Staged approach for correction of anomalous venous return to the azygos vein.

Partial anomalous pulmonary venous return into the azygous vein is a rare pathological finding. We describe the case of a 28-year-old girl who had a successful staged approach to treat this rare congenital heart disease. To avoid potential connection of a systemic venous return to the left atrium, the proximal part of the azygous vein was occluded with a percutaneous approach, then the azygous vein flow was redirected into the left atrium with a surgical procedure.

Innovative transcatheter procedures for the treatment of heart failure.

The prevalence of heart failure (HF) continues to rise over time, with aging of the population and increased survival of incident cases. Major improvements occurred in drug therapy but morbidity and mortality of HF patients remain high. Some non-pharmacologic approaches to HF are already part of standard treatment for HF, including implantable cardioverter-defibrillators, cardiac resynchronization therapy (CRT) and left ventricular assist devices (LVADs). A number of transcatheter treatments and devices have been developed to improve management of valvular heart diseases (VHD), and some of them are being used or tested in specific HF conditions. For example, transcatheter aortic valve implantation (TAVI) to unload the left ventricle in patients with moderate aortic stenosis (AS) and HF or TAVI for severe aortic regurgitation (AR) in patients with LVADs. Similarly, percutaneous mitral valve repair can be used to improve prognosis and quality of life in patients with functional mitral valve regurgitation, and has been proposed as a bridge-to-LVAD or to heart transplant in selected patients. Other devices have been specifically developed for the treatment of chronic HF. In this review we describe the main devices used in the treatment of HF associated with aortic and mitral valve disease, as well as novel transcatheter interventions for chronic HF with different pathophysiologic targets.

The Triple-Layer Patch Technique for Postinfarction Ventricular Septal Rupture.

Postinfarction ventricular septal rupture (VSR) represents a well-known mechanical complication of myocardial infarction, determining cardiogenic shock with high mortality rates. Surgical correction requires significant expertise to avoid cardiac rupture, uncontrollable bleeding, residual shunts, heart failure, and death. In the last year, we observed a substantial increase of VSR at our hospital, related to the delayed presentation of people with acute chest pain to the emergency departments during the coronavirus disease 2019 pandemic. We discuss our innovative triple-layer patch technique in a recent consecutive series of 8 patients. This technique proved effective in all patients, with no residual shunt or cardiac rupture.

Right-left atrium by-pass as salvage treatment for graft failure after heart transplantation.

Chronic functional pulmonary hypertension (FPH) secondary to end-stage cardiomyopathy constitutes a risk factor for graft right ventricular failure (RVF) after orthotopic heart transplantation (HTx). A novel form of mechanical assist circuit, the extracorporeal right to left atrium bypass (ECRLAB), has been proposed. Since 1998, at our institution, a total of six patients with FPH who experienced graft RVF after HTx, as ischemic end-stage cardiomyopathy, during the effort to wean from cardiopulmonary bypass, underwent ECRLAB support. There were five men and one woman with a mean age of 55+/-3.5 years (49-59 years). The Jostra Rota Flow pump was used in five patients and the Bio-Medicus in one. Mean duration of support was 94.3+/-17.5 h (75-126 h). All (100%) patients were successfully weaned from ECRLAB support. Hemodynamic parameters improved in all patients. Two patients died from cerebral haemorrhage. Four (66.6%) patients were successfully discharged home. ECRLAB could be proposed during HTx in patients with increased preoperative transpulmonary gradient to promote the functional adaptation of the graft and avoid graft RVF, until the decline of pulmonary resistances.

Physiotherapy for Patients on Awake Extracorporeal Membrane Oxygenation: A Systematic Review.

