Functional anatomy and echocardiographic assessment in secondary mitral regurgitation.

BACKGROUND: Mitral valve apparatus is complex and involves the mitral annulus, the leaflets, the chordae tendinae, the papillary muscles as well as the left atrial and ventricular myocardium. Secondary mitral regurgitation is a consequence of regional or global left ventricle remodeling due to an acute myocardial infarction (75% of cases) or idiopathic dilated cardiomyopathy (25% of cases). It is associated with an increase in mortality and poor outcome. There is a potential survival benefit deriving from the reduction in the degree of severity of mitral regurgitation. So the correction of the valve defect can change the clinical course and prognosis of the patient. The rationale for mitral valve treatment depends on the mitral regurgitation mechanism. Therefore, it is essential to identify and understand the pathophysiology of mitral valve regurgitation. AIM OF THE STUDY: The aim of this review is to describe the crucial role of transthoracic and trans-esophageal echocardiography, in particular with three-dimensional echocardiography, for the assessment of the severity of secondary mitral regurgitation, anatomy, and hemodynamic changes in the left ventricle. Moreover, the concept that the mitral valve has no organic lesions has been abandoned. The echocardiography must allow a complete anatomical and functional evaluation of each component of the mitral valve complex, also useful to the surgeon in choosing the best surgical approach to repair the valve. CONCLUSIONS: Echocardiography is the first-line imaging modality for a better selection of patients, according to geometrical modifications of mitral apparatus and left ventricle viability, especially in preoperative phase.

Emerging role of positron emission tomography (PET) imaging in cardiac surgery.

Historically, structural and anatomical imaging has been the mainstay in the diagnosis and management of cardiovascular diseases. In recent years there has been a shift toward increased use of functional imaging studies, including positron emission tomography (PET). PET is a noninvasive nuclear medicine-imaging technique that uses radiotracers to generate images of a radionucleotide distribution by detecting the physiologic substrates that emit positron radionuclides. This article will focus on the applications of PET imaging for the cardiac surgeon and highlight the collaborative nature of using PET imaging for the management of complex heart disease. We present cases that demonstrate the value of using PET imaging in the diagnosis of coronary artery disease and management of complex endocarditis, and in targeted cardiovascular therapies.

Impact of digital transformation on the future of medical education and practice.

In this article, the author provides synopses of the factors that have finally propelled health-care education and practice to join, at times reluctantly, the overarching digital transformative process that has been swept other industries over the last few decades. The key contributors and driving forces that have energized the entry of health-care education and practices are mentioned. The roles of major universities, large technology companies, and the expanding roles of Artificial Intelligence and Machine Learning are described. The projected future developments are predicted to continue to be substantial, sweeping, and forcing changes that are unprecedented. Thus, academicians and practitioners should be alerted to what the rapidly changing landscape is likely to become and accordingly take steps to manage and preserve their roles or risk be left behind or worse be forced out.

Accessory left atrial cords: A case report and literature review.

INTRODUCTION: Accessory left atrial cords are fibroelastic structures found in the left atrium. Left atrial cords may be associated with mitral valve disease, atrial fibrillation, stroke, and other congenital left-side anomalies. METHODS: We presented the case of a man with severe Mitral Regurgitation and two accessories left atrial cords attached to P2 scallop by a single tendon and performed a literature review using PUBMED/MEDLINE, Web of Science, and EMBASE databases on December 4, 2021. RESULTS: According to our review, accessory left atrial cords were found more frequently in women (36 patients, 62%), more frequently attached to the mitral valve (66% of reports) and mitral regurgitation was the most frequently reported pattern of mitral valve disease (64.2%). No other cases of double left atrial cords attached to P2 segment were found. CONCLUSION: Accessory left atrial chords may be related to mitral valve disease and other left-side congenital abnormalities. These structures were found more frequently in females and A2 insertion was the most frequently observed pattern in the review.

The effect of tracheostomy on extracorporeal membrane oxygenation outcomes.

