Case report: A hybrid technique for a safe nephrectomy in a giant kidney angiomyolipoma.

Background: Giant angiomyolipoma is usually associated with genetic syndromes and complications (spontaneous rupture and bleeding, hematuria, hypertension) and mass-related symptoms (flank and abdominal pain). Case presentation: We present a case of a 20-year-old woman suffering from tuberous sclerosis who was referred to our hospital with a giant angiomyolipoma causing abdominal pain. A contrast-enhanced computed tomography showed a left angiomyolipoma, measuring 28 cm × 17 cm × 27 cm. After a multidisciplinary team discussion, the patient was submitted for a nephrectomy. Percutaneous temporary occlusion of the main renal artery was achieved through an endovascular balloon catheter. Through the balloon catheter guidewire, 2,500 IU of heparin was infused to reduce the risk of tumor vein thrombosis and venous embolism. This allowed a safe kidney manipulation through a left thoracoabdominal approach. The postoperative course was uneventful. Pathology showed a 40 cm × 30 cm × 9 cm and 10 kg AML. One year after surgery, the patient is on follow-up, and her estimated glomerular filtration is 120.5 ml/min/1.73 m2. Conclusion: The present case showed that the endovascular control of the main renal artery could be considered a useful approach to safely managing huge renal masses when renal hilar control is expected to be very difficult.

Conduction disorders after aortic valve replacement: what is the real impact of sutureless and rapid deployment valves?

BACKGROUND: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. METHODS: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). RESULTS: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P<0.001). This finding was confirmed after adjusting for the estimated propensity of SURD-AVR (OR: 6.3, P=0.009). CONCLUSIONS: Our study revealed that the risk of PPM implantation in patients receiving surgical AVR is heavily influenced by the presence of pre-existing conduction disturbances rather than the type of valve prosthesis. Conversely, SURD-AVR emerged as an independent predictor for LBBB and was associated with an increased risk of PPM in patients presenting with RBBB.

[Transcatheter cerebral embolic protection in open heart surgery: our initial experience in Ancona, Italy]. / Protezione cerebrale transcatetere in cardiochirurgia: la nostra esperienza in Ancona.

BACKGROUND: Neurological events after cardiac surgery or transcatheter aortic valve implantation (TAVI) have a dramatic effect on patients' prognosis. Recent development of transcatheter cerebral protection systems aims to reduce their incidence, even if their use is currently limited to TAVI. Here we report our initial experience with transcatheter cerebral protection devices used in patients at high brain embolic risk undergoing cardiac surgery. METHODS: Between December 2018 and March 2020, at the Cardiac Surgery Unit of Lancisi Cardiovascular Center in Ancona, Italy, 9 patients (mean age 77 years; median EuroSCORE II: 2.2%) underwent cardiac surgery using a transcatheter cerebral protection system (Sentinel, Claret Medical, Santa Rosa, CA, USA). In all cases, a preoperative computed tomography scan highlighted the presence of severely calcified ascending aorta. RESULTS: The brain protection system was successfully implanted in all patients. Total time for device implantation and removal was less than 10 min in all cases. Four patients underwent aortic valve replacement, 2 mitral surgery, whereas 3 received combined valve surgery. Calcified debris were found within filters in 100% of patients. Postoperatively, there were neither neurological events nor major complications. CONCLUSIONS: In our experience, transferring transcatheter brain protection techniques and technologies to cardiac surgery allowed us (with excellent results) to avoid palliative percutaneous or medical management in patients with severe aortic calcifications. Waiting for more solid evidence, we believe that our example supports the concept of hybrid surgery as a therapeutic approach capable of extending traditional surgical indications with improved patients' outcomes.

Bioconduit subannular implantation for aortic root endocarditis after previous cardiac surgery: Results from two Italian centers.

OBJECTIVES: Infective endocarditis (IE) with extensive peri-annular abscesses and aortic root involvement is a life-threatening disease. Aortic root replacement with a valved conduit is the most common intervention in this setting and represents a serious challenge for the surgeon. In the present two-center study we analyzed early and midterm outcomes of a high-risk series of IE patients undergoing aortic root reconstruction with a sub-annular implantation of a totally biological valved conduit at our centers. METHODS: The series comprised 29 patients (18 males, mean age: 72.3 ± 10.1 years) operated at "Lancisi Cardiovascular Center" of Ancona and "Pasquinucci Heart Hospital" of Massa, Italy, between May 2016 and October 2019. All patients had undergone a previous cardiac surgery. Median Euroscore-II was 12.6%. Following aggressive debridement, a Bioconduit was implanted using a sub-annular implantation technique in all cases. RESULTS: Thirty-day mortality was 13.8% (n = 4). Multiorgan failure was cause of death in all cases. Respiratory complications occurred in eight patients (27.6%). Renal complications requiring temporary or permanent dialysis occurred in six (20.7%) and two (6.9%) patients, respectively. Mortality and morbidity were not related to the surgical approach. At 1-year follow-up three patients died and no patients underwent reoperation neither reported endocarditis of the biological conduit. CONCLUSION: Considered the high-risk profile of the study cohort, our results suggest safety and efficacy of our approach at 1-year. Indeed, we contend that our subannular implantation of a 100% pericardial valved conduit, allowing an effective abscess exclusion and a conduit anchoring to healthy tissues, can reduce the risk of reinfection and dehiscence.

Minimally invasive versus standard extracorporeal circulation system in minimally invasive aortic valve surgery: a propensity score-matched study.

OBJECTIVES: The impact of minimally invasive extracorporeal circulation (MiECC) systems on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. This study compared in-hospital and 1 year outcomes of MI-AVR interventions using MiECC systems versus conventional extracorporeal circulation (c-ECC). METHODS: Data from 288 consecutive patients undergoing primary isolated MI-AVR using MiECC (n = 102) or c-ECC (n = 186) were prospectively collected. Treatment selection bias was addressed by the use of propensity score matching (MiECC vs c-ECC). After propensity score matching, 2 groups of 93 patients each were created. RESULTS: Compared with c-ECC, MiECC was associated with a higher rate of autologous priming (82.4% vs 0%; P < 0.001) and a greater nadir haemoglobin (9.3 vs 8.7 g/dl; P = 0.021) level and haematocrit (27.9% vs 26.4%; P = 0.023). Patients who had MiECC were more likely to receive ultra-fast-track management (60.8% vs 26.9%; P < 0.001) and less likely to receive blood transfusions (32.7% vs 44%; P = 0.04). The in-hospital mortality rate was 1.1% in the MiECC group and 0% in the c-ECC group (P = 0.5). Those in the MiECC group had reduced rates of bleeding requiring revision (0% vs 5.3%; P = 0.031) and postoperative atrial fibrillation (AF) (30.1% vs 44.1%; P = 0.034). The 1-year survival rate was 96.8% and 97.5% for MiECC and c-ECC patients, respectively (P = 0.4). CONCLUSIONS: MiECC systems were a safe and effective tool in patients who had MI-AVR. Compared with c-ECC, MiECC promotes ultra-fast-track management and provides better clinical outcomes as regards bleeding, blood transfusions and postoperative AF. Thus, by reducing surgical injury and promoting faster recovery, MiECC may further validate MI-AVR interventions.