BACKGROUND AND PURPOSE: Extracorporeal membrane oxygenation (ECMO) is used as temporary life support in subjects with potentially reversible respiratory/cardiac failure. The principal purpose of this review was to assess the characteristics and potential advantages of physiotherapeutic interventions in subjects on awake ECMO support. METHODS: Seven databases were interrogated: we searched titles, abstracts and keywords using the Medical Subject Headings terms 'extracorporeal membrane oxygenation' and 'rehabilitation' linked with the Boolean operator 'AND'. RESULTS AND CONCLUSION: In total, 216 citations were retrieved. Nine citations satisfied our inclusion criteria and were subjected to full-text analysis. The numbers of patients enrolled in the included studies (most of which were case series) were low (n = 52). We found no prospective studies or randomized controlled trials. Overall, subjects on awake ECMO usually received a combination of passive and active physiotherapy, and most achieved an acceptable degree of autonomy after treatment. Emerging research in the field affords preliminary evidence supporting the safety of early mobilization and ambulation in patients on awake veno-venous ECMO support. Copyright © 2015 John Wiley & Sons, Ltd.

Surgery for atrial fibrillation using radiofrequency catheter ablation.

OBJECTIVE: We present the results obtained in 40 patients with chronic atrial fibrillation using direct intraoperative radiofrequency to perform atrial fibrillation surgery. METHODS: Between April 2001 and June 2002, 40 patients underwent surgery for atrial fibrillation using radiofrequency ablation and cardiac surgery at the Department of Cardiovascular Surgery of the University of Bologna [corrected]. There were 8 men and 32 women with a mean age of 62 +/- 11.6 years (range: 20 to 80 years). RESULTS: Concomitant surgical procedures were: mitral valve replacement (n = 13), mitral valve replacement plus tricuspid valvuloplasty (n = 11), combined mitral and aortic valve replacement (n = 8), and combined mitral and aortic valve replacement plus tricuspid valvuloplasty (n = 5). Moreover, 1 patient underwent tricuspid valvuloplasty plus atrial septal defect repair, another required aortic valve replacement plus coronary artery bypass graft, and a third underwent aortic valve replacement. After the mean follow-up time of 16.5 +/- 2.5 months survival was 92.8% and the overall cumulative rate of sinus rhythm was 88.5%. CONCLUSIONS: We conclude that the radiofrequency ablation procedure is a safe and effective means of curing atrial fibrillation with negligible technical and time requirements, allowing recovery of the sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who underwent cardiac surgery (88.5% of our study population).

Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study.

BACKGROUND: The purpose of this study was to evaluate the efficacy of radiofrequency (RF) ablation in the treatment of atrial fibrillation, by comparatively analyzing the outcomes of the patients who underwent RF ablation with those of patients who underwent Cox/Maze III surgery. METHODS: Between April 1995 and June 2002, 70 patients underwent surgery for atrial fibrillation and open-heart surgery at the Department of Cardiovascular Surgery of the University of Bologna: 30 patients underwent the surgical Cox/Maze III procedure (group 1), and 40 patients underwent the RF ablation according to the Maze III configuration at least on the left atrium (group 2). There were 14 males and 56 females, with a mean age of 61.5 +/- 12.5 years (range 22 to 80 years old). RESULTS: Groups 1 and 2 did not differ in terms of baseline characteristics. The perioperative mortality rate was not significantly different between the two groups (6.6% in group 1 vs 7.5% in group 2). The overall cumulative rates of sinus rhythm were 68.9% in group 1 and 88.5% in group 2 (not statistically significant). Biatrial contraction was assessed by transthoracic echocardiography in 70.4% of the patients in group 1 and 76.5% of the patients in group 2 (p = 0.65). CONCLUSIONS: The RF ablation procedure offers as good results as the Cox/Maze III operation, allowing recovery of the sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who underwent open heart surgery; it is a safe and effective means of curing atrial fibrillation with negligible technical and time requirements.

Simultaneous temporary CentriMag right ventricular assist device placement in HeartMate II left ventricular assist system recipients at high risk of right ventricular failure.

An approach is reported for right ventricle temporary mechanical support in long-term axial left ventricular assist device (LVAD) patients preoperatively judged at high risk of right ventricular (RV) failure. The timing for RV assist device (RVAD) weaning and the technique for its removal through a right mini-thoracotomy are described. This strategy provides a good outcome in LVAD recipients avoiding the risk of immediate postoperative RV failure.

