Cardiac Vascular Hamartoma: Adult Diagnosis and Cardiac Reconstruction.

Cardiac hamartoma is a rare benign tumor of the heart, and the vascular type is an extremely rare histologic diagnosis. A small number of cases have previously been described in childhood. We report the case of a 63-year-old woman with an incidentally detected cardiac mass that was finally diagnosed as vascular hamartoma. Approval for publication was obtained from the patient.

Percutaneous treatment of a aorto-caval fistula in a old high risk patient.

BACKGROUND: To remark the feasibility of endovascular treatment of an aorto-caval fistula in a old high risk patient with "hostile" abdomen for previous surgeries. METHODS: In September 2009 a 81-years-old patient was admitted in emergency at our department because of abdominal pain and massive oedema of the lower extremities associated to dyspnoea (New York Heart Association (NYHA) functional class III). A CT scan showed an aorto-caval fistula involving the abdominal aorta below the renal arteries. This abnormal communication was likely due to the previous abdominal surgeries, was complicated by occlusion of the inferior vena cava at the diaphragm and was responsible for the massive oedema of the lower extremities. Because of unstable conditions and hostile abdomen the patient was considered unfit for conventional surgery and an endovascular approach was planned. After unsuccessful attempt by positioning of an Amplatzer vascular ring into the fistula, a Medtronic covered stent-grafts were implanted from the renal arteries to the both common iliac arteries. The patient had an impressive improvement characterized by a 18 Kg weight loss and a complete restoration of the functional capacity (from NYHA class III to NYHA class I) associated to a complete resolution of the lower extremities oedema as confirmed at the a month-CT-scan. CONCLUSION: Endovascular surgery of aorto-caval fistula represents a good option in alternative to conventional surgery mostly in old high risk patient.

Treatment of a rapidly expanding thoracoabdominal aortic aneurysm after endovascular repair of descending thoracic aortic aneurysm in an old patient.

BACKGROUND: Aortic pathology progression and/or procedure related complications following endovascular repair should always be considered mostly in older patients. We herein describe a hybrid procedure for treatment of rapidly expanding thoracoabdominal aneurysm following endovascular treatment of a descending thoracic aortic aneurysm in an older patient. CASE PRESENTATION: A 82-year-old man at 18 months after endovascular surgery for a contained rupture of descending thoracic aortic aneurysm revealed a type IV thoracoabdominal aneurysm with significant increase of the aortic diameters at superior mesenteric and renal artery levels. A hybrid approach consisting of preventive visceral vessel revascularization and endovascular repair of entire abdominal aorta was performed. Under general anaesthesia and by xyphopubic laparotomy, the infrarenal aneurysmatic aorta and common iliac arteries were replaced by a bifurcated woven prosthetic graf. From each of the prosthetic branches two reverse 14 x 7 mm bifurcated PTFE prosthetic grafts were anastomized to both renal arteries and to the celiac axis and superior mesenteric artery, respectively. Vessel ischemia was restricted to the time required for anastomosis. Three 10 cm Gore endovascular stent-grafts for a total length of 15 cm, were used. The overlapping of the stent-grafts was carried out from the bottom upwards, starting from the aorto-iliac prosthetic body up to the healthy segment of thoracic aorta, 40 mm from the previous stent-grafts.The patient was discharged on the 9th postoperative day. CONCLUSION: This technique offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications, mostly in older patients.

Clinical Validation of a Coronary Surgery Technique That Minimizes Aortic Manipulation.

BACKGROUND: To minimize aortic manipulation and maximize use of arterial conduits are aims of modern coronary surgery. METHODS: From March 2012 to October 2016, 890 consecutive patients with multivessel coronary disease underwent isolated coronary operations using both internal thoracic arteries (ITAs). In 205 (23%; mean age, 67.6 ± 9.2 years), the right ITA was proximally transected and used as a free graft, while its in situ stump was elongated with a saphenous vein graft. The new arteriovenous I conduit was directed to the inferolateral cardiac wall. Operative data and early outcomes of these patients (I group) were compared with the remaining 685 patients (control [C] group). Early and late outcomes were also compared in 184 pairs identified with propensity score matching. RESULTS: Between the I and C groups there was no significant difference in expected operative risk (European System for Cardiac Operative Risk Evaluation II, p = 0.28), although diseased ascending aorta (p < 0.0001) and critical preoperative state (p = 0.027) were more frequent in the I group. Despite a higher number of coronary anastomoses (mean, 4 ± 0.9 vs 3.7 ± 1, p < 0.0001), cardiopulmonary bypass time was shorter in the I group both in overall (86.7 ± 23.7 vs 105.7 ± 34.2 minutes, p < 0.0001) and matched series (86.8 ± 24.1 vs 108.8 ± 31.9 minutes, p < 0.0001). In-hospital mortality (1% vs 1.9%, p = 0.54) and the rates of postoperative complications were similar. During the follow-up period, no intergroup difference was found in matched patients in the nonparametric estimates of freedom from all-cause death (p = 0.39) and major adverse cardiac and cerebrovascular events (p = 0.44). CONCLUSIONS: Surgery using this arteriovenous I conduit is safe, minimizes aortic manipulation, shortens cardiopulmonary bypass time, and aids complete revascularization.

