Can a "broken heart" successfully be transplanted? A brief report.

A 59-year-old woman, with dilated ischemic cardiomyopathy, was urgently admitted to our Intensive Care Unit for cardiogenic shock. ECMO VA was implanted and placed on the national emergency waitlist for transplantation. A potential donation was identified ten days later. The donor was a 58-year-old woman, with no cardiovascular risk factors, had died of a rupture of a cerebral aneurysm with left ventricle dysfunction due to Takotsubo syndrome. Brain injuries such as hemorrhage, trauma and stroke have been extensively documented in literature to cause a surge in stress hormones, such as catecholamines. Such a surge can have a direct effect on the heart, resulting in a transient myocardial dysfunction commonly referred to as "Takotsubo cardiomyopathy" or "broken heart syndrome". Many studies have shown that hearts that are dysfunctional at the start of transplant screening, with normal contractile function at the time of organ retrieval, have similar outcomes to hearts that do not have dysfunction. In our case, the transplanted heart, at the time of sampling, still had moderate dysfunction (EF 40%) which completely disappeared after the transplant.

A comparison of intracardiac echocardiography and transesophageal echocardiography for guiding device closure of ostium secundum atrial septal defect: A 15-year experience.

BACKGROUND AND AIM: Our aim was to evaluate the fluoroscopy time (FT), procedure time (PT) safety and efficacy when using intracardiac echocardiography (ICE) in comparison to transesophageal echocardiography (TEE) guidance for transcatheter closure of Ostium Secundum Atrial Septal Defect (OS-ASD). METHOD: Ninety patients (n = 90) diagnosed with OS-ASD underwent transcatheter closure between March 2006 and October 2021. Fifty-seven patients were treated under ICE guidance, while 33 patients were treated under TEE guidance. RESULTS: Mean age was 43 ± 15 years and 42 ± 10 years in the ICE and TEE groups, respectively. The majority of patients had a centrally placed defect. Median FT was 8.40 min versus 11.70 min (p < .001) in the ICE group compared to the TEE group, respectively. Median PT was 43 min versus 94 min (p < .001) in the ICE group compared to the TEE group, respectively. Both ICE and TEE provided high quality images. All interventions were completed successfully, except for one patient in the ICE group who experienced a device migration, the development of atrial tachycardia in one patient and atrial fibrillation in two patients in the ICE group which spontaneously cardioverted. There were no other complications. CONCLUSION: This study on a consistent cohort of patients with OS-ASD undergoing percutaneous closure suggests that use of ICE is safe and efficacious. Compared to TEE, ICE demonstrated significantly shorter FT and PT, decreasing the entire duration of the procedure and x-ray exposure. No relevant differences were observed in terms of success rate and complications.

Heart transplant in a Sars-CoV-2 positive recipient: Management protocol of the world's first case.

The advent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in China at the end of 2019 has developed into a global outbreak, and COVID- 19 is an ongoing major public health issue. During the pandemic, transplant programs had to devise strategies to deal with the possibility of COVID-19-positive donors and recipients. We describe the case of a heart transplant recipient who tested positive with the SARS- CoV2 swab upon admission to our Unit of Cardiac Surgery when a suitable donor became available. Given his clinical status of end-stage heart failure and the absence of imaging and clinical signs suggestive of COVID-19, and his having been vaccinated with three doses, we decided to proceed with the transplant.

Quadricuspid aortic valve repair with a modified-tricuspidization technique.

INTRODUCTION: Quadricuspid aortic valve (QAV) is an extremely rare developmental abnormality with an incidence of 0.006%. QAV is an incidental finding that in some patients (23%) may determine aortic regurgitation (AR). Altogether 16% of patients indeed require surgery with AR being the most frequent indication. METHODS AND RESULTS: We describe a case report of a 46 year-old female affected by severe aortic regurgitation due to QAV successfully treated with a  modified-tricuspidization technique associated with cusp extension, prolapsing commissure suturing, and sub-commissural annuloplasty. DISCUSSION: QAV repair represents an attractive perspective to overcome the drawbacks of either mechanical or biological prosthesis.

Artificial chordae for mitral valve repair.

