Early and Mid-term Outcome of the St. Jude Medical Regent 19-mm Aortic Valve Mechanical Prosthesis. Functional and Haemodynamic Evaluation.

BACKGROUND AND OBJECTIVES: The aim of the present study is to report the early and mid-term clinical and haemodynamic results of the St Jude Medical Regent 19-mm aortic mechanical prothesis (SJMR-19). MATERIALS AND METHODS: Between January 2002 and January 2012, 265 patients with aortic valve disease underwent AVR (Aortic Valve Replacement) with a SJMR-19 (St Jude Medical Regent Nr.19). There were 51 males. Mean age was 67.5±12.72years and mean body surface area (BSA) was 1.67±0.14m2. Thirty-six patients required annulus enlargement. The mean follow-up was 34.5±18.8months (range 6-60 months). All patients underwent echocardiographic examination at discharge and within 1 year after surgery. RESULTS: There were 14 (5.3%) hospital deaths. Six of the hospital deaths were identified in patients undergoing reoperation, significantly higher than patients undergoing first time operation (p=0.0001). Also the postoperative mortality was significantly higher in patients undergoing annulus enlargement versus patients not requiring annulus enlargement (p=0.02). The mean transprosthesis gradient at discharge was 19±9mmHg. At 6 months follow-up the mean NYHA FC class was 1.6±0.5 significantly lower than preoperatively 2.4±0.75 (p <0.0001). The M-TPG was 15.2±6.5mmHg within 1 year after surgery. Left ventricular mass (LVM) and indexed left ventricular mass (LVMi) were significantly lower than preoperatively The actuarial survival and cumulative freedom from reoperation at 1, 2 and 3 years follow-up were 99.5%, 97.5%, 96.7% and 99.2%, 96.5%, 94.5% respectively. The cumulative actuarial free-events survival at 4 years was 92%. The Cox model identified age (p=0.015), LVEF≤35% (p=0.043), reoperation (p=0.031), combined surgery (p=0.00002), and annulus enlargement (p=0.015) as strong predictors for poor actuarial free-major events survival. CONCLUSIONS: The SJMR-19 offers excellent postoperative clinical, haemodynamic outcome and LVMi reduction in patients with small aortic annulus. These data demonstrate that the modern St Jude small mechanical protheses do not influence the intermediate free-reoperation survival.

The Strange Case of the Infarcted Myxoma.

In the setting of an acute coronary syndrome, the differential diagnosis between a thrombus and a myxoma may be cumbersome. We describe the case of a patient presenting with an acute coronary syndrome associated with an aneurysmatic apical left ventricular myxoma.

Barriers to cardiac rehabilitation access of older heart failure patients and strategies for better implementation.

In heart failure (HF), cardiac rehabilitation (CR) may reduce decompensations, hospitalization, and ultimately mortality in long term. Many studies over the past decade have demonstrated that aerobic exercise training is effective and safe in stable patients with HF. Exercise CR resulted in a clinically important improvement in the QOL. Several clinical and psychosocial factors are associated with decreased participation in CR programs of elderly HF patients, such as perception of exercise as tiring or painful, comorbidities, lack of physician encouragement, and opinion that CR will not improve their health status. Besides low functional capacity, and chronic deconditioning may also deter patients from participating in CR programs. Recent data suggest that current smoking, a BMI ≥30 kg/m2, diabetes mellitus, and cognitive dysfunction are associated with failure to enroll in outpatient CR in older age group. Moreover the lack of availability of CR facilities or the absence of financial refunds for enrolment of CHF patients in cardiac rehabilitation programs can play a crucial role. Many of this factors are modifiable through patient education and self care strategy instruction, health providers sensibilization, and implementing economic measures in order to make CR affordable.

Cardiac rehabilitation is safe and effective also in the elderly, but don't forget about drugs!

In the setting of heart failure (HF) pharmacotherapy demonstrates a quantifiable improvement in exercise tolerance also in HF with preserved ejection fraction (HFpEF). For patients with HFpEF, often older, with higher prevalence of hypertension, diabetes mellitus, atrial fibrillation and other comorbidities, endpoints such as quality of life and functional capacity may be more clinically relevant. However several study show as the use of ACE-I and B-blocker were lesser than expected. Beta-blocker therapy is the keystone of pharmacotherapy of HF patients and exercise training is the essential core of rehabilitation programs, it is important to elucidate the relationship between these therapies. Exercise training improves the clinical status of HF, improving left ventricular ejection fraction and improving quality of life, but it is possible that b-blocker may attenuate exercise training adaptations. Despite this, possible adverse b-blocker effects are just presumed and not confirmed by published randomized clinical trials. Metanalysis suggests that b-blocker compared with placebo enhances improvements in cardiorespiratory performance in exercise training intervention. Despite these evidences, prescription of gold standard therapy and adherence are still suboptimal and should be a priority goal for all CR program.

