Case Report: Severe Aortic Valve Regurgitation and Pseudoaneurysm in Aortic Valve-Sparing Operation: The Usefulness of Multimodality Imaging in a Complex Clinical Scenario.

Background: Failure of the native aortic valve and degenerative anatomy of ascending aorta in patients with previous Tirone-David operation may represent a clinical challenge, because sometimes the risk of reoperation is prohibitive. Case: We described the case of a patient suffering from severe aortic valve regurgitation and pseudoaneurysm of the aortic arch, 6 years after cardiac surgery operation. The aim of this clinical case was to assess if the complex anatomy of aortic pseudoaneurysm and aortic root geometry can be accurately reproduced from contrast-enhanced computed tomography scan into a three-dimensional (3D) printed model. Based on this procedural method, with the aid of transesophageal 3D ultrasound, we efficaciously treated the patient percutaneously with a combination of transcatheter occluder device plus microcoil embolization and transfemoral aortic valve implantation. The patient was free from complications and the need to redo cardiac surgery. Conclusion: To the best of our knowledge, this is the first description of two simultaneous complications and their staged treatment in a patient with previous aortic valve-sparing operation. This is a useful report in a single 3D model applying such specific technology to these two simultaneous clinical settings.

How to evaluate the outflow tract of LVAD after minimally invasive implantation by 3D CT-scan.

During a minimally invasive implantation technique, the outflow graft of left ventricular assist device (LVAD) is tunnelled blindly through the pericardium or left pleura, with an inability to assess for twisting or malposition. Three-dimensional computed tomography scan (CT-scan) has a role in qualitative evaluation of the different outflow tract configurations. The different surgical minimally invasive approaches include: (a) mini-sternotomy and left mini-thoracotomy, (b) right mini-thoracotomy and left mini-thoracotomy, (c) subclavian artery access and left mini-thoracotomy. The outflow graft could be anastomosed to the left axillary artery or the ascending aorta. CT-scan reconstruction using syngo InSpace4D (Siemens, Muenchen, Germany) was used to provide fast segmentation and high-resolution images. The 3D reconstructions permit an evaluation of different anastomosis configurations and to assess the route of outflow graft.

Pulmonary arteriopexy to prevent pulmonary artery kinking in orthotopic heart transplantation.

Heart transplantation is still the best treatment for patients with end-stage heart failure unresponsive to medical therapy or those treated with mechanical circulatory support. The surgical technique for heart transplantation is fraught with potential complications. One of these potential complications, kinking of the pulmonary artery after anastomosis of the recipient and donor pulmonary arteries, has been reported as a cause of acute right ventricular failure. We describe a technique to ensure proper configuration of the pulmonary artery after heart transplantation via a pulmonary arteriopexy to restore a physiologically appropriate angle of the great vessels.

Clinical and radiological outcome after endovascular abdominal aortic aneurysm repair: comparison of different grafts. preliminary single-center experience.

Endovascular repair (EVAR) represents a useful and validated alternative to conventional surgery in selected patients with abdominal aortic aneurysm (AAA) because it is associated with a significantly lower long-term AAA-related mortality. Data regarding a series of 91 patients (88 men, 3 women, median age 71 years, range 65-82 years) is reported. The patients were divided into three groups, according to the type of implanted stent (Endurant, Excluder and Talent). High American Society of Anesthesiologists Physical Status Classification System (ASA) was important in increasing the likelihood of an early complication (p=0.0007), while it did not have any effect on later adverse events, which were more closely related to the size of the aneurysm (p=0.006). As expected, the aneurysm diameter influenced the endoleak incidence (p=0.011), aneurysmal sac expansion (p=0.029), re-intervention risk (p=0.031) and the success of treatment (p=0.006). A significantly lower tendency for the development of endoleak (p=0.035) and other late complications (p=0.048) was observed in patients with Endurant device. This group seems to be more likely destined to achieve therapeutic success, but the difference was not significant. A borderline significance (p=0.071) with regard to early complications was also recorded. However, the use of this type of device did not affect survival, which was exclusively related to ASA (p=0.040). No other statistically significant differences were found between groups. Since open surgery for elective suprarenal AAA repair is still associated with considerable mortality, EVAR may offer several advantages over open repair surgery, including a less invasive operative procedure, and shortened intensive care unit and hospital stay. The technological improvements of the prosthesis for EVAR will likely reduce complications related to this technique in the near future.