BACKGROUND: Mitral valve repair using expanded polytetrafluoroethylene sutures to replace mitral chordae tendineae is a well-established procedure. However, the incidence of neo-chordae failure causing recurrent mitral regurgitation is not well defined. METHODS: We have reviewed the reported cases of complications after mitral valve repair related to the use of neo-chordae. This study was mainly carried out through PubMed, Medline, and Google Chrome websites. RESULTS: We have identified a total of 26 patients presenting with rupture of polytetrafluoroethylene neo-chordae, mostly being described as isolated cases. Few other cases of recurrent mitral regurgitation with hemolysis were found, where reoperation was not caused by neo-chordal failure but most likely by technical errors. At pathological investigation the findings were substantially similar in all reported cases. The neo-chordae retained their length and pliability, became covered with host tissue and rupture was mainly related to suture size. Mild calcification was observed not interfering with chordal function; chordal infection did never occur. CONCLUSIONS: The use of artificial neo-chordae provides excellent late results with durable mitral valve repair stability. Chordal rupture may occur late postoperatively leading to reoperation because of recurrent mitral regurgitation. Despite its rarity, this potential complication should not be overlooked during follow-up of patients after mitral valve repair using artificial neo-chordae.

Use of Pericardium for Cardiac Reconstruction Procedures in Acquired Heart Diseases-A Comprehensive Review.

BACKGROUND: Reconstruction of cardiac structures has been the goal of many surgeons even before the advent of open-heart procedures with cardiopulmonary bypass. Unsatisfactory results with synthetic materials has switched the attention to biological tissues, among which pericardium, either autologous or of animal origin, has been widely used as patch material. METHODS: We have reviewed the literature to assess the effective role of pericardial tissue in the correction of various acquired cardiac lesions. Particularly, special attention was given not only to established techniques but also to detect any peculiar and unusual application of pericardium. RESULTS: Autologous pericardium is frequently used as patch material particularly when limited valvular lesions must be corrected, while xenograft pericardium appears particularly useful in patients with endocarditis and extensive destruction of the intracardiac structures by infection and abscesses. Pericardium is an extremely versatile material owing to its pliability and strength; however, it tends to calcify in the long term when in contact with blood, although stability of the repair is maintained in most cases. CONCLUSIONS: Pericardium plays an important role in various cardiac and aortic pathologies. Tissues resistant to fibrosis and calcification to be used as patch material are the ideal solution for more successful cardiac reconstruction procedures and will hopefully be provided by the ongoing research.

Blood cysts of the cardiac valves in adults: Review and analysis of published cases.

BACKGROUND AND AIM: Blood cysts of cardiac valves are generally seen in newborns and infants and very rarely in adults. Although in most cases they are incidental findings they may be associated to severe cardiac or systemic complications. This study analyzes incidence, presentation, and treatment of valvular blood cysts in adults. METHODS: A review of the pertinent literature through a search mainly on PubMed and Medline was performed. RESULTS: In patients ≥18 years of age, our search disclosed 54 patients with mitral blood cysts (mean age, 48 ± 18 years), 9 with a tricuspid valve cyst (mean age, 67 ± 15 years), 3 with a blood cyst on the pulmonary valve (age 31, 43, and 44 years), and 1 aortic valve cyst in a 22-year-old man. Most patients were asymptomatic while stroke, syncope, or myocardial infarction occurred in six patients with a mitral valve cyst. Blood cysts were removed surgically in 70% of patients with a mitral cyst, in 55% with a tricuspid cyst, and in all those with a pulmonary or aortic cyst. At histology, the cyst wall was composed mainly by fibrous tissue and with the inner surface lined with typical endothelium. CONCLUSIONS: Blood cysts of cardiac valves are rare in adults but may cause life-threatening complications, particularly when located on the mitral valve. For such reason, surgical removal appears advisable, with low-risk procedures. Widespread use of multimodality imaging techniques will most likely increase the number of valvular blood cysts diagnosed also in adults.

Durability of the Mitroflow Pericardial Prosthesis: Influence of Patient-Prosthesis Mismatch and New Anticalcification Treatment.