St. Jude Trifecta versus Carpentier-Edwards Perimount Magna valves for the treatment of aortic stenosis: comparison of early Doppler-echocardiography and hemodynamic performance.

OBJECTIVE: Aim of this study was to compare the hemodynamic profiles of 2 aortic valve bioprostheses: the Carpentier Edwards Perimount Magna (CEPM) valve and the Trifecta valve. METHODS: 100 patients who underwent AVR for severe symptomatic AS between September 2011 and October 2012 were analyzed by means of standard trans-thoracic Doppler-echocardiography. RESULTS: Mean and peak gradients were significantly lower for the 21 mm Trifecta vs CEPM (11 +/- 4 vs 15 +/- 4 mmHg, and 20 +/- 6 vs 26 +/- 7 mmHg, respectively; all p < 0.05) and the 23 mm Trifecta vs CEPM (8 +/- 2 vs 14 +/- 4 mmHg, and 17 +/- 6 vs 25 +/- 9 mmHg; all p < 0.05). Effective orifice area tended to be slightly higher for the Trifecta valve. CONCLUSION: The new bioprosthetic valve Trifecta has an excellent hemodynamic profile, and lower trans-prosthesic gradients when compared to CEPM valve.

The pressure/volume relationship during dobutamine stress echocardiography in transplanted heart: comparison with quality of life and coronary anatomy.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a major late complication in cardiac transplant recipients and has a relevant impact on outcome of these patients. AIMS OF THIS STUDY: to compare, in cardiac transplant recipients patients, the diagnostic value of pressure/volume relationship (ESPVR) during dobutamine stress echocardiography (DSE) for coronary artery disease, assessed by Multislice Computed Tomography (MSCT), and by coronary angiography (CA). We also analyzed any possible relationship between ESPVR and the Health Related Quality of Life of the patients (HRQoL), evaluated by SF-36 questionnaire. METHODS: 25 consecutive patients underwent DSE within 24 hours after MSCT coronary angiogram and then they underwent CA. The HRQoL questionnaire was administered to the patients in the settings of DSE. They were followed-up for 6 months. RESULTS: DSE has a sensitivity in detecting CAV of 67%, specificity of 95%, positive predictive value of 67% and negative predictive value of 95%; DSE with ESPVR has a sensitivity of 100%, specificity of 95%, positive predictive value of 75%, negative predictive value of 100%; MSCT has a sensitivity of 100%; specificity of 82%; positive predictive value of 43%; negative predictive value of 100%. Htx recipients with a flat-biphasic ESPVR, although asymptomatic, perceived a worst HRQoL compared with the up-sloping ESPVR population, and this is statistically significant for the general health (p 0.0004), the vitality (p 0.0013) and the mental health (p 0.021) SF-36 subscale. CONCLUSIONS: Evaluation with DSE and ESPVR is accurate in the clinical control of heart transplant recipients reserving invasive evaluation only for patients with abnormal contractility indexes.

Congenitally corrected transposition of the great arteries with severely stenotic bicuspid aortic valve in an adult: a case report.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare disease accounting for 0.5-1.4% of patients with congenital heart disease. In this congenital cardiopathy, the left atrium is connected to the right ventricle, from which the aorta stems. We present a case of an adult with CCTGA associated with aortic stenosis and bicuspid aortic valve-an association not yet described to our knowledge.

Role of a multidisciplinary program in improving outcomes in cognitively impaired heart failure older patients.

