A Rare Case of Effusive-Constrictive Pericarditis Caused by Streptococcus agalactiae: Emergency Surgical Treatment.

A 70-year-old male patient was admitted to the emergency room in cardiac arrest. The patient was resuscitated and then referred to our cardiac surgery department, where he was diagnosed with suspected effusive constrictive pericarditis. A failed trial of TEE-guided pericardiocentesis led to the decision of surgical intervention. Sternotomy was performed and revealed pericardial thickening and very dense adhesions involving the pericardium and both pleurae, suggesting a neoplastic disease. An extensive pericardiectomy and bilateral pleural decortication were performed. After surgery, the patient improved significantly and was discharged from the intensive care unit 24 h later. Pericardial thickening, dense adhesions, the amount and color of pericardial fluid and the aspect of epicardial tissue increased our suspicion of neoplastic disease. Histological samples were sent to be analyzed immediately; a few days later, they were unexpectedly negative for any neoplastic disease but showed a group-B-hemolytic Streptococcus agalactiae infection, which causes pericarditis in extremely rare cases. Postoperatively, the patient, under intravenous antibiotic and anti-inflammatory therapy, remained asymptomatic and was discharged ten days after the surgery. At the three-month follow-up, transthoracic echocardiography showed a normal right and left ventricular function with no pericardial effusion.

Challenging report of cardiopulmonary bypass in 16th week pregnant patient with endoventricular mass.

BACKGROUND: Pregnancy usually represents a risk factor for aortic dissection or thrombotic events, but therapeutic options are very scarce because the foetus limits the common approaches especially in the early stages of pregnancy. CASE PRESENTATION: We present a challenging case of a young woman in her 16th week of gestation with an history of multiple abortions associated with autoimmune thrombophilia. A strictly designed perioperative management protocol was required to remove a huge right endoventricular mass, due to her decision to not terminate the pregnancy. CONCLUSIONS: Nowadays the mother, completely healthy, gived birth to her baby so it demonstrates how cardiac surgery, even in complicated circumstances, can be feasible during pregnancy through a multidisciplinary approach.

Mechanical complications of myocardial infarction during COVID-19 pandemic: An Italian single-centre experience.

COVID-19 pandemic triggered in many patients the fear to go to the emergency rooms in order to avoid a possible infection. This phenomenon caused a significant reduction in acute coronary syndrome-related interventional procedures with a subsequent increase in critical hospitalizations and post-infarction mechanical complications. A case series of cardiac ruptures during the COVID-19 lockdown and the surgical treatment of a huge post-ischemic cardiac pseudoaneurysm complicated by a "contained" free wall rupture are presented.

Endothelial nitric oxide synthase expression in postmenopausal women: a sex-specific risk factor in coronary surgery.

BACKGROUND: After coronary artery bypass graft surgery, older women have less favorable clinical outcome and lower conduit patency compared with men. This less favorable outcome can be in part ascribed to impaired endothelium-derived nitric oxide (eNOS) production. This study evaluated endothelial nitric oxide synthase expression in internal mammary artery from postmenopausal women undergoing coronary artery bypass graft surgery. METHODS: Internal mammary artery segments were obtained from 20 postmenopausal woman and 20 matched male patients. Twenty more segments from younger patients were used as controls. Expression of eNOS messenger RNA in internal mammary artery endothelial cells were evaluated by polymerase chain reaction and real-time quantitative reverse transcription polymerase chain reaction. The eNOS protein level was assayed by Western blot. Vascular dynamics of specimens were evaluated by organ chamber methodology. RESULTS: In postmenopausal women, the band of messenger RNA for eNOS was reduced by 37.4% and by 25.2%, respectively, compared with matched men and the control group (62.6%±4.8% versus 74.8%±5.3%, p<0.001). In comparison with the control group lane, the eNOS protein immunoreactive band was 44.2% decreased in postmenopausal women and 34.5% decreased in matched men, and was significantly decreased in postmenopausal women as compared with matched men (55.8%±4.6% versus 65.5%±5.2%, p<0.001). Nitric oxide-mediated vasomotor dynamics were consistent with reduced eNOS production. CONCLUSIONS: Internal mammary artery endothelial cells from women after menopause undergoing coronary surgery have impaired expression of messenger RNA for eNOS and reduced eNOS levels. Reduced bioactivity of nitric oxide translates into impaired endothelial metabolism that could contribute to worse surgical outcome.

Combination therapy with warfarin plus clopidogrel improves outcomes in femoropopliteal bypass surgery patients.

