Congenital Ventricular Diverticulum.

Herein, we describe a 54-year-old patient with a congenital ventricular diverticulum (CVD), referred to our emergency department for presyncope episodes and multiple re-entrant ventricular tachycardias (VT). Significantly, echocardiographic findings were not clear, and the diagnosis was made by cardiac magnetic resonance imaging (CMRI), which showed the presence of an apical accessory cavity connected to the ventricle and contracting synchronously. CMRI allowed the differential diagnosis with other outpouching cardiac defects. The patient underwent a subcutaneous implantable cardioverter defibrillator (S-ICD) implant and was referred for heart transplantation (HT). The diagnosis, treatment, and main findings of the CVD are discussed in this case report.

A Case of Dyspnea in a Patient with a Previous Coronavirus Disease Infection: Pulmonary is not always the Cause.

Myxoma is the most common benign primary tumor of the heart. Diagnosis of cardiac myxoma is difficult as it presents itself with varying nonspecific symptoms, and an echocardiography can easily diagnose it. Sometimes, it can cause cardiac syncope and thromboembolic events. A woman with a recent infection by severe acute respiratory syndrome coronavirus-2 was admitted to our hospital with respiratory symptoms: dyspnea and tachypnea; cardiac symptoms: atrial fibrillation; and neurological symptoms: syncope. Initially, she performed brain computed tomography (CT) and CT angiography value. Transthoracic echocardiogram and transesophageal echocardiogram showed an atrial mobile mass. Chest X-ray did not show any interstitial lesions. Therefore, urgent cardiac surgery was performed to remove the mass. The histological examination confirmed the presence of a cardiac myxoma. Our experience could show the importance of early diagnosis and prompt surgical treatment to prevent stroke.

Cardiac surgery practice during the COVID-19 outbreak: a multicentre national survey.

OBJECTIVES: Healthcare systems worldwide have been overburdened by the coronavirus disease 2019 (COVID-19) outbreak. Accordingly, hospitals had to implement strategies to profoundly reshape both non-COVID-19 medical care and surgical activities. Knowledge about the impact of the COVID-19 pandemic on cardiac surgery practice is pivotal. The goal of the present study was to describe the changes in cardiac surgery practices during the health emergency at the national level. METHODS: A 26-question web-enabled survey including all adult cardiac surgery units in Italy was conducted to assess how their clinical practice changed during the national lockdown. Data were compared to data from the corresponding period in 2019. RESULTS: All but 2 centres (94.9%) adopted specific protocols to screen patients and personnel. A significant reduction in the number of dedicated cardiac intensive care unit beds (-35.4%) and operating rooms (-29.2%), along with healthcare personnel reallocation to COVID departments (nurses -15.4%, anaesthesiologists -7.7%), was noted. Overall adult cardiac surgery volumes were dramatically reduced (1734 procedures vs 3447; P < 0.001), with a significant drop in elective procedures [580 (33.4%) vs 2420 (70.2%)]. CONCLUSIONS: This national survey found major changes in cardiac surgery practice as a response to the COVID-19 pandemic. This experience should lead to the development of permanent systems-based plans to face possible future pandemics. These data may effectively help policy decision-making in prioritizing healthcare resource reallocation during the ongoing pandemic and once the healthcare emergency is over.

Fifty-one years with an aortic valve prosthesis despite suboptimal anticoagulation: half a century with the Smeloff-Cutter valve.

This case report describes an unusual case of a 69-year-old man who had an aortic valve replacement with the Smeloff-Cutter aortic mechanical prosthesis for aortic valve regurgitation at the age of 18 years. Echocardiography revealed a well-suited and well-functioning mechanical prosthesis. Even though the patient did not take any anticoagulant therapy or anti-platelets agent for 12 years, he was in surprisingly good health. To the best of our knowledge, this is the first time a mechanical 'ball-in-cage' valve prosthesis has lasted for such a long time without complications, although the patient has not been compliant with the anticoagulant therapy for 12 consecutive years.

The Importance of Ultrasound in a Case of Stroke Caused by Left Atrial Myxoma.

