[Follow-up after surgical treatment of type A acute aortic dissection: current evidence and controversies]. / Follow-up dei pazienti sottoposti ad intervento per dissezione aortica acuta di tipo A: evidenze e controversie.

Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.

[ANMCO/GISE/SICCH Inter-Society Consensus Document: Antithrombotic therapy after surgery or structural interventional procedures for valvular heart diseases: how to treat postoperative complications]. / Documento di consenso intersocietario ANMCO/GISE/SICCH: Terapia antitrombotica nei pazienti sottoposti a chirurgia e/o interventistica cardiaca valvolare: come trattare le complicanze.

Continuous improvement of technologies, devices and drugs needs a renewal and update of current recommendations and guidelines on antithrombotic strategies, especially in those fields where literature lacks of established scientific evidences. Accordingly, the aim of this consensus statement is to provide support for antithrombotic therapy based on current guidelines and the most recent scientific evidences.After an overview on the currently available devices, the appropriate therapy according to type of procedure and implanted device is discussed. The occurrence of postoperative thromboembolic and/or hemorrhagic complications is analyzed, along with the appropriate diagnostic tools and therapeutic approach. A section is dedicated to counseling to pregnancy in women with heart valve prosthesis. Finally, the role of novel oral anticoagulants is discussed, and indications are provided for the management of patients undergoing surgery or interventional procedures on oral anticoagulation therapy.

ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement.

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

Transesophageal Echocardiography and Radiation-induced Damages.

The long-term sequelae of mantle therapy include, especially lung and cardiac disease but also involve the vessels and the organs in the neck and thorax (such as thyroid, aorta, and esophagus). We presented the case of 66-year-old female admitted for congestive heart failure in radiation-induced heart disease. The patient had undergone to massive radiotherapy 42 years ago for Hodgkin's disease (type 1A). Transesophageal echocardiography was performed unsuccessfully with difficulty because of the rigidity and impedance of esophageal walls. Our case is an extraordinary report of radiotherapy's latency effect as a result of dramatic changes in the structure of mediastinum, in particular in the esophagus, causing unavailability of a transesophageal echocardiogram.

[ANMCO/SIC/SICI-GISE/SICCH Consensus document: Risk stratification in elderly patients undergoing cardiac surgery and transcatheter aortic valve implantation]. / Documento di consenso ANMCO/SIC/SICI-GISE/SICCH: Stratificazione del rischio in chirurgia cardiaca e per l'impianto transcatetere di valvola aortica specifico per il paziente anziano.

Aortic stenosis is one the most frequent valvular diseases in developed countries, and its impact on public healthcare resources and assistance is increasing. A substantial proportion of elderly patients with severe aortic stenosis is frequently not eligible for surgery because of advanced age, frailty and multiple comorbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant proportion of patients die or do not achieve an improvement of quality of life in the short to medium-term follow-up. It is important to determine: 1) whether and how much patient frailty influences the procedural risk; 2) whether quality of life and the individual patient survival are influenced by aortic valve disease alone or by other associated factors; 3) whether a geriatric specialist intervention to evaluate and correct other diseases with their potential or already evident disabilities can improve the results of TAVI, in particular patient quality of life. Consequently, in addition to risk stratification with conventional tools, a number of factors including multimorbidity, disability, frailty and cognitive function should be considered in order to assess the expected benefit of TAVI. Preoperative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, renal) that can potentially worsen the reduced physiological reserves characteristic of frailty. The systematic implementation into clinical practice of multidimensional assessment instruments of frailty and cognitive function for screening and exercise, and the adoption of specific care pathways should facilitate this task.

The Strange Case of the Infarcted Myxoma.

In the setting of an acute coronary syndrome, the differential diagnosis between a thrombus and a myxoma may be cumbersome. We describe the case of a patient presenting with an acute coronary syndrome associated with an aneurysmatic apical left ventricular myxoma.

Thrombotic aortic restenosis after transapical SAPIEN valve implantation.

We describe a patient previously implanted with a SAPIEN Edwards valve by the transapical approach, who subsequently experienced a valve thrombosis. The literature on this subject is reviewed.

The importance of being "three-dimensional": how to save a mitral valve. Case report.

In a 72-year-old male patient an acute coronary syndrome (ACS) was complicated by left ventricular aneurysm and severe mitral regurgitation. Two-dimensional echocardiography failed in detecting mechanism of mitral regurgitation. Transthoracic three dimensional echocardiography allowed us to obtain a better visualization of the relationship between papillary muscles, ventricular walls and mitral leaflets and dynamic systolic displacement of the posterior papillary muscle associated with restriction of both leaflets with greater apical tethering of anterior leaflet (A3-A2 scallops). Echocardiography performed after cardiac surgery revealed that ventricular reshaping after posterior papillary muscle realignment allowed the mitral regurgitation resolution.

[Primary lymphoma of the right atrium: a case report]. / Linfoma primitivo dell'atrio destro: descrizione di un caso clinico.

Primary cardiac tumor is an extremely rare disease and is associated with a high mortality. The cases described in the literature are recently increased thanks to the employment of the new diagnostic methodologies (computed tomography, nuclear magnetic resonance, transesophageal echocardiography). Particularly the primitive lymphoma, non-HIV correlated, is very rare (< 1.5% of all cardiac tumors), but it is treatable when appropriately diagnosed. We report a case of 52-year-old patient who presented with an infiltrative mass in the right atrium. The examination of the tissue obtained by transvenous intracardiac biopsy with transesophageal echocardiography guidance revealed high grade non-Hodgkin's lymphoma of B-cell lineage. The patient achieved complete tumor remission after treatment with standard chemotherapy. This case demonstrates that early diagnosis might contribute to a better prognosis for patients with malignant lymphoma of the heart.