Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair.

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.

When 3D echocardiography truly makes the difference: a case report of mitral annular ring dehiscence.

Real time 3D echocardiography has an established incremental diagnostic value over 2D imaging, especially during transesophageal evaluation of native and prosthetic heart valves. A 66 years old male patient, with an history of previous cardiac surgery for mitral annuloplasty and recurrent fever, came to the attention of our echo lab with an indication for transesophageal echocardiography after previous inconclusive transthoracic echocardiograms. Real time 3D echocardiography and 3D color doppler imaging resulted of outmost importance to clarify the presence of annular ring dehiscence, previously not well defined from 2D echocardiography imaging.

Left ventricular free-wall rupture, a potentially lethal mechanical complication of coronaric angioplasty : an unusual case report.

The incidence of complications of coronary perforation varied significantly among studies probably due to population heterogeneity and interventional techniques applied in each centre. Free wall rupture, cardiac tamponade and miocardial infarction are the most  feared. The treatment of perforation remains a challenge of every cath- lab team. The management strategies range from observation to urgent operation depending on patient's hemodynamic status, severity and location of the perforation, coronary anatomy, interventional practice and equipment in each centre and operators' skills on-site. In this case an extracorporeal circulation and cardioplegic arrest with anterograde hot blood cardioplegia was done. A composite Dacron with autologous pericardium patch was used for left ventricular free wall rupture repair and the geometry of the left ventricle was restored. Subsequently aorta was declamped; the patient was weaned from CEC and a good spontaneous hemodynamic was recovered.

Everything in the "right" place: multifocal transient ST segment elevation in patient with single coronary artery arising from the right Valsalva sinus.

Single coronary artery (SCA) is a rare coronary anomaly that occurs with an incidence of 0.024%. We report the case of an 83-year-old woman with a Lipton's type 3 SCA, which is the rarest anomaly within this group, occurring only in the 0.004% of general population.  The clinical presentation of this patient was chest pain at rest with multifocal transient ST segment elevation as a marker of multifocal ischemia secondary to severe three vessels coronary artery disease (CAD). This patient was proposed for coronary artery bypass grafting (CABG) with an excellent mid-term outcome.

Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience.

OBJECTIVES: Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury. METHODS: We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods. RESULTS: Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively. CONCLUSIONS: Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.

Primary Endovascular Repair of the Ascending Aorta.

Different case series have been published demonstrating the feasibility of endovascular repair of the ascending aorta in selected patients deemed unfit for open surgery. However, the use of commercially available stent graft in the ascending aorta remains off-label, and their excessive length often prevents their deployment in the ascending aorta. Here we report a case of successful primary endovascular repair of the ascending aorta using a physician modified off-the-shelf device.

The use of RemoweLL oxygenator-integrated device in the prevention of the complications related to aortic valve surgery in the elderly patient: Preliminary results.

Background The effects of fat microembolization due to cardiopulmonary bypass are well known in cardiac surgery. Our aim is to evaluate the use of the RemoweLL device (Eurosets, Medolla, Italy) during elective aortic valve replacement in elderly patients (>70 years old) to rate its biochemical and clinical effects. The RemoweLL device is an oxygenator-integrated reservoir which combines two strategies for fat emboli and leucocytes removal: filtration and supernatant elimination. Methods Forty-four elderly patients were enrolled and assigned randomly to a Group A (standard device) and a Group B (RemoweLL). Biochemical effects were evaluated by blood samples, which were tested for white blood cells, neutrophils, protein SP-100 and interleukin 6 besides standard lab tests. Our clinical endpoints were any type of neurological, cardiac, respiratory, gastrointestinal or renal complications, and length of stay in the intensive care unit. Statistical analysis was carried out with chi square test for non-parametric data; t test and analysis of variance for repeated measures were used for parametric data. Results Group B showed lower levels of white blood cells, neutrophils, interleukin 6 and protein SP-100 immediately and 24 hours after the operation. Group B also showed a lower amount of neurocognitive type II dysfunction even if the length of stay in the ICU did not change. Conclusions The RemoweLL system is safe and effective in reducing inflammatory response to cardiopulmonary bypass and it could be a useful tool in minimizing negative effects of cardiopulmonary bypass; however, it does not seem to have any effect on elderly patients' hospital stay.