BACKGROUND: The Mitroflow pericardial bioprosthesis (MPB) has been recently associated with a high incidence of early structural failures, questioning its validity as cardiac valve substitute. We have therefore reviewed our experience with this device. MATERIALS AND METHODS: A total of 398 patients with a mean age of 75 ± 7 years (58% above the age of 75 years) had aortic valve replacement with a Mitroflow prosthesis (2005-2015). Most patients had calcific aortic stenosis (86%) and were in sinus rhythm (89%). Mean EuroSCORE II was 5.5 ± 6.2. Mean follow-up was 4 ± 2 years (range: 4 months to 10 years), which was 100% complete. RESULTS: Hospital mortality was 6.5%; at discharge, 25% of patients had a moderate patient-prosthesis mismatch and none had a severe mismatch. Cumulative incidence of structural valve deterioration in the entire series was 2% (95% confidence interval [CI]: 1-4) at 5 years and 7% (95% CI: 4-14) at 8 years. Significant factors influencing MPB durability were age ≤ 65 years (p < 0.001) and the presence of patient-prosthesis mismatch (p = 0.01). No cases of structural valve deterioration were observed in patients with the new prosthetic model incorporating an anticalcification treatment the first 4 years of follow-up. CONCLUSIONS: The Mitroflow prosthesis has shown satisfactory results in the first decade of use. Durability appears adversely influenced by patient age and patient-prosthesis mismatch. Thus, a careful valve size selection and implantation in patients >65 years of age appears to be associated with excellent valve durability in the aortic position. Whether the new anticalcification treatment will provide a more durable prosthesis must be verified at a longer follow-up.

Aortic Valve Replacement for Aortic Stenosis in Low-, Intermediate-, and High-Risk Patients: Preliminary Results From a Prospective Multicenter Registry.

OBJECTIVE: To evaluate current results of surgical aortic valve replacement (SAVR) ± coronary artery bypass grafting surgery. DESIGN: Independent, multicenter, prospective registry. SETTING: Tertiary university hospitals. PARTICIPANTS: The study comprised 1,192 consecutive patients, stratified as low-, intermediate-, and high-risk according to EuroSCORE II (<4, 4-9, >9, respectively). INTERVENTIONS: SAVR ± coronary artery bypass grafting surgery. MEASUREMENTS AND MAIN RESULTS: Thirty-day mortality and major morbidity, 2-year actuarial survival and freedom from stroke, and independent predictors of mortality in each risk category were assessed. These data were considered in light of published randomized controlled trials. Thirty-day mortality was 1.0%, 3.0% and 2.1% in the low-, intermediate-, and high-risk patients, with a 2-year actuarial survival of 98.6%, 93.8%, and 94.0%, respectively. Preoperative atrial fibrillation (odds ratio [OR] 8.3), minithoracotomy access (OR 5.8), postoperative dialysis (OR 3.4), type V acute myocardial infarction (OR 20.4), and moderate aortic regurgitation (OR 28.8) predicted 30-day mortality in the low-risk group. Preoperative dialysis (OR 18.3), critical state (OR 36.7), postoperative transfusions of plasma (OR 1.9 per unit transfused), and de-novo dialysis (OR 6.2) predicted 30-day mortality in the intermediate-risk group. Prior cardiac surgery (OR 18.1), postoperative extracorporeal membrane oxygenation (OR 9.8), and gastrointestinal complications (OR 17.2) predicted 30-day mortality in the high-risk group. Although baseline differences existed, low-risk patients demonstrated low 30-day mortality and 30-day to 12-month stroke in light of the PARTNER 3 and EVOLUT Low Risk trial results. Intermediate-risk patients demonstrated low 30-day to 2-year mortality, when the PARTNER 2 trial was considered, and low 30-day to 2-year stroke, when the PARTNER 2 and SURTAVI trials were considered. High-risk patients showed low 30-day to 2-year mortality in light of the results of the PARTNER 1 and CoreValve US trials. CONCLUSIONS: SAVR is still a safe and effective surgery for aortic stenosis regardless of risk category.

Transapical mitral valve-in-valve procedure with elective venoarterial ECMO in a patient with severe kyphoscoliosis.

Transcatheter mitral valve-in-valve replacement (TMVR) is a feasible alternative in high-risk patients requiring reoperation for failing mitral bioprosthesis. Such patients may present with hemodynamic instability or sudden complications, which may jeopardize the outcomes. We report a successful transapical TMVR in a patient, with severe kyphoscoliosis and on prolonged mechanical ventilation, with prophylactic extracorporeal membrane oxygenator support. This combined procedure may be helpful to reduce the complications of TMVR in critically ill subjects.

Deceptive appearance of a rapidly growing left atrial myxoid sarcoma with pancreatic metastasis.