BACKGROUND: Cognitive impairment (CI) frequently complicates Heart failure (HF) and is associated with increased mortality and morbidity. Previous studies reported that nurse-lead home-based multidisciplinary program (MP) may not improve the prognosis of this high-risk group. In the present study, we analysed the relative effectiveness of an integrated hospital-based MP in patients with cognitive impairment. METHODS: Consecutive (n = 173) community-living outpatients aged > 70 years (mean 77 +/- 6, 48% women) randomized to a MP (n = 86) or usual care (UC) (n = 87) were enrolled in stable clinical conditions. Cognitive status was assessed by means of Folstein Mini Mental State Examination (MMSE). RESULTS: CI (MMSE < or = 24) was present in 41.6% (42,5% UC vs 40.7% MP p =ns). The variables independently associated to CI were: older age, education level <5 years, anemia and severe renal dysfunction. During a 2-year follow-up, 59 patients died (31.4%) with no significant difference between intervention group. At multivariate analysis, in the entire cohort, CI was independently associated to death (HR 2,07 7[95%CI 1,097-3,931]), HF admissions (2,133[1,346-3,381]), death/HF admissions (1,784[1,132-2,811]) and all-cause admissions (1,473[1,008-2,153]. When considered according to intervention groups, CI was independently associated to all-cause death (3,603 [1,553-8,358], death/HF admissions (2,029[1,200-3,432]) and HF admissions (2,474[1,406-4,353]) but not to all-cause admissions. The assignment of patients with CI to MP was associated to a significant reduction in HF admissions vs UC (0,503[0,253-0,999] (all interaction tests p = ns). CONCLUSIONS: This study suggests that CI is very common and associated to worse prognosis in heart failure and that hospital-based MP seems to improve outcomes in these patients through reduction of heart failure hospital admission.

Early Doppler-echocardiography evaluation of Carpentier-Edwards Standard and Carpentier-Edwards Magna aortic prosthetic valve: comparison of hemodynamic performance.

OBJECTIVES: This study was designed to describe Doppler-echocardiography values of Carpentier-Edwards Perimount Standard (CEPS) and Carpentier-Edwards Perimount Magna (CEPM) aortic prosthetic valves, evaluated by a single, experienced echo-laboratory, early in the postoperative phase. METHODS: Three-hundred-seventy-seven consecutive patients, who had had a CEPS or a CEPM implanted in our Hospital due to aortic stenosis and/or insufficiency, underwent baseline Doppler echocardiography evaluation within 7 days after surgery. Hemodynamic performances of CEPS and CEPM were accurately described, evaluating flow-dependent (transprosthetic velocities and gradients) and flow-independent (effective orifice area, indexed effective orifice area and Doppler velocity index) Doppler-echocardiography parameters. RESULTS: Out of the 377 patients 48.8% were men (n = 184), mean age was 74.63 ± 6.77 years, mean BSA was 1.78 ± 0.18 m2, mean ejection fraction was 57.78 ± 8%. Two-hundred and sixty two CEPS and 115 CEPM were implanted. Comparing size-by-size CEPS with CEPM, both prostheses showed a good hemodynamic profile, with fairly similar values of pressure gradients (PGmax and mean, in mmHg, = 37,18 ± 11.57 and 20.81 ± 7.44 in CEPS n°19 compared to 32,47 ± 7,76 and 17,67 ± 4.63 in CEPM n°19 and progressively lower in higher sized prostheses, having PGmax and mean 15 ± 3,16 and 9.15 ± 1,29 in CEPS n°29 compared to 15,67 ± 1,53 and 9 ± 1 in CEPM n°29) and EOAi (being 0,65 ± 0,33 cm²/m² in CEPS n°19 compared to 0,77 ± 0,29 cm²/m² in CEPM n°19 and progressively higher in higher sized prostheses, being 1,28 ± 0,59 cm²/m² in CEPS n°29 compared to 1,07 ± 0,18 cm²/m² in CEPM n°29), the latter resulting, however, basically less flow obstructive. CONCLUSIONS: Our data confirm the good hemodynamic performance of both aortic bioprostheses and the more favourable hemodynamic profile of CEPM compared to CEPS, pointing out the need to perform routinely an accurate baseline Doppler-echocardiography evaluation early after surgery to allow an adequate interpretation of data at follow-up.

An isolated anterior mitral leaflet cleft: a case report.