Myxoma is one of the most common cardiac tumors. It is relatively straightforward to diagnose by echocardiography. Sometimes, It can causes cardiac syncope and thromboembolic events. A woman without comorbidities was admitted to our hospital with stroke symptoms: left-sided hemiplegia and dysarthria. After brain computed tomography (CT) and angio-CT value, she was initially treated with pharmacological thrombolysis. Due to persisting symptoms, cerebral angiography and thrombectomy were then performed. At the end of this procedure, the patient had a complete neurological recovery, but she developed new symptoms, such as dyspnea and orthopnea. Transthoracic echocardiogram and transesophageal echocardiogram showed an atrial mobile mass. Therefore, an urgent cardiac surgery was performed in order to remove the mass. Histological examination confirmed cardiac myxoma. Our experience could show the importance of echocardiography to early diagnosis.

[Follow-up after surgical treatment of type A acute aortic dissection: current evidence and controversies]. / Follow-up dei pazienti sottoposti ad intervento per dissezione aortica acuta di tipo A: evidenze e controversie.

Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.

[Functional tricuspid regurgitation: imaging, surgical indications, reparative techniques and results]. / L'insufficienza tricuspidale funzionale: imaging, indicazioni chirurgiche, tecniche riparative e risultati.

Although the indications for surgical management of severe functional tricuspid regurgitation (TR) are now generally accepted, controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, particularly in patients with annular dilation. Echocardiographic imaging is the gold standard to identify functional TR and distinguish it from a primitive or degenerative form. Currently, surgery remains the best approach for the interventional treatment of TR. Ring annuloplasty seems to provide better results than suture annuloplasty (De Vega technique) and rigid rings appear to be more reliable in the long term, in comparison with flexible bands. Tricuspid valve repair is more beneficial compared with replacement, except in highly selected cases of long-standing TR with multifactorial mechanism.

Double Valve Failure Due to Perceval Sutureless Aortic Valve Migration.

A 76-year-old woman was admitted to the authors' hospital with pulmonary edema five months after the successful implantation of a Perceval sutureless aortic valve (Sorin Group Srl, Saluggia, Italy). Both echocardiography and computed tomography scanning demonstrated migration of the aortic valve into the left ventricle, causing severe aortic and mitral (secondary) insufficiency. Following heart team discussions, the sutureless valve was replaced with a standard bioprosthesis (Perimount, Magna Ease; Edwards Lifesciences, Irvine, California, USA) with spontaneous restoration of native mitral valve competence. The present case is the first of a new presentation of early Perceval sutureless aortic valve proximal migration, and highlights the importance of careful preoperative assessment and regular postoperative follow up after sutureless aortic valve implantation.

Direct Transaortic TEVAR: An Alternative Option for Selected Patients With Unsuitable Peripheral Access.

Thoracic endovascular aortic repair (TEVAR) is effectively executed in patients with arch or descending aortic diseases. Peripheral access sites are preferably used as standard gates for TEVAR. Feasibility of a peripheral approach might need an intraoperative evaluation and alternative routes should have been carefully assessed. In this article, we report 2 successful cases of direct transaortic TEVAR, where stent grafts were directly introduced into the native ascending aorta without external conduits. A satisfactory result and the absence of aortic-related complications were observed at 2 and 5 years' follow-up, respectively.

Direct Flow Implantation in a Patient With Mechanical Mitral Prostheses.

We describe a case of Direct Flow (Direct Flow Medical Inc, Santa Rosa, CA) transcatheter aortic valve implantation in a patient with a mechanical valve in a mitral position.

Mitral valve endocarditis due to Abiotrophia defectiva in a 14th week pregnant woman.

Infective endocarditis during pregnancy carries a high mortality risk, both for the mother and for the foetus and requires a multidisciplinary team in the management of complicated cases. We report our experience with a 39-year old patient, affected by an acute active mitral endocarditis due to Abiotrophia defectiva at the 14th gestational week, strongly motivated to continue the pregnancy. Our patient successfully underwent mitral valve replacement with a normothermic high-flow cardiopulmonary bypass under continuous intraoperative foetal monitoring. Caesarean section occurred at the 38th gestational week. The delivery was uneventful and both the mother and child are doing well at the 16-month follow-up.

Alternative transarterial access for CoreValve transcatheter aortic bioprosthesis implantation.

Transcatheter aortic valve implantation (TAVI) is used to treat elderly patients with severe aortic stenosis who are considered extremely high-risk surgical candidates. The safety and effectiveness of TAVI have been demonstrated in numerous studies. The self-expanding CoreValve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) was the first transcatheter aortic valve to be granted the Conformité Européene (CE) mark in May 2007 for retrograde transfemoral implantation. However, TAVI patients are also often affected by severe iliofemoral arteriopathy. In these patients, the retrograde transfemoral approach carries a high risk of vascular injury, making this approach unusable. Alternative arterial access sites, such as the subclavian artery, the ascending aorta, and the carotid artery, have been used for retrograde implantation of the CoreValve bioprosthesis. In the present report, we present the procedural considerations, risks, and benefits of the different types of arterial access used to implant the CoreValve bioprosthesis.

