Seven-year follow-up of Perceval sutureless bioprosthesis for aortic valve endocarditis.Antonio Piperata1 MD, Nicolas d’Ostrevy1 MD, Olivier Busuttil1 MD, Mathieu Pernot1 MD.1Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, 33604, FranceCorresponding Author: Antonio Piperata,Avenue Magellan,33600, Pessac, FRPhone: +33 771768872E-mail: [email protected] words: Aortic valve replacement, endocarditis, suturelessWord count :

Preliminary results of single centre experience with the “release and perfuse technique” during aortic arch surgery.Antonio Piperata1 MD; Nicolas d’Ostrevy1 MD; Olivier Busuttil1 MD; Thomas Modine1 MD, PhD; Giulia Lorenzoni2 PhD; Danila Azzolina2PhD; Dario Gregori2 PhD; Louis Labrousse1 MD, PhD; Mathieu Pernot1MD.1Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, 33604, France2Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, ItalyCorresponding Author : Antonio Piperata,Avenue Magellan,33600, Pessac, FRPhone: +33 771768872E-mail: [email protected] words : aortic arch repair; circulatory arrest; frozen elephant trunk, aortic arch, aortic surgery.Acknowledgments: noneData availability statement: Data cannot be shared for ethical/privacy reasons. The data will be shared on reasonable request to the corresponding author.Funding statement and Conflict of interest disclosure: All authors have no conflicts of interest or financial conflicts to disclose. No funding source was provided for this study.

Case reportWe report the case of a 77-year-old man affected by type II diabetes, arterial hypertension, and dyslipidaemia. At age 56 years he underwent cardiac surgery for aortic valve endocarditis due to streptococcus started from a dental abscess. The aortic root replacement was performed, and a 27 mm homograft was implanted. At age 69 years he presented a recurrence of endocarditis on the homograft, causing severe valve regurgitation. At that time the isolated bacterium was an Enterococcus faecalis ,  started from diverticulosis. Despite optimal medical therapy based on gentamicin, ceftriaxone, and vancomycin, he did not improve, and due to worsening clinical conditions, the patient was transferred to our department for surgery.The clinical examination observed a temperature of 38,5°C, dyspnoea at rest, and sinus tachycardia. Transthoracic echocardiography (TTE) revealed a 9 mm vegetation on the homograft with severe aortic valve regurgitation. Urgent surgery was performed; the aortic prosthesis was resected, the infective tissue removed and the Perceval bioprosthesis (Livanova Group S.p.A., Saluggia,Italy) XLwas implanted.The Cross-Clamp time was 35 minutes with a total cardiopulmonary bypass (CPB) time of 73 minutes. The post-operative transesophageal echocardiogram (TEE) showed good results without paravalvular leaks. The ICU stay was 4 days, and the total hospital stay was 19 days. The patient was periodically controlled with regular echocardiographic analysis.At the moment, the patient lives with his wife. He is in good clinical condition, with NYHA functional class I, and no other symptoms are reported. The last TTE shows a mean transprosthesis gradient of 12 mmHg (Fig.1) without paravalvular leaks and normal ejection fraction (57%), no infective or embolic episodes were reported during the 7 years and three months follow-up time.

The heart transplantation (HT) is undoubtedly the best treatment for end-stage heart failure patients (2). However, the organ shortage remains a major challenge in cardiac surgery. Facing this problem, the medical community starts to extend the donor criteria to select more suitable organs for HT. The use of ECDs is still controversial, since it is associated with a high incidence of primary graft failure (3), and although it guarantees longer survival than without transplantation, there is still some hesitation in accepting this practice.

We carefully read the recent paper by Hammond et al. (1) on the use of sutureless bioprosthetic valve for homograft failure in the setting of infective endocarditis (IE). This article is the latest demonstration that new sutureless and rapid deployment (RD) valve prostheses are safe and easy-to-use devices for surgical aortic valve replacement, and indicates their suitability for different scenarios and peculiar surgical situations as infective endocarditis (IE).

Bilateral antegrade selective cerebral perfusion has the undisputed advantage of being more physiological and theoretically ensuring complete perfusion of the whole brain. However, it requires longer execution times and manipulation of the epiaortic vessels. On the other hand, unilateral selective cerebral perfusion (u-ASCP) avoids the vessels manipulation, placement of catheters into the ostia of the great vessels which clutters the operative field and incurs both atherosclerotic and air embolism risk. Neverthless, an ongoing debate about which technique yields the best clinical outcomes is still open.

ABSTRACT Heart transplantation is the gold standard treatment for patients with end-stage heart failure. The limited availability of organs has led to the expansion of the donor criteria by introducing the use of marginal donors. Although the use of marginal donors has reduced waiting lists, the results are worse than with standard donors. For this reason, the use of marginal donors in clinical practice is still controversial. We describe two cases of heart transplantation from marginal donors with pre-transplant angiography evidence of coronary stenosis and normal ventricular function.

We are very thankful to Dr. Vendramin et al. (1) for their interest in our article about the “off label” use of new cardiac prosthetic valves in different clinical scenarios, and for their thoughtful comments.

We describe two cases of favorable and unexpected recovery in positive patients with COVID-19, suffering from multiorgan comorbidity and already assisted with the left ventricular assist device. We have observed that, although in the presence of more comorbidities, when the maintenance of a valid support of the cardiovascular function is guaranteed, the possibility of successfully overcoming the SARS-CoV-2 infection is still alive.

We describe the case of a 59-year old female affected by aortic extensive endocarditis with communication between aortic annulus and right cavities, treated with double pericardial patch reconstruction and rapid-deployment aortic valve prosthesis implantation.