Extracorporeal membrane oxygenation for intraoperative cardiac support in children with congenital heart disease.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) is commonly used in children to allow recovery from ischemic injury or cardiac surgery, to support the circulation in case of end-stage cardiomyopathy, as bridge-to-bridge therapy and as bridge to transplantation as well. It has achieved success in providing cardiac support for these kind of patients with expected mortality due to severe myocardial dysfunction. In this modern era, ECMO support should be considered an important option for children with cardiopulmonary failure refractory to medical therapy or resuscitation. We report our experience in pediatric patients supported by ECMO for intraoperative cardiac failure between November 1991 and December 2006. METHODS AND RESULTS: Sixty-six patients with a mean age of 5.2+/-4 years (range: 1 day-17 years) and mean weight of 14.3+/-11 kg (range: 2.8-69 kg) had intraoperative ECMO support for failure to wean off cardiopulmonary bypass (n=46, 69.7%), low cardiac output syndrome (n=8, 12.1%), isolated right ventricular failure (n=6, 9.1%), isolated left ventricular failure (n=3, 4.5%), malignant arrhythmia (n=1, 1.5%) and pulmonary hypertension (n=2, 3.1%). Mean duration of ECMO support was 5.1+/-3 days. Overall 30 (45.4%) patients were successfully weaned off ECMO and survived to decannulation. Overall 6 (9.1%) patients were successfully bridged to heart transplantation while on ECMO support. Thirty patients died (54.4%) (16 while on ECMO and 14 after decannulation) because of multi-factorial complications, i.e. cerebral hemorrhage, pulmonary failure, consumption coagulopathy and therapy-resistant myocardial insufficiency, leding to an overall hospital mortality rate of 45.4%. Mean survival time after decannulation was 28+/-16 h. Overall survival rate on ECMO as bridge to recovery and transplantation has been 54.5% with successful hospital discharge of patients. CONCLUSIONS: Our experience shows that ECMO support can be offered intraoperatively to any children after palliative or corrective surgery for congenital heart disease with potentially reversible pulmonary, cardiac or cardiopulmonary failure. In the majority of patients who did not survive late after weaning from ECMO support, significant myocardial dysfunction persisted or pulmonary hypertensive events. Nevertheless, an acceptable proportion of patients who were successfully weaned from ECMO ultimately survived to leave the hospital.

Heartmate II axial-flow left ventricular assist system: management, clinical review and personal experience.

OBJECTIVES: The excellent results with left ventricular assist devices (LVADs) have revolutionized the treatment options for end-stage heart failure. The use of pulsatile devices is associated with significant comorbidity and limited durability. The axial-flow HeartMate II LVAD represents the new generation of devices. The clinical use of this pump resulted in superior outcomes. We review the HeartMate II technology, management, clinical usage and our experience. METHODS: Between 3/2002 and 12/2008, 18 transplantable adult patients were supported on long-term HeartMate II LVAD at our institution (13 men, age 52 +/- 8.4 years, range: 31-64 years). Primary indications were: ischemic cardiomyopathy (CMP) (n = 13), idiopathic CMP (n = 5). All patients were in New York Heart Association (NYHA) Class IV heart failure. None of patients had prior open-heart surgery. Implantation via cannulation of the left ventricular apex and the ascending aorta was always elective. RESULTS: Mean support time was 217 +/- 212.3 days (range: 1-665 days). Early (30-day) mortality was 27.7% (five patients) with multiple organ failure and sepsis as main causes of death. Bleeding requiring reoperation occurred in six (33.3%) cases. Cerebral hemorrhage occurred in one patient. There were two driveline infections and no device failure. Twelve (66.6%) patients were successfully discharged home. Overall nine patients (50%) were transplanted and two patients are actually waiting for a suitable organ (n = 2 patients discharged home and n = 1 patient in hospital). At latest, follow-up survival rate after heart transplantation is 66.6% (six patients). CONCLUSION: Long-term HeartMate II LVAD provides good mid-term, long-term results. This new technology requires delicate management. Functional status and quality of life greatly improve in patients who survive the perioperative period.