INTRODUCTION: The anterior mitral leaflet cleft is an unusual congenital lesion most often encountered in association with other congenital heart defects. The isolated anterior leaflet cleft is quite a rare anomaly and is usually cause of mitral valve regurgitation. The importance of the lesion is that it is often correctable. When feasible, cleft suture and, eventually, annuloplasty are preferable to valve replacement. Echocardiography is the first choice technique in the evaluation of mitral valve disease, providing useful information about valve anatomy and hemodynamic parameters. CASE PRESENTATION: We present a case of an isolated anterior mitral leaflet cleft producing moderate-severe mitral regurgitation correctly identified by echocardiography and successfully surgically corrected. CONCLUSION: Isolated cleft is a rare aberration, that has to be known in order to be diagnosed. Transthoracic and transesophageal echocardiography is the most useful non invasive technique for cleft diagnosis and to indicate the right surgical correction.

Preoperative scallop-by-scallop assessment of mitral prolapse using 2D-transthoracic echocardiography.

BACKGROUND: This study was conducted to assess the accuracy of harmonic imaging 2D-transthoracic echocardiography (2D-TTE) segmental analysis compared to surgical findings, in degenerative mitral regurgitation (MR). METHODS: Seventy-seven consecutive patients with severe degenerative MR were prospectively enrolled. Preoperative 2D-TTE with precise localization of prolapsing or flailing scallops/segments was performed. All patients underwent mitral valve surgical repair. Surgical reports (SR), including valve description, were used as references for comparisons. A postoperative control 2D-TTE was performed. RESULTS: Out of 462 scallops/segments studied, surgical inspection identified 102 prolapses or flails (22%), 92 of which had previously been detected by 2D-TTE (90.2% sensitivity, 100% specificity). Agreement between preoperative 2D-TTE segmental analysis and SR was 97.8% (k = 0.93; p < 0.0001). Sixty-nine out of 77 2D-TTE reports were completely concordant with SR (89.6% diagnostic accuracy). None of the 8 non-concordant 2D-TTE reports were in complete disagreement with SR. P2 scallop was always involved in posterior leaflet prolapse or flail and was described correctly by 2D-TTE in 68 out of 69 patients (98,7% agreement, k = 0,93; 98.5% sensitivity). The anterior leaflet was involved in 14 patients (18%); A2 segment was involved in all of those cases and was correctly detected by 2D-TTE in 13 (98,7% agreement, k = 0,95; 92,8% sensitivity). Antero-lateral and postero-medial para-commissural prolapse or flail had a lower prevalence (14% and 10% respectively), with 2D-TTE sensitivity respectively of 64% and 50%. CONCLUSIONS: 2D-TTE, performed by an experienced echo-lab, has very good diagnostic accuracy in localizing the scallops/segments involved in degenerative MR, particularly for the middle ones (P2-A2), which represent almost the totality of prolapses. More invasive, time consuming and expensive exams should be reserved to selected cases.

Left ventricular myxoma originating from the interventricular septum and obstructing the left ventricular outflow tract.

In a 60-year-old woman with episodic exertional faintness, a large left ventricular (LV) myxoma attached by a pedicle to the apical interventricular septum and prolapsing through the LV outflow tract and the aortic valve causing a severe obstruction was found by echocardiography. Early surgical excision was successfully performed using the transaortic approach.

Rest and Dobutamine stress echocardiography in the evaluation of mid-term results of mitral valve repair in Barlow's disease.

BACKGROUND: Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up. METHODS AND RESULTS: Twenty patients selected for the study (12 men and 8 women, mean age 60 +/- 9 years) underwent pre- and post-operative transthoracic echocardiography (TTE) and intra-operative transesophageal echocardiography (TEE). At mid-term follow-up (20 +/- 5 months) all patients underwent rest TTE and DSE (3 min. dose increments up to 40 microg/Kg/min protocol). Pre-discharge and one-month TTE showed absence of MR in 11 pts., trivial or mild MR in 9 pts. and normal mitral valve area and gradients. Mid-term TTE showed decrease in left atrial and ventricular dimension, in pulmonary artery pressure (sPAP) and grade of MR. During DSE a significant increase in mitral valve area, maximum and mean gradients, sPAP, heart rate and cardiac output and a decrease in systolic annular diameter and left ventricular volume were found; in 6 pts. a transient left ventricular outflow tract obstruction was observed. CONCLUSION: Basal and Dobutamine stress echocardiography proved to be valuable tools for evaluation of mid-term results of mitral valve repair. In our study population, the surgical technique employed had a favourable impact on several cardiac parameters, evaluated by these methods.

Feasibility, safety and tolerability of accelerated dobutamine stress echocardiography.