The third case reported in the literature of a left atrial neoplasm characterized by a very deceptive, low grade cellular component at its early stage of growth, so as to be diagnosed as a myxoma is presented. Two months after surgical excision, regrowth of the mass occurred, producing a pancreatic mass also. The new atrial mass was excised; a left atrial myxoid sarcoma and a pancreatic metastasis were diagnosed. One week later the atrial sarcoma grew again. This time surgery was contraindicated and the patient underwent chemotherapy with a satisfactory control of the sarcoma growth. The myxoid sarcoma may present with the deceptive appearance of a myxoma in their early stages. Therefore, patients who have undergone surgical removal of a myxoma should have a close follow-up to monitor unexpected malignant turnover.

Mesothelial/monocytic incidental cardiac excrescence in autoimmune disease.

Mesothelial/monocytic incidental cardiac excrescence (MICE) is a rare benign finding made of mesothelial cells, histiocytes, and fibrin, usually found during heart valve surgery. The clinical relevance resides in the potential misdiagnosis as metastatic carcinoma or arterial embolism. The pathogenesis remains uncertain, with artifactual and reactive hypotheses. Here we present a case of MICE with paradigmatic clinical, imaging, and histological features in a 28-year-old woman with undifferentiated connective tissue disease without previous cardiac catheterization with possible pathogenesis, highlighting the importance of awareness of the existence of this lesion in patients with autoimmune disease.

Acute aortic dissection and pregnancy: Review and meta-analysis of incidence, presentation, and pathologic substrates.

OBJECTIVES: Pregnancy has been recognized as a predisposing factor for acute aortic dissection (AAD) although its occurrence is quite rare. Currently, no trial and few prospective studies exist about this catastrophic event. The present review and meta-analysis aims to update information on clinical presentation, potential risk factors, treatment, and outcome of acute dissection during pregnancy and puerperium. METHODS: A comprehensive search of three databases was performed to identify all patients reported in articles published from January 1987. A proportional single-arm meta-analysis with random-effects model was used to pool these variables: risk factors, pregnancy/postpartum occurrence, surgical characteristics, and outcomes. RESULTS: A total of 11 reports and 85 patients with pregnancy-related AAD were available for this study. The prevalence of connective tissue disorders was 62%, Marfan syndrome being the most common. Out of 76 patients, 46 (61%) had dissection during pregnancy and 30 (39%) during puerperium; 40% of events occurred in primigravidae and 60% in multigravidae. Type A and type B dissection occurred in 67% vs 33% of patients. Surgery was performed in 73% of cases with a maternal and fetal mortality of 23% and 27%, respectively. CONCLUSIONS: Throughout pregnancy, AAD is quite rare but fatal, especially in Marfan and Loeys-Dietz syndromes, while isolated bicuspid aortic valve is not a risk factor. Even in Marfan syndrome, pathogenesis and evolution of the disease are still unclear. Occurrence of dissection also during puerperium indicates the need for continuous counselling and aortic size monitoring in women at-risk.

Excellent Durability of the Mosaic Porcine Aortic Bioprosthesis at Extended Follow Up.

BACKGROUND: Biological prostheses are widely employed for aortic valve replacement (AVR). The study aim was to evaluate the performance of the Mosaic porcine bioprosthesis in the aortic position over two decades. METHODS: Between November 1995 and December 2016, a total of 254 patients (194 males, 60 females; mean age 74 ± 9 years) underwent AVR with a Mosaic bioprosthesis at the authors' institution. Among the patients, 14% were aged ≥80 years and 86% had pure or prevalent calcific aortic stenosis. Preoperatively, the mean NYHA functional class was 2.5 ± 1.0. RESULTS: Overall hospital mortality was 5%. A total of 107 late deaths occurred, but only 15 were valve-related (0.72 ± 0.19% per patient-year). Actuarial survival at 15 years was 34 ± 7%. Fourteen embolic episodes occurred, with no cases of bioprosthetic thrombosis; freedom from thromboemboli was 88 ± 4% at 15 years. Eight cases of endocarditis occurred, with a freedom of 95 ± 2% at 15 years. Structural valve deterioration (SVD) was observed in four patients, all of whom were successfully reoperated. Freedom from SVD was 97 ± 2% at 15 years and 96 ± 2% at 20 years. At the last follow up, 23 mm and 25 mm prostheses showed mean gradients of 17 ± 6 mmHg and 15 ± 4 mmHg, respectively. A significant reduction in left ventricular mass was noted in patients with aortic stenosis. CONCLUSIONS: The Mosaic bioprosthesis has shown excellent durability over two decades of clinical use, with a negligible incidence of valve degeneration and need for reoperation. Thus, it may be considered a valid option for AVR, especially in elderly patients.