Aneurysms after coarctation repair associated with hypoplastic aortic arch: surgical management through median sternotomy.

Aneurysm development after repair of aortic coarctation is not a rare complication, but it is highly related to hypoplasia of the transverse aortic arch. The optimal management of such cases is not clearly established. We propose a single-stage transmediastinal re-repair using moderate hypothermic cardiopulmonary bypass and antegrade selective cerebral perfusion.

Double orifice tricuspid valve in an infant with tetralogy of Fallot.

Atrioventricular valve duplication, also known as double orifice valve, is an excitingly rare anomaly that can involve either the mitral or more uncommonly the tricuspid valve. Herein we describe a case of a double orifice tricuspid valve that prejudiced the complete repair in a symptomatic infant with tetralogy of Fallot.

Early results of valve-sparing reimplantation procedure using the Valsalva conduit: a multicenter study.

BACKGROUND: This study evaluates the midterm clinical results of valve-preserving aortic root reconstruction by means of a modified conduit incorporating sinuses of Valsalva. METHODS: During a 5-year period, 151 patients with aneurysm of the aortic root underwent a reimplantation type of valve-sparing procedure using the Gelweave Valsalva prosthesis that incorporates sinuses of Valsalva. There were 121 males (80.1%), and the mean age was 56.4 +/- 14.4 years (range, 14 to 83). Fourteen percent of the patients had Marfan syndrome and 8.6% had bicuspid aortic valve. Seven patients (4.6%) suffered from acute aortic dissection. Aortic replacement was extended to the arch in 14 patients (9.3%). Sixteen patients (10.6%) had associated cusp repair. RESULTS: In-hospital mortality was 3.3%, and it was significantly higher among patients operated on for acute dissection (p = 0.001) and in symptomatic patients (III-IV New York Heart Association class; p = 0.021). Follow-up (mean, 18 months; range, 1 to 60) was 100% complete. There were 2 late deaths. Ten patients (6.8%) had 3 to 4+ aortic regurgitation, and 8 of these required late aortic valve replacement. Cusp repair was associated with a high incidence of late aortic valve replacement (p = 0.005). At 5 years, freedom from aortic valve replacement and freedom from grade 3 to 4 aortic insufficiency was 90.8% +/- 3.3% and 88.7% +/- 3.6%, respectively. CONCLUSIONS: The reimplantation valve-sparing procedure with the Gelweave Valsalva prosthesis provides satisfactory results for patients with aortic root aneurysm. Aortic cusp repair may lead to late aortic insufficiency. Proper leaflet evaluation is of paramount importance in preventing residual valve regurgitation.

Valsalva prosthesis in aortic valve-sparing operations.

Aortic valve-sparing operations have provided very good clinical outcomes. However, the absence of the sinuses of Valsalva might limit valve durability. The Gelweave Valsalva prosthesis, which presents pre-fashioned neo-sinuses, has been designed in order to avoid early leaflets deterioration. We report our results in 63 patients who underwent valve-sparing operations (reimplantation technique) using the Gelweave Valsalva graft. The main indication was ascending aorta aneurysm or annuloaortic ectasia, with or without aortic insufficiency. The operation was performed also in cases of Marfan syndrome, Bicuspid Aortic Valve (BAV), and acute Type A dissection. In-hospital mortality was of 4.7%, and two thirds were acute Type A dissection patients (P=0.01). There were no late deaths. Three years freedom from grade 3-4 AI and freedom from late aortic valve replacement were 91.7+/-4.3% and 93.8+/-5.1%, respectively. Aortic valve-sparing operations show good results in patients electively operated for aortic root ectasia. Aortic cusps repair may lead to late failure. Even if the Gelweave Valsalva prosthesis is easy to implant and it also reproduces pseudosinuses, a long-term follow up is necessary to determine if this graft may reduce leaflets deterioration.

Traumatic aorto-right ventricular fistula with aortic insufficiency.

We present a case of a traumatic aorto-right ventricular fistula coexistent with aortic insufficiency due to perforation of the left coronary leaflet, which is a lesion rarely described in the literature. We compare our experience with reports from the literature.