Combination of Double Chimney Technique and Prosthesis Post-Dilation After Valve-in-Valve Implantation.

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is an effective treatment for aortic bioprosthetic valve degeneration. ViV-TAVI could lead to coronary occlusion. We describe the case of a patient treated with double chimney technique to protect coronary ostia followed by post-dilation for high residual transvalvular gradient using "three-kissing balloon" approach. (Level of Difficulty: Advanced.).

Successful mitral valve replacement in a patient with a severe form of beta-thalassaemia.

beta-Thalassaemia is an inherited haemoglobin (Hb) disorder resulting in chronic haemolytic anaemia. The most anaemic patients require regular red blood cell (RBC) transfusions for survival but iron accumulation leads to multisystem dysfunction. Heart complications represent the leading cause of mortality in beta-thalassaemia patients. In this case report we present a successful mitral valve replacement (MVR) in a patient with a severe form of beta-thalassaemia.

Mitral valve myxoma involving both leaflets.

Mitral valve myxomas are extremely uncommon, and their presence raises differential diagnosis with other pathologic conditions. We report on the case of a patient with an unspecific clinical presentation and an equivocal echocardiographic finding: mass prolapsing through the mitral valve into the left ventricle. The tumor was strongly attached by a wide pedicle, involving both the anterior and posterior mitral valve leaflets. Tumor excision was not feasible, and the mitral valve was replaced. Histologic analysis confirmed the myxomatous nature of the mass.

Left atrial ball thrombus after edge-to-edge mitral valve repair.

A thrombus can develop in the left atrium during atrial fibrillation because the loss of contractile function leads to blood flow stasis. Anticoagulation therapy is indicated for prevention of systemic embolism, usually maintaining an international normalized ratio between 2 and 3. Rarely a massive thrombosis develops in the atrium resulting in a peduncolated ball valve thrombus or in a free-floating thrombus. These two conditions are characterized by variables in the physical findings. Such masses are hazardous and upon discovery surgical treatment, often in emergency, is mandatory. We present here the case of a patient who developed an unnoticed huge left atrial ball thrombus despite warfarin therapy after previous mitral valve surgery. .

[Transcatheter valve-in-valve implantation in a patient with a degenerative sutureless aortic bioprosthesis: case report and literature review]. / Impianto transcatetere di valvola aortica in paziente con bioprotesi aortica sutureless degenerata: descrizione di un caso e revisione della letteratura.

Sutureless aortic bioprostheses (SAB) provide shorter aortic cross-clamp time and cardiopulmonary bypass duration compared to conventional aortic valve replacement. Similarly to other bioprostheses, reintervention may become necessary in some cases because of long-term structural degeneration of the valve. Valve-in-valve (ViV) transcatheter aortic valve replacement may represent an effective and safe alternative to aortic valve replacement in patients with degenerated bioprostheses who carry a high risk for reintervention. We report the case of a self-expandable transcatheter ViV procedure in a degenerated SAB.

Incidence, etiology, histologic findings, and course of thoracic inflammatory aortopathies.

BACKGROUND: The aims of this study were to detect the incidence of thoracic histologically proven aortitis in a large series of 788 patients operated on for thoracic aortic disease, to describe the surgical and histologic features of inflammatory thoracic aortopathies, and to evaluate the frequency of postsurgical complications and mortality. METHODS: Thirty-nine patients (4.9%) were affected by aortitis (mean age, 72.6 +/- 9.6). There were 24 women (61.5%). Thirty-four (87.2%) were operated on because of aneurysms and 5 because of dissection. In all cases the diagnosis of aortitis was incidental and was made on the basis of histopathologic findings. RESULTS: Histologically, there were 30 cases of giant cell aortitis (76.9%), 3 inflammatory aneurysms (7.7%), 2 cases of aspecific lymphoplasmacellular aortitis (5.1%), 1 of Takayasu aortitis, 1 of systemic erythematosus lupus-associated aortitis, and 1 of Behçet's disease-associated aortitis. The only case of infectious aortitis was a syphilitic aortitis. In 79.5% of cases, inflammatory infiltrates were moderate to severe in degree; the most widespread inflammation was seen in Takayasu aortitis, systemic erythematosus lupus-associated aortitis, and in Behçet's disease. The overall in-hospital mortality was 10.3% (4 of 39 patients). Neurologic complications occurred in 4 patients (10.3%). CONCLUSIONS: During surgery of the thoracic aorta, an inflammatory etiology of aneurysms is found in almost 5% of cases. The inflammatory process is in a histologically advanced phase, often with systemic development. Surgery can be associated with high morbidity and mortality.

Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients.

AIMS: The purpose of this retrospective study was to assess the risk factors for the early and late outcome of the surgical treatment of acute type A aortic dissection, in terms of mortality and morbidity. METHODS AND RESULTS: From 1976 to 2003, 487 patients with acute type A aortic dissection treated surgically were enrolled. Twenty-five pre-operative and intra-operative variables were analysed to identify conditions influencing early and late morbidity and early mortality. The in-hospital mortality rate including operative death was 22% (107 patients). Multivariable analysis indicated that pre-existing cardiac disease (RR=3.7, 95% CI=1.8-7.4) and cardiopulmonary resuscitation (RR=6.8, 95% CI=2.3-20.2) were independent predictors of in-hospital death. The causes of in-hospital mortality were low cardiac output in 32 patients (6.6%), major brain damage in 24 patients (5.9%), haemorrhage in 11 patients (2.2%), sepsis in nine patients (1.8%), visceral ischaemia in eight patients (1.6%), multiple organ failure in seven patients (1.4%), rupture of the thoracic aorta in six patients (1.2%), respiratory failure in six patients (1.2%), and four intra-operative deaths. The follow-up was 100% complete. The actuarial survival was 94.9+/-1.2% and 88.1+/-2.6%, at 5 and 10 years, respectively. CONCLUSIONS: Patients' pre-operative co-morbidities and dissection-related complications significantly affect early and late survival and morbidity after surgical treatment of acute type A aortic dissection.

Outcome after aortic valve replacement in octogenarians.

BACKGROUND: The advancing age of the population in the western world and improvements in surgical techniques and postoperative care have resulted in an increasing number of very elderly patients undergoing cardiac operations. Therefore, the aim of this study is to evaluate the surgical outcome in 115 octogenarians after aortic valve replacement. METHODS: We retrospectively identified 115 patients (47 men, 68 women) aged 82.3 +/- 2.1 years (mean, 80 to 92 years) who underwent aortic valve replacement alone (71 patients, 62.1%) or in combination with coronary artery bypass grafting (44 patients, 37.9%), between January 1992 and April 2003. These patients had significant severe aortic stenosis with a mean valve area of 0.62 +/- 0.15 cm(2) and a mean gradient of 88.62 +/- 24.06 mm Hg. RESULTS: The in-hospital mortality rate was 8.5%. The late follow-up was 100% complete. Actuarial survival at 1 and 5 years was 86.4% and 69.4%, respectively. Predictors of late mortality were ejection fraction (p < 0.01), preoperative heart failure (p < 0.03), and the type of prosthesis (p < 0.03). CONCLUSIONS: The outcome after aortic valve replacement in octogenarians is excellent; the operative risk is acceptable and the late survival rate is good. Therefore, cardiac surgery should not be withheld on the basis of age alone.