[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.

CT angio for the evaluation of graft patency.

Invasive coronary angiography (ICA) is the traditional method for the follow-up of graft patency in coronary artery bypass graft (CABG) patients. Nevertheless, the advent of multidetector computed tomography (MDCT) opened new perspectives for using a noninvasive, equally reliable method to study CABG patients. This review article will analyze the current feasibility of modern multi-slice MDCT, as well as its future perspectives.

Cardiac tamponade caused by a migrating sewing needle.

: Penetrating injuries of the heart caused by migrating needles have been rarely described. They usually occur accidentally or are self-inflicted in the setting of an underlying psychiatric disorder. We present an unusual case of cardiac tamponade caused by a sewing needle that migrated to the heart from the chest wall through the lung. The lesions were successfully repaired through a median sternotomy without cardiopulmonary bypass. The pathophysiological mechanism and the pertinent literature are briefly analysed.

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.

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.

Aortic valve repair after blunt chest trauma: repair of traumatic aortic valve rupture.

A frequent reason of admission to the emergency room is blunt chest trauma following car accidents. Chest injuries may cause a wide range of cardiac lesions, extending from myocardial contusion, to heart or great vessels rupture, to valvular lesions. We present a case of aortic valve rupture after blunt chest trauma.

Partial obstruction of the inferior vena cava after surgery for left atrial myxoma.

We present a case of iatrogenic partial obstruction of the inferior vena cava after removal of a left atrial myxoma. The closure occurred subsequent to repair of a discontinuity between the right atrium and inferior vena cava caused by excessive traction on frail tissues.

Noninvasive midterm follow-up of radial artery bypass grafts with 16-slice computed tomography.

BACKGROUND: The standard invasive procedure to evaluate graft patency is selective coronary angiography. The recent introduction of a new generation of multidetector row computed tomography made possible the noninvasive study of grafts with excellent results in terms of visualization and resolution. We used computed tomography to study all patients with a radial artery graft operated on in 2002. METHODS: Between April and October 2005, we reviewed all patients operated on by coronary artery bypass grafting at our institution between January and December 2002. A total of 62 patients received a radial artery graft. Of these, 22 were lost at the time of follow-up. The other 40 patients were enrolled for a multidetector row computed tomography study. Demographic and instrumental data were collected for all the patients. A total number of 145 grafts were studied, with complete and excellent visualization. RESULTS: The scans revealed a 97.77% (44 of 45) patency rate for left internal mammary arteries, 90.57% (48 of 53) for vein grafts, and 73.91% (34 of 46) for radial arteries (mammary artery plus vein grafts versus radial artery patency, p < 0.001). If analyzed for target vessel, we found the poorest result of radial grafts when placed on the right coronary artery (40% [2 of 5] patency rate). CONCLUSIONS: Noninvasive control of previously bypassed patients is feasible, with no discomfort for them and excellent visualization of grafts. The use of the radial artery as a conduit for bypass graft can be achieved with good results, after a careful choice of the target vessel.

[Surgical myocardial revascularization in patients over and under 70 years of age: results and prognostic factors]. / Rivascolarizzazione miocardica chirurgica nei pazienti di età superiore ed inferiore a 70 anni: risultati e fattori prognostici.

BACKGROUND: The increase in mean age has made older patients candidates to myocardial revascularization. This study is focused to evaluate hospital mortality and major postoperative complications in two groups of patients < or = 70 or > 70 years. The possible confounder effect of other important risk factors has been studied in multivariate models. METHODS: From January 1 to December 31, 2002, 228 patients < or = 70 years (group A) and 116 patients > 70 years (group B) underwent isolated myocardial revascularization. We analyzed the incidence of hospital mortality, cardiac failure, postoperative bleeding, major arrhythmias, atrial fibrillation, respiratory failure, renal failure, sternal infection, stroke, transient ischemic attack, total neurological complications, and number of patients with at least one of these complications. Univariate statistical analysis was used to compare this two groups and multivariate analysis to adjust for four known important risk factors, i.e. sex, diabetes, ejection fraction < 0.40, and off-pump surgical technique. RESULTS: Hospital mortality was statistically higher in group B than in group A (7.8 vs 1.7%, p < 0.05). The incidence of cardiac failure, although higher in group B, was not statistically significant. Multivariate analysis confirmed low ejection fraction as the only statistical risk factor for low cardiac output (p < 0.05). Atrial fibrillation was statistically higher in group B (p < 0.05). No difference was found for all other complications considered. Age, low ejection fraction and the use of cardiocirculatory bypass at multivariate analysis were statistically significant risk factors for the incidence of at least one postoperative event. CONCLUSIONS: Myocardial revascularization in patients > 70 years has a higher mortality and morbidity. At multivariate analysis, low ejection fraction is also confirmed as a significant risk factor for low cardiac output and total morbidity. At the same time, the technical option of "beating heart" myocardial revascularization seems to achieve better results and probably it should be used more extensively in this group of patients.