Federico Giorgi

Management of the left subclavian artery (LSA) during aortic arch surgery is complex due to its deep anatomical location and potential pathological alterations, posing risks such as stroke, spinal cord injury, and recurrent laryngeal nerve damage. Revascularization of the LSA is critical in various clinical scenarios to maintain adequate perfusion to the vertebral arteries, spinal cord, and upper limb, especially in patients with anatomical variations, prior bypass surgeries, or increased risk of ischemia. Coverage of the LSA during thoracic endovascular repair (TEVAR) without revascularization significantly increases stroke and spinal cord ischemia rates. We provided a narrative review, evaluating contemporary open and endovascular options for the treatment of the aortic arch, and consequently of the LSA. Frozen elephant trunk (FET), endovascular strategies (branched and fenestrated TEVAR), but also emerging hybrid devices, are all valuable treatments with respective strengths and limitations to be understood to obtain the best patient-prosthesis match. Individualized treatment selection based on pathology, urgency, and patient factors is essential to optimize outcomes. This evolving paradigm integrates open and endovascular techniques to enhance patient care in complex aortic arch disease.

Background: Surgical correction of severe degenerative Mitral Regurgitation (DMR) is indicated in the presence of symptoms and signs of left ventricular (LV) dysfunction. However, conventional clinical and resting echocardiographic parameters may underestimate myocardial impairment. Cardiopulmonary exercise testing (CPET) and exercise stress echocardiography (ESE) may provide a more complete functional and haemodynamic assessment. Objectives: To characterize preoperative CPET and ESE findings in patients with severe DMR and to explore, in a hypothesis-generating analysis, their association with early functional and left ventricular outcomes after surgery. Methods: We included patients with severe DMR who underwent CPET and ESE before surgery. Functional improvement was defined as an improvement of at least one NYHA class from the preoperative baseline to early follow-up. LV function was evaluated as the continuous change in LVEF from discharge to early follow-up (Delta LVEF = follow-up LVEF − discharge LVEF). Baseline parameters were compared between patients who did and did not improve functionally. Random forest analyses were used only as an exploratory secondary analysis to assess whether baseline variables showed any non-linear signal of association with the outcomes and to document the instability of variable-importance rankings. Results and Conclusions: We included 60 patients, of whom 72% were in NYHA class II and all had preserved LV function. At CPET, rest and peak oxygen uptake were 6 +/− 1.5 and 17.2 +/− 5 mL/kg/min, respectively; the VE/VCO₂ slope was 33 +/− 8.9 and the Oxygen Uptake Efficiency Slope was 1.6 (1.3–1.9). At ESE, LVOT-VTI increased from 18.3 +/− 3.9 cm at rest to 24.5 +/− 4.9 cm at peak; stroke volume from 51.0 (43.0–60.0) mL to 72.5 +/− 21.6 mL; and cardiac output from 3.8 (3.2–5.1) L/min to 9.0 +/− 3.2 L/min. No baseline clinical, CPET or ESE parameter significantly distinguished patients who improved functionally from those who did not, and early Delta LVEF was negligible. Random forest analyses did not discriminate above chance and variable-importance rankings were unstable. Patients with severe DMR and preserved LVEF showed objectively abnormal exercise responses despite mild symptoms, supporting the use of CPET and ESE for preoperative functional and haemodynamic characterization; larger prospective studies are required before any predictive or decision-support use can be proposed.

Objective: Robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) is a proven alternative to conventional off-pump sternotomy for revascularizing the left anterior descending artery (LAD) in low-risk patients. However, its role in higher-risk candidates remains poorly established. This study compares RA-MIDCAB with off-pump CABG (OPCAB) in intermediate/high-risk patients with moderately reduced left ventricular ejection fraction (LVEF). Methods: We retrospectively analyzed all consecutive high/intermediate-risk patients with depressed LVEF who underwent left internal mammary artery to LAD RA-MIDCAB or OPCAB at our center between January 2021 and August 2025. The primary outcome, assessed at discharge and follow-up, was a composite of all-cause mortality, stroke, and repeat revascularization. Secondary outcomes included ICU stay, red blood cells (RBC) transfusion volume, oro-tracheal intubation time, and acute kidney injury. Kaplan–Meier curves estimated the cumulative freedom from the primary outcome. Restricted mean survival time (RMST) at 1 year was calculated, with non-inferiority confirmed if the lower bound of the 95% CI exceeded − 8 days. A generalized linear model adjusted for confounders. Results: Seventy-two patients were included: 20 RA-MIDCAB and 52 OPCAB. EuroSCORE was 3.8 ± 1.9 and 3.5 ± 2.4 in RA-MIDCAB and OPCAB, respectively (p = 0.384), while mean LVEF was 40 ± 13 and 45 ± 9, respectively (p = 0.454). Other variables were comparable; however, RA-MIDCAB patients had higher rates of prior myocardial infarction (MI) (45% vs. 11.5%; p = 0.003) and PCI (40% vs. 13.4%; p = 0.022). Procedural time was longer for RA-MIDCAB (196 ± 66 vs. 182 ± 66 min; p = 0.048). Thirty-day mortality was comparable (0% RA-MIDCAB, 3.8% OPCAB; p = 0.374), while ICU stay and intubation time were shorter in the RA-MIDCAB group. Fewer RA-MIDCAB patients required >5 RBC units. At one year, freedom from the primary outcome was 95% vs. 83.6% (p = 0.2), with RMST favoring RA-MIDCAB by 34.6 days (p = 0.0067), meeting the non-inferiority threshold. Results remained consistent after adjustment. Conclusions: RA-MIDCAB is noninferior to OPCAB in intermediate- to high-risk patients with moderately depressed LVEF, offering a valuable alternative to conventional surgical revascularization. These findings need further confirm through the analysis of larger datasets and longer follow-up.

Introduction: Due to the selective criteria and short-term follow-up of previous transcatheter aortic valve implantation (TAVI) trials, the coronary revascularization incidence after TAVI has been difficult to determine. This study investigated the epidemiology of coronary revascularization after surgical aortic valve replacement (SAVR) and TAVI in patients with severe aortic valve stenosis (AS), with and without coronary artery disease (CAD), in a mid-term follow-up, single-center, real-world setting. Methods: Between 2010 to 2020, 1486 patients with AS underwent SAVR or TAVI with balloon-expandable Edwards^® transcatheter heart valves (THVs). Using hospital discharge records, we could estimate for each patient resident in Emilia Romagna the rate of ischemic events treated with percutaneous coronary intervention (PCI). A subgroup without CAD was also analyzed. Results: The 5-year overall survival was 78.2%. Freedom from PCI after AVR and TAVI at 5 years was 96.9% and 96.9%, respectively, with previous PCI as a predictor (HR 4.86, 95% CI 2.57–9.21 p < 0.001). The freedom from PCI curves were not significantly different. Conclusions: Notwithstanding the aged population, the revascularization incidence was only 2.4%, requiring further evaluation even in younger patients with longer follow-up. Despite the profile frame raise due to the evolution of Edwards^® balloon-expandable THVs, PCI or coronarography feasibility were not compromised in our population.