Intravenous central line catheters are often at risk of line-related thrombosis. We report on how the cardiopulmonary bypass strategy was tailored to the particular anatomical challenges with the use of an unconventional venous cannulation site to optimise intraoperative venous drainage, improve surgical exposure and avoid circulatory arrest in a case with a complex intracardiac thrombosis. This report also highlights the importance of assiduously monitoring the efficacy of anticoagulation therapy, especially in the context of small bowel syndrome.

Objective - The aim was to evaluate early and long-term outcomes of re-sternotomy for aortic valve replacement with previous patent coronary artery grafts. Methods - Data for re-sternotomy for aortic valve replacements (group 1 isolated AVR, group 2 AVR with concomitant procedure) were collected (2000-19). Logistic regression analysis was performed to identify predictors of in-hospital mortality and postoperative composite outcome (in-hospital death, TIA/stroke, renal failure requiring new hemofiltration, deep sternal wound infection, re-exploration for bleeding/tamponade and length of stay >30 days). Survival curves were compared using log rank test. Cox proportion hazards model was used for predictors of long term survival. Results – Total 178 patients were included (groups 1 - 90 patients, group 2 - 88 patients). Mean age was 75±4 years and mean log EuroSCORE was 17±12% (15 ± 8% - group 1 vs 19 ± 14% - group 2, p=0.06). Mean follow up was 6.3±4.4 years. Cardiovascular injury occurred in 12%. LIMA was most commonly injured. In-hospital mortality was 7.8% (5% - group 1 versus 10.2% - group 2, p=0.247). NYHA class III-IV, perioperative IABP and cardiovascular injury were independent predictors of in-hospital mortality (HR; 13.33, 95% CI; 2.04, 83.33, p=0.007). Survival was significantly worse with cardio-vascular injury at re-sternotomy up to 5 years (46% versus 67%, p=0.025) and postoperative complications (p=0.023). Survival was significantly lower than age matched first time AVR and UK population. Conclusions – Long term survival is significantly impaired by cardiovascular injury and perioperative complications of re-sternotomy.

Background The Infection of aortic valve graft conduit is still burdened by notable morbidity and mortality. Medical and surgical strategies play a crucial role in patient outcome and vary depending on infection extend into adjacent cardiac structures, systemic spread and micro-organism involved. Methods In this retrospective study, we report our experience in the management of thirty consecutive patients admitted to our centre with composite aortic valve graft infection during the period 2008-2018. We review the early and mid-term outcomes of patients who underwent a reoperation or received a conservative medical treatment. Results Twenty patients underwent redo surgery with an early mortality of 10% and a survival of 83% at 7-year follow-up. Ten patients were treated medically and experienced an early mortality of 30% and a mid-term survival of 33%. Conclusion A surgical reoperation, despite a non-negligible perioperative risk, is the only radical treatment able to provide a good survival also in patients with complicated infective endocarditis.

Abstract Objectives: The use of minimally invasive or transcatheter interventions rather than standard full sternotomy operations to treat Tricuspid valve disease is increasing. Debate however is still open regarding venous drainage management during cardiopulmonary bypass and wheatear or not superior and inferior vena cava should be occluded during opening of the right atrium to avoid air entrance in the venous line. The aim of the present study is to report operative outcomes and mid-term follow-up results of minimally invasive tricuspid valve surgery performed without caval occlusion. Methods: This is a retrospective outcome evaluation from institutional records with prospective data entry. We searched for all the patients who underwent right mini-thoracotomy tricuspid valve surgery isolated or combined with mitral valve surgery during the period June 2013 – February 2020. Results: During the study period 68 consecutive patients underwent minimally invasive tricuspid valve surgery without occlusion of cava veins. Survival at a 5-year and 8-year follow up was 100% and 79%, respectively. At follow-up no patient had an NHYA class greater than two, only one patient was re-hospitalized for heart failure for an atrial fibrillation episode. One patient was hospitalized for a pericardiocentesis twenty days after discharge No severe tricuspid regurgitation was evident at echocardiographic follow up. Five patients had 2+ TR. Conclusion Our results show that performing tricuspid surgery without caval occlusion is safe. There is no clinical evidence of gas embolism. Mid-term follow up data confirm that minimally invasive approach does not alter the quality of surgery.

Introduction - The impact of manufacturer labelled prosthesis size and predicted effective orifice area (EOA) on long term survival after aortic valve replacement is not clear although indexed effective orifice area (iEOA) has been associated with worse survival. Methods - Data was retrospectively collected from Jan 2000 – Dec 2019 for prosthesis type, model and size for isolated aortic valve replacements. Stratified survival was compared between groups and subgroups for labelled valve size, EOA and predicted PPM. Results – Total of 3444 patients were included. Moderate and severe PPM was 15.6% and 1.6% respectively. Cumulative life time hazard was worse for biological valves (mortality: biological 77.7% vs mechanical 64.8%, p=0.001). Mean survival was 132.7 months for biological versus 191.3 months for mechanical valves (p=0.001). Moderate prosthetic AS (EOA = 1-1.5 cm2) was12.1% and severe prosthetic AS (EOA≤1 cm2) was 0.8% respectively. Worse survival in the presence of moderate-severe prosthetic AS was seen in biological valves (115.2 months versus 133.7 months, p=0.001 for EOA≤1.5cm2 and >1.5cm2 respectively). There was a statistically significant correlation between survival and iEOA (Spearman’s rho=0.084, p=0.001, BCa bootstrap 95% CI;0.050, 0.120). Moderate to severe PPM (iEOA≤0.85cm2/m2) was a predictor of worse long term survival (HR 3.56; 95% CI: 1.37 - 9.25; p=0.009). Conclusion - Predicted prosthetic moderate to severe AS and moderate to severe PPM adversely affect long term survival. Smaller valves are associated with reduced survival in all groups.