Right anterior mini-thoracotomy direct aortic self-expanding trans-catheter aortic valve implantation: A single center experience.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for surgery. These patients are also often affected by severe iliac-femoral arteriopathy, rendering the trans-femoral approach unusable. We report our experience with the direct-aortic approach to treat these patients. METHODS: From May 2008 to November 2013 two hundred and thirty-two patients (131 female, 56%) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were evaluated for TAVI at our department. Of these patients, 202 were deemed eligible for TAVI. Of this group, 50 underwent CoreValve implantation by the direct aortic approach through a right anterior mini-thoracotmy (28 female, 56%), mean age 81.2±6.9. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. RESULTS: Twenty-eight (56%) patients were female and 11 (22%) were redo at TAVI. We used a 23-mm CoreValve Evolute in 3 patients (6%), and the most used valve size was the 29mm in 46% of patients. Mean hemodynamic trans-aortic gradient was less than 5mmHg. The paravalvular regurgitation was ≤ grade 1 in 46 patients as assessed by peri-procedural transesophageal echocardiography (TEE). Seven patients (7/43, 16%) required a permanent pacemaker implantation; 30-day mortality was 6% (3 patients). Seven patients (14.8%) died during follow-up. Actuarial survival at 2years is 84.7±5.3%. CONCLUSIONS: Transcatheter aortic valve implantation with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure.

Redo mitral valve replacement through a right mini-thoracotomy with an unclamped aorta.

Redo cardiac surgery represents a clinical challenge due to a higher rate of perioperative morbidity and mortality. Mitral valve (MV) re operations can particularly be demanding in patients with patent coronary grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, leaks or thrombosis). In this article we describe our technique to manage complex mitral reoperations using a minimally invasive approach, moderate hypothermia and avoiding aortic cross-clamping. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of less invasive access and continuous myocardial perfusion. The advantage of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, reducing the risk of cardiac structures or patent graft injury. Moderate hypothermia and continuous blood perfusion can guarantee adequate myocardial protection particularly in the case of patent grafts, decreasing the dangers of an incomplete or imperfect aortic clamping at mild hypothermia and potential lesions due to demanding clamp placing. Complex MV reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space with an unclamped aorta.

Minimally invasive approach for redo mitral valve surgery.

Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.

Postsurgical intrapericardial adhesions: mechanisms of formation and prevention.

Postsurgical intrapericardial adhesions are still considered an unavoidable consequence of cardiothoracic operations. They increase the technical difficulty and the risk of reoperations. The pathogenesis of postsurgical adhesions is a multistep process, and the main key players are (1) loss of mesothelial cells, (2) accumulation of fibrin in areas devoid of mesothelial cells, (3) loss of normal pericardial fibrinolysis, and (4) local inflammation. Today, very promising methods to reduce adhesions are available for clinical use. This report reviews the process of formation of adhesions and the methods to prevent them, classified according to the mechanism of action.

Redox proteomics identification of oxidatively modified myocardial proteins in human heart failure: implications for protein function.

Increased oxidative stress in a failing heart may contribute to the pathogenesis of heart failure (HF). The aim of this study was to identify the oxidised proteins in the myocardium of HF patients and analyse the consequences of oxidation on protein function. The carbonylated proteins in left ventricular tissue from failing (n = 14) and non-failing human hearts (n = 13) were measured by immunoassay and identified by proteomics. HL-1 cardiomyocytes were incubated in the presence of stimuli relevant for HF in order to assess the generation of reactive oxygen species (ROS), the induction of protein carbonylation, and its consequences on protein function. The levels of carbonylated proteins were significantly higher in the HF patients than in the controls (p<0.01). We identified two proteins that mainly underwent carbonylation: M-type creatine kinase (M-CK), whose activity is impaired, and, to a lesser extent, α-cardiac actin. Exposure of cardiomyocytes to angiotensin II and norepinephrine led to ROS generation and M-CK carbonylation with loss of its enzymatic activity. Our findings indicate that protein carbonylation is increased in the myocardium during HF and that these oxidative changes may help to explain the decreased CK activity and consequent defects in energy metabolism observed in HF.