[Beating heart surgical treatment of atrio-esophageal fistula after radiofrequency ablation of atrial fibrillation]. / Trattamento chirurgico a cuore battente di una fistola atrio-esofagea post-ablazione tramite radiofrequenza di fibrillazione atriale.

Atrio-esophageal fistula (AEF) is a rare (0.02-0.1%) complication of radiofrequency ablation for atrial fibrillation and is associated with high mortality. It typically presents between 2 and 6 weeks after catheter ablation. AEF was reported to be the second complication as cause of death after radiofrequency ablation with a mortality rate of 71%. Common clinical features of AEF include dysphagia, nausea, heartburn, hematemesis or melena, high fever, sepsis, pericardial or pleural effusions, mediastinitis, seizures, and stroke. Once the diagnosis of AEF is made, early surgical repair is mandatory. Herein, we report a case of a AEF treated surgically without extracorporeal circulation.

Postangioplasty aneurysm of right coronary artery.

BACKGROUND: Coronary artery aneurysms are an uncommon disease whose incidence ranges from 0.3% to 5.3%. The right coronary artery is affected in 40%-70% of cases. Percutaneous coronary angioplasty is among causative factors, in particular with stent implantation. AIMS: We present a case of large postangioplasty aneurysm of the right coronary artery requiring surgical correction. MATERIALS & METHODS: A 70-year-old man with history of multiple coronary angioplasty procedures was admitted with diagnosis of aneurysm of the right coronary artery at the site of past DES insertion. RESULTS: Under cardiopulmonary bypass, the large aneurysm was incised and oversewn with final grafting of the posterior descending artery with in situ right internal mammary artery. The postoperative course was uneventful. DISCUSSION: The treatment options for coronary artery aneurysms range from medical, percutaneous and surgical approaches. CONCLUSION: In this case the surgical approach was indicated due to the large aneurysm and the high risk of rupture.

Pericardiectomy for constrictive pericarditis.

Chronic constrictive pericarditis results from inflammation and fibrosis of the pericardium. This situation eventually leads to impairment of diastolic filling and right heart failure. Once the diagnosis is made, because the disease is basically irreversible, a pericardiectomy is the mandatory treatment. The standard surgical treatment has been extensively described. The goal of this video tutorial is to render a visual explanation of the described techniques and to provide tips to help make the procedure easier to perform. The standard technique is performed through a median sternotomy, preferably without cardiopulmonary bypass if feasible. The procedure includes the complete removal of the anterior pericardium from phrenic nerve to phrenic nerve and the removal of the diaphragmatic pericardium and of part of the pericardium posterior to both phrenic nerves. Before starting the actual pericardiectomy procedure, it is useful to separate the pericardial rigid shell from the pleurae and from the diaphragm; this step allows the operator to see both phrenic nerves clearly and to give clear boundaries between the pericardium and the diaphragm, which are not often as clear as desirable due to fat, edema, inflammation, and scarring. Once a portion of the pericardium has been detached from the myocardium, it can be excised, making the portion yet to be removed more visible.

TAVI for Failed Valve-Sparing Operations: In-Hospital and Mid-Term Outcome.

BACKGROUND AND AIM OF THE STUDY: Although transcatheter aortic valve implantation (TAVI) is a steadily expanding treatment for the pathology of the aortic valve, its role in the replacement of native aortic valves following valve-sparing surgery has not been investigated. METHODS: Among 150 patients who underwent TAVI at the authors' institution, three (2%) had a failed valve-sparing operation. The in-hospital outcome, mid-term mortality, and valvular function of the three patients were evaluated retrospectively. These patients, who were deemed at high surgical risk by the heart team, underwent TAVI for predominant severe aortic stenosis (n = 2) or pure severe aortic regurgitation (AR) (n = 1). RESULTS: A self-expandable CoreValve prosthesis was inserted via femoral access in all three patients. Based on the Valve Academic Research Consortium 2 criteria (VARC-2), implantation was successful in all cases, with only one major access site complication and no more than mild residual AR. At a follow up of 13 ± 6 months there were no deaths and the mean transvalvular gradient remained low (7 ± 6 mmHg at discharge; 7 ± 4 mmHg at follow up), without any echocardiographic signs of valve deterioration. CONCLUSIONS: The results obtained with this small patient cohort demonstrated the feasibility, safety, and favorable mid-term outcomes of TAVI for failed valve-sparing operations in high surgical risk patients. However, these findings must be validated in larger cohorts before extending such treatment routinely to this subset of patients.