A continuous infusion of a single high dose of dobutamine has been, recently, suggested as a simple and effective protocol of stress echocardiography. The present study assesses the feasibility, safety, and tolerability of an accelerated dobutamine stress protocol performed in patients with suspected or known coronary artery disease. Two hundred sixty five consecutive patients underwent accelerated dobutamine stress echocardiography: the dobutamine was administered at a constant dose of 50 microg/kg/min for up to 10 minutes. The mean weight-adjusted cumulative dose of dobutamine used was 330 +/- 105.24 microg/kg. Total duration of dobutamine infusion was 6.6 +/- 2.1 min. Heart rate rose from 69.9 +/- 12.1 to 123.1 +/- 22.1 beats/min at peak with a concomitant change in systolic blood pressure (127.6 +/- 18.1 vs. 167.6 +/- 45.0 mmHg). Dobutamine administration produced a rapid increase in heart rate (9.4 +/- 5.9 beats/min2). The side effects were similar to those described with the standard protocol; the most common were frequent premature ventricular complexes (21.5%), frequent premature atrial complexes (1.5%) and non sustained ventricular tachycardia (1.5%); among non cardiac symptoms the most frequent were nausea (3.4%), headache (1.1%) and symptomatic hypotension (1.1%). No major side effects were observed during the test. Our data demonstrate that a continous infusion of a single high dose of dobutamine is a safe and well tolerated method of performing stress echocardiography in patients with suspected or known coronary artery disease. This new protocol requires the administration of lower cumulative dobutamine dose than standard protocol and results in a significant reduction in test time.

Atrial fibrillation management in older heart failure patients: a complex clinical problem.

BACKGROUND: Atrial fibrillation (AF) and heart failure (HF), two problems of growing prevalence as a consequence of the ageing population, are associated with high morbidity, mortality, and healthcare costs. AF and HF also share common risk factors and pathophysiologic processes such as hypertension, diabetes mellitus, ischemic heart disease, and valvular heart disease often occur together. Although elderly patients with both HF and AF are affected by worse symptoms and poorer prognosis, there is a paucity of data on appropriate management of these patients. METHODS: PubMed was searched for studies on AF and older patients using the terms atrial fibrillation, elderly, heart failure, cognitive impairment, frailty, stroke, and anticoagulants. RESULTS: The clinical picture of HF patients with AF is complex and heterogeneous with a higher prevalence of frailty, cognitive impairment, and disability. Because of the association of mental and physical impairment to non-administration of oral anticoagulants (OACs), screening for these simple variables in clinical practice may allow better strategies for intervention in this high-risk population. Since novel direct OACs (NOACs) have a more favorable risk-benefit profile, they may be preferable to vitamin K antagonists (VKAs) in many frail elderly patients, especially those at higher risk of falls. Moreover, NOACs are simple to administer and monitor and may be associated with better adherence and safety in patients with cognitive deficits and mobility impairments. CONCLUSIONS: Large multicenter longitudinal studies are needed to examine the effects of VKAs and NOACs on long-term cognitive function and frailty; future studies should include geriatric conditions.

Incremental Value of Gait Speed in Predicting Prognosis of Older Adults With Heart Failure: Insights From the IMAGE-HF Study.

OBJECTIVES: The aim of this study was to assess the relationship between gait speed and the risk for death and/or hospital admission in older patients with heart failure (HF). BACKGROUND: Gait speed is a reliable single marker of frailty in older people and can predict falls, disability, hospital admissions, and mortality. METHODS: In total, 331 community-living patients ≥70 years of age (mean age 78 ± 6 years, 43% women, mean ejection fraction 35 ± 11%, mean New York Heart Association functional class 2.7 ± 0.6) in stable condition and receiving optimized therapy for chronic HF were prospectively enrolled and followed for 1 year. Gait speed was measured at the usual pace over 4 m, and cutoffs were defined by tertiles: ≤0.65, 0.66 to 0.99, and ≥1.0 m/s. RESULTS: There was a significant association between gait speed tertiles and 1-year mortality: 38.3%, 21.9%, and 9.1% (p < 0.001), respectively. On multivariate analysis, gait speed was associated with a lower risk for all-cause death (hazard ratio: 0.62; 95% confidence interval: 0.43 to 0.88) independently of age, ejection fraction <20%, systolic blood pressure, anemia, and absence of beta-blocker therapy. Gait speed was also associated with a lower risk for hospitalization for HF and all-cause hospitalization. When gait speed was added to the multiparametric Cardiac and Comorbid Conditions Heart Failure risk score, it improved the accuracy of risk stratification for all-cause death (net reclassification improvement 0.49; 95% confidence interval: 0.26 to 0.73, p < 0.001) and HF admissions (net reclassification improvement 0.37; 95% confidence interval: 0.15 to 0.58; p < 0.001). CONCLUSIONS: Gait speed is independently associated with death, hospitalization for HF, and all-cause hospitalization and improves risk stratification in older patients with HF evaluated using the Cardiac and Comorbid Conditions Heart Failure score. Assessment of frailty using gait speed is simple and should be part of the clinical evaluation process.