BACKGROUND: Patients having undergone femoropopliteal bypass surgery remain at significant risk of graft failure. Although antithrombotic therapy is of paramount importance in these patients, the effect of oral anticoagulation therapy (OAT) on outcomes remains unresolved. We performed a randomized, prospective study to assess the impact of OAT plus clopidogrel vs dual antiplatelet therapy on peripheral vascular and systemic cardiovascular outcomes in patients who had undergone femoropopliteal bypass surgery. METHODS: Three hundred forty-one patients who had undergone femoropopliteal surgery were enrolled and randomized: 173 patients received clopidogrel 75 mg/d plus OAT with warfarin (C + OAT), and 168 patients received dual antiplatelet therapy with clopidogrel 75 mg/d plus aspirin 100 mg/d (C + acetylsalicylic acid [ASA]). Study end points were graft patency and the occurrence of severe peripheral arterial ischemia, and the incidence of bleeding episodes. RESULTS: Follow-up ranged from 4 to 9 years. The graft patency rate and the freedom from severe peripheral arterial ischemia was significantly higher in C + OAT group than in C + ASA group (P = .026 and .044, respectively, Cox-Mantel test). The linearized incidence of minor bleeding complications was significantly higher in C + OAT group than in C + ASA group (2.85% patient-years vs 1.37% patient-years; P = .03). The incidence of major adverse cardiovascular events, including mortality, was found to be similar (P = .34) for both study groups. CONCLUSIONS: In patients who have undergone femoropopliteal vascular surgery, combination therapy with clopidogrel plus warfarin is more effective than dual antiplatelet therapy in increasing graft patency and in reducing severe peripheral ischemia. These improvements are obtained at the expenses of an increase in the rate of minor anticoagulation-related complications.

Major complications following endovascular surgery of descending thoracic aorta.

We evaluated the impact of major complications on clinical outcome in a series of patients undergoing endovascular repair (EVAR) of descending thoracic aorta. From March 2001 to June 2005, 51 patients underwent EVAR for descending aortic diseases. Thirty-five were treated in emergency (60.7%) and 41 (80.4%) were in III-IV ASA class. There were no deaths, surgical conversion or paraplegia. A neurologic complication occurred in one patient (1.9%). Eleven major systemic complications occurred in 5 patients. One patient showed a primary type I endoleak at discharge, resolved spontaneously after 9 months. Three (5.9%) vascular injuries occurred during the endovascular procedure, requiring an emergency rescue iliac-femoral artery bypass. At follow-up (29+/-14 months), there was an overall mortality rate of 5.1% (3/51); 2 deaths (3.9%) were procedure related. Two secondary EVARs (3.9%) were successfully performed, one for a late type I endoleak six months after EVAR in a traumatic patient, and a second for a late rupture distally to the stent-graft implanted 36 months before in an acute type-B dissected patient. EVAR for descending aortic diseases is associated with decreased mortality and complications, however, long-term follow-up and additional studies are mandatory to detect late failure and to confirm clinical safety of this procedure.

Impact of blood coagulation and fibrinolytic system changes on early and mid term clinical outcome in patients undergoing stent endografting surgery.

OBJECTIVES: Blood coagulation and fibrinolytic system changes after endovascular repair (EVAR) of aortic pathologies are of great interest. We have examined the risk for consumption coagulopathy and its clinical implications early, and at a mid-term follow-up, in a prospective study. METHODS: From June 2002 to June 2004, 41 patients for abdominal aortic aneurysm (AAA), 16 for thoracic aortic aneurysm (TAA) and 13 for acute type-B dissection underwent EVAR. Plasminogen, fibrin degradation products (FDP) and D-dimer were monitored as markers of fibrinolysis. Platelet count, fibrinogen, antithrombin III and prothrombin were assayed as markers of coagulation. The aortic diameters were assessed by computed tomography (CT) scan. RESULTS: FDP and D-Dimer levels significantly increased, while plasminogen values significantly decreased, on postoperative day 1 and 5, coagulation parameters significantly decreased on postoperative day 1 and 5. All parameters recovered on the 1st month of follow-up, except fibrinogen levels that showed a significant increase on month 1 and 6. We did not observe clinical complications related to coagulative disorders. There was no correlation between the preoperative diameter and the coagulative and fibrinolysis variations in the AAA and TAA group. Type-B dissection patients showed a significant correlation between the preoperative presence of a large false lumen and a high level of fibrinolysis. CONCLUSION: EVAR leads to changes in coagulation and fibrinolysis, with characteristic developments. These latter have no clinical relevance and have no effect on early outcome and on mid-term follow-up.