Parannular Elliptical Posterior Resection: A Low-Impact Reparative Technique for Mitral Valve Prolapse.

OBJECTIVE: Although effective, Carpentier technique for mitral regurgitation presents two "Achille's heel": the resection of the whole prolapsing section of posterior mitral leaflet (PML) including chordae tendinae and the annular distortion due to plication. An alternative technique of limited PML resection, which preserves mitral anatomy decreasing the impact on valve function, and 9-year outcome are presented. METHODS: Since April 2005 till March 2014, of 205 patients affected by mitral prolapse scheduled for repair (mitral valve repair), 54 patients have been included in the study. The rationale of the new technique was to limit PML resection to achieve a fair reduction of the prolapsing scallop(s) height, to avoid leaflet and annular distortion, and to spare the coaptation surface and other substantial structures. According to the observation that the posterior smooth zone of PML is quite free from chordal insertions, an elliptical slice of tissue was resected from this area. Annuloplasty and neochordal insertion when indicated completed the procedure. RESULTS: Up to 9 years of follow-up was 98% complete. One in-hospital death, two late noncardiac deaths, one redo operation due to endocarditis were reported. On late follow-up, 92% patients were on New York Heart Association class I. Late echocardiography showed stability of repair (regurgitation grade of ≤1 in 92% of patients). Nearly two third of valves preserved good PML mobility. CONCLUSIONS: The parannular elliptical posterior leaflet resection, providing excellent stable midterm results, seems to be a safe alternative method for repair of PML prolapse. It avoids distortion and weakening of annulus and leaflet, and it allows restoring a proper coaptation surface and maintains a satisfactory PML motion.

Nine years' experience with the chordal cutting technique in ischemic mitral regurgitation.

OBJECTIVES: The optimal surgical management of chronic ischemic mitral regurgitation has not yet been clearly defined. Among the various approaches proposed, the excision of strut (or main) chordae, along with complete annuloplasty to relieve tethering, has been the one preferred by our institution to treat this particular subset of mitral disease. METHODS: Between October 2004 and May 2013, 11 patients underwent surgery for chronic ischemic mitral regurgitation. RESULTS: There was no perioperative death. No patient was lost to follow-up. There was one late death due to respiratory failure three years after the operation, and one patient received a ventricular assist device ten months after surgery. The remaining patients are all alive with residual trivial-to-mild regurgitation. CONCLUSION: Chordal cutting associated with complete annuloplasty may be a good surgical option in chronic ischemic mitral regurgitation.

Modified elephant trunk technique for chronic aortic dissection: the "double elephant trunk".

The most widely used technique for chronic dissection of the aortic arch and thoracoabdominal aorta is the "elephant trunk" (ET). A technique, in which an original modification of the ET technique was necessary to avoid visceral malperfusion due to the obliteration of the patent false lumen from where splanchnic arteries arose, is presented.

[Case report of a patient on extracorporeal memebrane oyxgenation for cardiogenic shock not suitable for weaning in a peripheral center. Just a "problem" or is it feasible a treatment before patient transfer to a Hub center?]. / Paziente in ossigenazione extracorporea a membrana per shock cardiogeno non svezzabile in un centro periferico. Solo un "problema" o è possibile un trattamento prima del trasferimento ad un centro Hub?

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is the treatment of choice for cardiogenic shock unresponsive to inotropes or intra-aortic balloon pumping. It provides a temporary mechanical circulatory support and blood oxygenation allowing time for cardiac recovery. If this is not the case, the patient may become suitable for heart transplantation or left ventricular assist device (LVAD) implantation and must be transferred to a referral center. In this setting, patient transport is asscociated with high risk and it is also difficult from a logistic point of view. We describe a relatively simple method to switch the assistance from VA ECMO to LVAD. Through a left minithoracotomy an apical cannula is inserted into the left ventricle and then connected to the venous return of ECMO. The progressive clamping of ECMO venous cannula transforms the circuit from VA ECMO to a LVAD. In fact, if the switching procedure is succesfully accomplished, the left ventricle is drained, and thus unloaded, through the apical cannula while the blood to systemic circulation is provided from the femoral artery cannula. In this final setting, the oxygenator can be removed and the patient extubated, allowing an easier and less hazardous transfer to a heart transplantation center.