Thoracic Endovascular Aortic Repair Through Cardiac Apex in the Setting of Thoracic Aortic Rupture.

Treatment of thoracic aortic rupture poses a substantial challenge for the aortic surgeon. The advent of thoracic endovascular aortic repair (TEVAR) revolutionized the treatment of this heterogeneous group of diseases. Some patients suitable for TEVAR, however, present severe peripheral vascular diseases that can prevent standard retrograde delivery of the stent graft through the femoral artery. In this report, we present a case series of 5 patients with thoracic aortic rupture successfully treated with cardiac transapical TEVAR.

Transapical access for thoracic endovascular aortic repair to elephant trunk completion.

The 2-stage elephant trunk procedure is widely used to treat extensive disease of the aortic arch and descending thoracic aorta. The 2nd stage of the procedure can be accomplished with both a standard surgical procedure and a retrograde transfemoral endovascular approach using the dangling graft as proximal landing zone. However, in some patients, severe disease of iliofemoral vessels can prevent standard retrograde thoracic endovascular aortic repair (TEVAR). In such cases, an alternative route to gain endovascular access must be used. Herein, we report a case of anterograde cardiac transapical approach for TEVAR as a 2nd stage of an elephant trunk procedure.

The rise of new technologies for aortic valve stenosis: A comparison of sutureless and transcatheter aortic valve implantation.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) and sutureless aortic valve replacement (SU-AVR) are suitable alternatives to conventional surgery. The aim of this study is to compare early outcomes of patients undergoing TAVI and SU-AVR. METHODS: Data were analyzed on patients who underwent TAVI and patients who underwent SU-AVR. Two matched cohorts (TAVI vs SU-AVR) were created using propensity scores; all analyses were repeated for transapical TAVI and transfemoral TAVI, separately. Outcomes were defined according to Valve Academic Research Consortium-2 criteria. RESULTS: A total of 2177 patients were included in the analysis: 1885 (86.6%) treated with TAVI; 292 (13.4%) treated with SU-AVR. Mortality in unmatched TAVI and SU-AVR patients was 7.1% and 2.1%, respectively, at 30 days, and 12.9% and 4.6%, respectively, at 1 year. No differences were found in 30-day mortality in the 214 matched patient pairs (3.7% vs 2.3%; P = .4), but patients treated with TAVI showed a lower incidence of device success (85.9% vs 98.6%; P < .001) and pacemaker implantation (2.8% vs 9.4%; P = .005), and a higher incidence of any paravalvular leakage (PVL). CONCLUSIONS: SU-AVR is associated with better device success and a lower incidence of PVL, compared with TAVI. Nevertheless, patients treated with SU-AVR were more likely to receive a permanent pacemaker. SU-AVR and TAVI provide good results in patients who have severe symptomatic aortic valve stenosis. Given the multiple therapeutic options available, patients may receive the treatment that is most appropriate for their clinical and anatomical characteristics.

Aortic valve regurgitation secondary to ectopia and atresia of the left main coronary artery.

Congenital atresia of the LMCA is an extremely rare anomaly which is often clinically complicated by silent angina, myocardial infarction, failure to thrive, or sudden cardiac death. Moreover, the atretic and ectopic origin of the LMCA associated with aortic valve anomalies is an even rarer condition. Herein, the case is described of a patient with a very rare association between the ectopic and atretic left main coronary artery (LMCA) and severe aortic valve regurgitation.

Coronary artery surgery in octogenarians: evolving strategies for the improvement in early and late results.