[Peripheral embolization and rapid growth of papillary fibroelastoma in a young woman]. / Embolizzazione periferica e rapida ricrescita di fibroelastoma papillare in una giovane donna.

Papillary fibroelastoma, a benign cardiac tumor, is a rare clinical condition. Before the echocardiography era, the diagnosis was often occasional, especially during other cardiac procedures; but nowadays it has improved with the advent of higher-resolution imaging technology. The clinical presentation can vary from asymptomatic to severe complications such as cerebrovascular or ischemic events due to tumor embolization.We present the case of a 33-year-old female with a papillary fibroelastoma on the anterior leaflet of the mitral valve undergoing clinical examination for claudicatio intermittens. An occlusion of the left common femoral artery was present. The diagnosis was made posteriorly after embolectomy. All cardiac imaging investigations were negative. The heart team decided a strict echocardiographic follow-up every 3 months, and after the first visit a pedunculated mass was detected on the anterior mitral leaflet. The surgical management included urgent resection of the tumor on cardiopulmonary bypass using a minimally invasive approach via a right anterior minithoracotomy. The postoperative course was uneventful. We emphasize the need for surgical treatment given the potential risk of relapse. When no mass is detected on imaging, a strict echocardiographic follow-up and antiplatelet therapy are mandatory.

Smoking cessation before coronary artery bypass grafting improves operative outcomes.

BACKGROUND: The detrimental effect of active smoking on operative outcome after coronary artery bypass grafting (CABG) is still debated and smoking cessation programs are usually deferred until after surgery. The potential benefit from smoking cessation on postoperative outcomes is investigated in this study. METHODS: A retrospective analysis on a large cohort of patients who underwent CABG at a single institution was performed. Generalized boosted regression modeling was used to estimate the multinominal propensity scores for smoking status categories and the average treatment effect on the treated was calculated for all outcomes of interest. RESULTS: A total of 6113 patients who underwent isolated CABG for the first time were included. At baseline, there were 640 (10.4%) current smokers, 3309 (54.1%) ex-smokers, and 2164 (35.3%) nonsmokers. Multilevel propensity score weighted analysis showed a beneficial effect of smoking cessation compared with current smoking, which increased the risk for all major pulmonary complications (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.13-2.10; P = .006), including reintubation (OR, 1.95; 95% CI, 1.17-3.25; P = .01), full tracheostomy (OR, 3.04; 95% CI, 1.49-6.18; P = .002), lung infection/consolidation (OR, 1.44; 95% CI, 1.02-2.02; P = .03). Although smoking cessation did not significantly improve other outcomes, it was associated with a nonsignificant trend toward a decreased risk for in-hospital mortality (OR, 1.83; 95% CI, 0.85-3.91; P = .1). CONCLUSIONS: This study showed that smoking cessation before CABG reduced the risk of serious pulmonary complications. The present findings indicate that embarking on a smoking cessation program should not be deferred until after surgery.

[Medical-legal issues in remote monitoring of implantable cardioverter-defibrillators]. / Aspetti medico-legali del controllo remoto dei defibrillatori impiantabili.

Patients with implanted automatic defibrillators should undergo careful monitoring during follow-up and may require access to the emergency department or hospitalization for device-related problems. Nowadays, the progressive development of information technology allows remote monitoring of patients with cardiac defibrillators using dedicated systems which make it possible to transfer clinical and technical data derived from device interrogation to the Cardiology Center through telephonic line. In patients with an implantable defibrillator, remote monitoring is effective in identifying device malfunctioning and clinical problems, such as heart failure, to an extent similar to traditional ambulatory monitoring, while allowing significant advantages for the patient quality of life and savings in resource management. This different way of organizing care has created new problems in terms of responsibility for manufacturers, responsible for the technical aspect, for the healthcare system, responsible for service supply and management, and for the physician, who should supervise the whole process and ensure the safety of the information provided. Telemedicine is configured as a highly complex activity and therefore any treatment provided through it will, in terms of responsibility, be assessed bearing in mind that "if performance involves the solution of technical problems of special difficulty, lenders are not liable for damages, except in cases of intent or gross negligence". Also important are minor legal issues, such as permissions, problems of inaccessibility to the service, the assessment of medical liability compared to the activity of the team, and all issues related to informed consent and privacy protection.