Atrial fibrillation, cognitive impairment, frailty and disability in older heart failure patients.

BACKGROUND: Aim of the study was to prospectively assess the relation between atrial fibrillation, cognitive impairment, frailty and disability in older patients with chronic heart failure . METHODS: Three hundred thirty-one ambulatory community-living patients aged 70 years and older (mean 78 ±â€Š6; range 70-93; 43% women) in stable conditions and optimized therapy were enrolled in seven heart failure cardiology clinics. Cognitive impairment was defined by a corrected Mini Mental State Examination score less than 24. Gait speed was used as marker of frailty and measured on a 4 m distance at usual pace. RESULTS: Ninety-eight patients (30%) were on atrial fibrillation at enrolment and 20 (6%) had a history of paroxysmal/persistent atrial fibrillation. Patients with atrial fibrillation were more frequently women with severe valvular disease, preserved left ventricular ejection fraction and less frequently on beta-blockers. At multivariable analyses, atrial fibrillation emerged as independently related to cognitive impairment [odds ratio (OR) 1.909 (1.072-3.397); P = 0.028], as well as to reduced gait speed [OR 4.366 (2.104-9.060); P < 0.001]. Furthermore, atrial fibrillation was significantly associated with disability in either basic or instrumental activities of daily living. No differences were found in mortality and morbidity. CONCLUSION: Among patients with chronic heart failure, those with atrial fibrillation present a high prevalence of frailty, cognitive impairment and disability. The hypothetical mechanisms by which atrial fibrillation and heart failure may affect these conditions are multiple and further studies are warranted. However, screening for these variables in clinical practice is simple and inexpensive and may allow better strategies for intervention in this high-risk population.

A normogram to anticipate dimension of neo-sinuses of valsalva in valve-sparing aortic operations.

OBJECTIVE: The aim of the present study was to define a method to pre-determine the correct size of neo-sinuses of Valsalva in the reimplantation type of valve-sparing aortic operation. METHODS: The objective was achieved in three steps: (1) evaluation in the healthy population, of the normal size of sinuses of Valsalva expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area; (2) elaboration of a normogram by which, given a known annular diameter, it is possible to select the appropriate graft size to obtain a normal beyond leaflets area; (3) validation of the normogram by comparing, in a population of 20 patients undergoing a valve-sparing procedure, the predicted and observed beyond leaflets area. RESULTS: The following values for beyond leaflets area were observed: mean normal 320.6+/-120.6mm(2), mean predicted 355+/-63.2mm(2), mean observed 364.7+/-72.8mm(2).No significant differences were obtained for predicted versus observed values. Regression analysis showed a linear distribution with an r value of 0.95. CONCLUSIONS: We proposed a simplified approach for sizing of the neo-aortic root in the reimplantation type of valve-sparing aortic operation focussed on the size of sinuses of Valsalva. Our normogram showed to be reliable in anticipating beyond leaflets area. It can be helpful in avoiding the selection of an undersized or excessively oversized graft.

Noncompaction and embolic myocardial infarction: the importance of oral anticoagulation.

Left ventricular noncompaction (LVNC) is characterized by left ventricular (LV) hypertrabeculations and is associated with heart failure, arrhythmias and embolism. We report the case of a 67-year-old LVNC patient, under oral anticoagulation (OAC) therapy for apical thrombosis. After she discontinued OAC, the thrombus involved almost the whole of the left ventricle; in a few months her condition worsened, requiring hospitalization, and despite heparin infusion she experienced myocardial infarction (MI), caused by embolic occlusion of the left anterior descending artery. Although infrequent as a complication of LVNC, and usually attributable to microvascular dysfunction, in this case MI seems due to coronary thromboembolism from dislodged thrombotic material in the left ventricle.