The purpose of this study was to investigate retrospectively early and late outcomes of coronary artery bypass grafting (CABG) in a large series of octogenarians. We retrospectively reviewed the data of 241 octogenarian patients who underwent CABG between April 2002 and April 2009 at our institution. Mean age was 84.7 ± 1.8 years. Patients affected by concomitant coexistent organic aortic, mitral, or tricuspid valve disease were excluded from the study. Patients with functional secondary ischemic mitral incompetence were included in the study. The majority of the patients were male. Angina pectoris functional class III/IV accounted for 164 patients (68%). Left ventricular ejection fraction ≤35% was diagnosed in 38 patients (15.8%). Early mortality rate was 5.8% (14 patients). Causes of death were cardiac related in 10 patients. Preoperative independent predictors of in-hospital mortality obtained with multivariate analysis were extracardiac arteriopathy, New York Heart Association class III/IV, and previous percutaneous transluminal coronary angioplasty (PTCA). The overall mean follow-up was 41.6 ± 25.9 months (range 1-87.6 months). Among the 222 contacted survivors, there were 16 (7.2%) deaths during the follow-up. The actuarial survival was 91.9% at 1 year and 83.5% at 5 years. On multivariate analysis, time to late death was adversely affected by preoperative extracardiac arteriopathy and previous PTCA. Advanced age alone should not be a deterrent for CABG if it has been determined that the benefits outweigh the potential risk. A careful selection of optimal candidates, based on the evaluation of their systemic comorbidities, appears mandatory in order to obtain the greatest benefit for these high-risk patients.

Giant aneurysm of Valsalva's sinus: diagnosis and preoperative planning using 64-slice computed tomography.

We describe a giant unruptured acquired aneurysm of the noncoronary sinus of Valsalva, which was detected incidentally in a 30-year-old rugby player with clinical suspicion of dermatomyositis. Sixty-four-slice cardiac computed tomography showed a giant aneurysm (diameters: 91 x 78 x 100 mm) of noncoronary sinus of Valsalva compressing both atrial chambers. The patient underwent cardiac surgery according to the Tirone David technique based on the information provided by cardiac computed tomography.

Saccular ascending aorta aneurysm: report of an unusual presentation.

We describe an unusual presentation of a large saccular aneurysm of the ascending aorta, mimicking an acute coronary syndrome. The compression of the aneurysm on the left main coronary artery was probably the cause of these confusing symptoms. Our experience confirms the fundamental role of modern cardiac imaging techniques in the differential diagnosis of these unusual cases and in the planning of the correct surgical procedure.

Immediate endovascular treatment of blunt aortic injury: our therapeutic strategy.

BACKGROUND: Posttraumatic aortic rupture is a potentially lethal injury. Endovascular procedure has recently proved to be a valid option. Timing of the treatment, however, is still a debated issue. We evaluated the feasibility and safety of immediate stent-graft repair of acute posttraumatic aortic injury. METHODS: From 1998 to 2005, 15 patients (11 men and 4 women, mean age 42.3 years) with blunt aortic injury were treated with immediate stent-graft positioning. In patients with clinical and radiologic signs of impending rupture, endovascular treatment was performed in an emergency setting (11 cases). In the 4 remaining patients the aortic lesion was treated after clinical management. When present, immediate life-threatening nonaortic lesions were treated before endovascular stenting (6 cases). In 1 case emergency laparotomy and endovascular procedure were performed simultaneously. Stent positioning was monitored by intraoperative transesophageal echocardiography in all cases. RESULTS: Endovascular procedure was successful in 100% of the patients. Two patients died perioperatively as a consequence of a multiorgan failure. Both patients were in American Society of Anesthetists class V and were in severe intractable hemorrhagic shock before the procedure. Computed tomography scan performed before discharge showed correct positioning of the stent graft and absence of endoleaks in all cases. At a mean follow-up of 29 months (range 1-79) all patients were alive but 1, who died of unrelated cause, and no intervention-related complication had occurred. CONCLUSIONS: Immediate stent-graft repair of posttraumatic aortic injury is a feasible and safe procedure. It allows us to minimize the surgical risks and to treat stable and unstable lesions even when associated lesions would contraindicate traditional surgical intervention.