Early clinical and haemodynamic results after aortic valve replacement with the Freedom SOLO bioprosthesis (experience of Italian multicenter study).

OBJECTIVES: The present study investigates early clinical and haemodynamic results with the Freedom SOLO bioprosthesis (FSB) for aortic valve replacement (AVR) in eight Italian institutions. METHODS: From 2004 to 2008, a total of 229 patients [139 females (60.7%); mean age 74 ± 8 years, left ventricular (LV) ejection fraction >40%] underwent AVR with FSB. One hundred and four patients underwent preoperatively, at 1-3 and at 12 months after AVR resting transthoracic echocardiography with the effective orifice area index (EOAi) assessment, peak and mean transvalvular pressure gradients and the LV mass index (LVMi) measurement. A subset of 34 patients underwent exercise stress echocardiography at a mean of 9.6 months after AVR. RESULTS: Post-operative mortality was 3.1%. At 1-3 months, FSB showed a significant increase in the EOAi (0.39 ± 0.17 to 1.04 ± 0.17 cm(2)/m(2); P < 0.0001), a reduction in the mean gradient (43.2 ± 16.9 to 4.3 ± 2.3 mmHg; P < 0.0001) and a significant regression of the LVMi (147.6 ± 30.5 to 121.6 ± 27.4 g/m(2); P < 0.0001). During exercise stress echocardiography, the mean aortic gradients increased from 4.4 ± 1.7 at rest to 7.0 ± 2.7 mmHg at peak stress (P < 0.001). The EOA increased from 1.74 ± 0.33 to 1.80 ± 0.36 cm(2) (P = 0.0291). Mean gradients at peak stress had better correlation with resting EOAi (r = -0.74; P < 0.001) than with the prosthesis size (r = 0.43; P = 0.01). CONCLUSIONS: The supra-annular implantation of FSB offers excellent haemodynamic performance both at rest and during exercise and is associated with the rapid regression of the LV.

[Rare endocarditis due to Abiotrophia defectiva. Case report and literature review]. / Rara endocardite da Abiotrophia defectiva. Presentazione di un caso e revisione della letteratura.

Endocarditis by Abiotrophia defectiva is rare but associated with high rates of complications and mortality. The microbiological identification is challenging. Two cases without preexisting valvulopathy and one case with mitral-aortic involvement are described in the literature. A case of this subacute form of endocarditis, with normal mitral and aortic valves, is reported. Surgery was necessary, and mitral repair and aortic homograft implantation were performed with good 3-month results. In case of subacute endocarditis, especially when etiology is difficult to detect, Abiotrophia defectiva should be suspected.

Obstruction of the tricuspid valve orifice by a huge right atrial myxoma associated with the Carney complex: a case report.

Carney complex (CNC) is an inherited autosomal dominant disorder associated with multiple neoplasms. Myxomas associated with CNC differ from their sporadic forms because the former usually develop at a younger age and they may be multicentric and have a tendency to recur. Furthermore, their localization may be atypical. We report the case of a 57-year-old man, with a huge right atrial myxoma obstructing the tricuspid valve orifice. A diagnosis of CNC was established by genetic analysis. The importance of early diagnosis and an adequate follow-up is emphasized.

Posterior mitral leaflet: new anatomical insight and review of nomenclature (mitral valve anatomy).

