using Ovid interface, from 1950 to April 2009. Four hundred and five papers were found, of which 18 were deemed relevant to the topics. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. Seven out of 18 papers showed statistical evidence of benefit of concomitant coronary artery bypass grafting (CABG) in patients undergoing surgical repair of VSD. They showed a benefit especially with complete revascularization. Another five papers recommended CABG with VSD even in the absence of statistical evidence. The reported papers showed a mortality benefit from 26.3% without revascularization down to 21.2% with revascularization and an actuarial survival at five years from 29 up to 72%. However, six out of 18 papers did not find any difference. The largest study in this area was by Jeppsson et al. where 119 patients underwent VSD repair with revascularization and 70 underwent VSD repair only, the mortality was 38% vs. 46% (P=0.29). Barker et al. compared a group of 23 patients undergoing repair of VSD only and 42 patients undergoing concomitant CABG. The in-hospital mortality was 39.2% vs. 26.2%, and the four-year survival rate was 33.2% and 88.2%, respectively. Lundblad et al. found that in 66 patients undergoing concomitant CABG out of 102 undergoing repair of VSD, complete revascularization and revascularization of the culprit artery, both resulted in improved 30-day survival and long-term survival. Muehrcke et al. reported on 75 patients undergoing surgical repair of post-infarction VSD. Out of those, 33 (44%) had a concomitant CABG. The authors found that concomitant CABG increases long-term survival when compared with patients with unbypassed coronary artery disease (CAD) (P=0.0015). We conclude that patients undergoing concomitant CABG to all the stenotic coronary arteries, supplying the non-infarcted area, fare better both in improved 30-day survival and long-term survival. The improvement of the collateral flow to the myocardium contributes to its better recovery.