OBJECTIVES: Previous studies described single components of the mitral valve, but somewhat lacked the spatial analysis of their relationship. Moreover, further information is necessary regarding reconstructive surgery. The current work aimed at in-depth analysis of the anatomy of the posterior mitral leaflet (PML) and its changes due to degenerative disease, completing the already existing anatomical information about PML and proposing a reorganization of the actual terminology. METHODS: Nine normal PMLs harvested from cadavers have been compared with 12 pathological specimens from partial resection of PML in the course of valve repair in adult patients. Dimensions of smooth and rough surfaces of the PML have been measured and compared and their dimensional relationships have been assessed; the chance of finding chordae tendineae inserting into the smooth, periannular portion of PML as well as their type have been checked. MEDLINE has been searched for the most relevant publications about PML anatomy. RESULTS: Observation of normal specimens has confirmed the presence of three types of chordae tendineae: marginal, intermediate and basal, but between the last two, there is some of alternative nature. In degenerative mitral valve disease, the rough part is only 13% greater than the smooth one. In collagen degeneration, both parts contribute in more or less equal proportion to the dimensional increase of the middle scallop, so that the ratio between rough and smooth surface is maintained as in normal specimens. CONCLUSION: This study reorganizes the previously proposed terminology of PML chordae tendineae. The research identifies the complemental and alternative presence of 'strut' and 'basal' chordae of PML, and it specifies the dimensions of the different anatomical components of the leaflet, in particular of the intermediate scallop. The observations give an accurate anatomical reference for the space of mitral reconstruction with minimal functional impact.

Is lower limb venous drainage during peripheral extracorporeal membrane oxygenation necessary?

Extracorporeal membrane oxygenation (ECMO) is becoming a gold standard in acute heart failure, not responsive to inotrops and intra-aortic balloon contrapulsation. This diffusion is due to the possibility to implant it through peripheral cannulation and to perform long-time assistance. Nevertheless, this technique implies some problems concerning inferior limb perfusion. It is widely accepted that arterial distal cannulation and perfusion of the limb is mandatory, especially for long periods of assistance; but the necessity to implant a distal venous drainage is still discussed. We would like to present our experience on peripheral ECMO where we could avoid venous distal drainage uneventfully.

Repair of posterior left ventricular aneurysm through transatrial approach.

Repair of posterior left ventricular ischemic aneurysms implies an extracardiac approach to reshape the ventricular geometry frequently associated with mitral surgery. A transatrial technique was described for lesions following mitral surgery or for subvalvular idiopathic cases. A transmitral approach was used for ischemic or traumatic pseudoaneurysm. We describe a case of postinfarction posterior true aneurysm with associated mitral incompetence. Both lesions were treated through an intracardiac approach. The posterior mitral leaflet was detached posteriorly to close the aneurysm with a patch, and the valve replaced sparing all subvalvular apparatus. This technique seems to be safe and allows to treat both lesions avoiding ventriculotomy.

Postinfarction septal dissection and rupture evolved as an inferobasal pseudoaneurysm: a specific anatomical pattern.

In rare cases of posterior myocardial infarction, septal rupture is the consequence of a dissecting interventricular hematoma that evolves as a fibrotic septal chamber with two separate communications, towards left and right ventricle. This unusual anatomical pattern is generally unsuspected and described as a normal interventricular defect associated with a basal left ventricular aneurysm or pseudoaneurysm. We present a case where echocardiography and ventricular angiography did not detect this situation. As surgical implications are important, this peculiar anatomical pattern should be suspected especially in patients with asymptomatic postinfarction posterior septal rupture or in those with minimal clinical impairment.

An unusual left ventricular outflow pseudoaneurysm: usefulness of echocardiography and multidetector computed tomography for surgical repair.

Left ventricular outflow tract (LVOT) pseudoaneurysm is a rare but potentially lethal complication, mainly after aortic root endocarditis or surgery. Usually it originates from a dehiscence in the mitral-aortic intervalvular fibrosa and it arises posteriorly to the aortic root. Due to these anatomical features, its imaging assessment is challenging and surgical repair requires complex procedures. An unusual case of LVOT pseudoaneurysm is described. It was detected by transthoracic ecocardiography 7 months after aortic root replacement for acute endocarditis. Multidetector computed tomography (MDCT) confirmed the presence of a pouch located between the aortic root and the right atrium. Computed tomography also detected the origin of the pseudoaneurysm from the muscular interventricular septum of the LVOT, rather below the aortic valve plane. It was repaired with an extracardiac surgical approach, sparing the aortic root bioprosthesis previously implanted. The high-resolution three-dimensional details provided by the preoperative MDCT allowed us to plan a simple and effective surgical strategy.