INTRODUCTION: The optimal timing for pursuing tracheostomy in patients with prolonged mechanical ventilation with either veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is a discussion of risk versus benefit. Depending on the etiology, cardiothoracic surgical patients carry some of the highest risk for respiratory failure postprocedure. Given that patients with end-stage cardiopulmonary status may be fraught with substantial comorbidities, it is critically important to manage the risk-benefit profile of performing a tracheostomy procedure on a patient requiring ECMO support. These cohorts have risk factors that may depend on each patient's inflammatory state, lung de-recruitment peri-procedure and postprocedure and bleeding requiring transfusions to name a few. We provide a descriptive analysis of ECMO patients on both VA and VV configurations who survived to hospital discharge receiving tracheostomy either during or after their ECMO course. METHODS: A retrospective single-institutional study collected all consecutive patients age 18 and above who received any form of ECMO between 2016 and 2020. Five hundred forty-five patients were screened based on having received ECMO. Patients with mixed EMCO modality were excluded due to heterogeneity of disease process. A total of 521 patients received either VV or VA ECMO. A total of 54 patients received tracheostomy and had sufficiently clean data for analysis. Tracheostomy patients were compared based on survival to discharge, tracheostomy surgical complications, ECMO duration, ECMO configuration, inotrope and vasopressor use, transfusion rates, total ventilator days, total days on intravenous sedation, and history of cardiotomy or heart transplant were assessed. Baseline characteristics of race, age, gender, and body mass index (BMI) were also collected. RESULTS: A total of 54 patients received tracheostomy. Twenty-nine of those patients received tracheostomy during the course of their ECMO, of whom 13 were on VV ECMO, 16 on VA ECMO. Another 25 patients underwent tracheostomy after successful ECMO explant; 8 of those were VV ECMO with the remaining 17 were on VA ECMO before explantation, with mean delay to tracheostomy, 10 and 19 days after explant between both modalities, respectively. A statistically significantly greater proportion of VV ECMO patients received a tracheostomy at any point versus VA ECMO patients (25.93% vs. 8.35%, p ≤ .0001). No statistically significant difference was noted in timing of tracheostomy when stratified by EMCO modality (VA 51.51% after explant vs. VV 38.10% after explant, p = .33). There was a greater frequency of minor tracheostomy complications in patients who were on ECMO at the time of their tracheostomy (p = .014) than in those who received their tracheostomy after being explanted. However, these minor complications did not contribute to a change in survival to hospital discharge (p = .58). Similarly, the small number of major complications (n = 13) did not impair survival to hospital discharge (p = .84). Finally, mean duration of ECMO was longer in those who received tracheostomy during ECMO versus after ECMO. (488.45 vs. 259.72 h, p < .01). CONCLUSIONS: Tracheostomy is known to increase patient mobility, clinical participation, and overall decrease in sedation use. Pursuing tracheostomy during ECMO is feasible, does not result in major bleeding, and is associated with only minor complications that overall do not decrease survival. While there is an increased duration of ECMO support in the tracheostomy cohort, this may be due to existing patient conditions, and may not be causal. Research is needed to further determine the external patient factors and specific timing to optimize both VV and VA ECMO courses. CLINICAL IMPLICATIONS: We hope that our analysis will pave the initial pathway for an evidence-based guideline on optimal timing of tracheostomy in ECMO patients, whether initiated during or after ECMO and taking into consideration ECMO configuration, its expected duration, and patient comorbidities.

Mid-term outcomes of concomitant Cox-Maze IV: Results from a multicenter prospective registry.

BACKGROUND: Benefits of concomitant atrial fibrillation (AF) surgical treatment are well established. Cardiac societies support treating AF during cardiac surgery with a class I recommendation. Despite these guidelines, adoption has been inconsistent. We report results of routine performance of concomitant Cox-Maze IV (CMIV) from participating centers using a standardized, prospective registry. METHODS: Nine surgeons at four cardiac surgery programs enrolled 807 patients undergoing concomitant CMIV surgery over 12 years. Lesions were created using bipolar radiofrequency clamps and cryoablation probes. Follow-up occurred at 3- and 6-months, then annually for 3 years. Freedom from AF was defined as no episode >30 s of atrial arrhythmia. RESULTS: Sixty-four percent of patients were male, mean age 69 years, mean left atrial size 4.6 cm, mean preoperative AF duration 4.0 years, mean EuroSCORE 6.4, and mean CHADS2 score 3.1. Thirty-day postoperative mortality and neurologic event rates were 3.3% and 1.3%, respectively. New pacemaker implant rate was 6.3%. Freedom from AF rates at 1- and 3-years stratified by preoperative AF type were: paroxysmal 94.6% and 87.5%, persistent 82.1% and 81.9%, and longstanding persistent 84.1% and 78.1%. At 3-year follow up, 84% of patients were off antiarrhythmic drugs and 74% of sinus rhythm patients were off oral anticoagulants. CONCLUSIONS: Routine CMIV is safe and effective. Acceptable outcomes can be achieved across multiple centers and multiple operators even in a moderate risk patient population undergoing more complex procedures. Surgeons and institutions should be encouraged by all cardiac societies to adopt the CMIV procedure to maximize patient benefit.

Review of bioprosthetic structural valve deterioration: Patient or valve?

BACKGROUND: With guidelines progressively recommending bioprosthetic aortic valves in younger patients, a greater emphasis is placed on structural valve deterioration (SVD) as an important clinical endpoint for both transcatheter and surgically implanted valves. However, SVD of bioprosthetic valves is a complex entity with varying definitions in the literature and a multifaceted pathogenesis. AIM: This review first aims to establish the most updated definitions of SVD as per the literature. We then explore the patient- and valve-related factors that play the greatest roles in facilitating early SVD. METHODS: A PubMed literature review was conducted to identify the relevant research in this field within the past two decades. CONCLUSION: Increasing rates of obesity and metabolic syndrome pose a significant risk to the longevity of bioprosthetic valves. Additionally, externally mounted valves have proven to sacrifice durability for superior haemodynamics. Bioprosthetic SVD continues to be a multifactorial issue that will require various patient- and valve-related factors to be addressed.

Transapical mitral valve repair procedures: Primetime for microinvasive mitral valve surgery.

INTRODUCTION: Nowadays micro-invasive-procedures (off-pump, beating-heart) for mitral valve repair (MVRe) are abruptly expanding with the potential to be adopted as a valuable alternative to surgery. In the present manuscript, the authors review the available technologies intended to treat mitral regurgitation (MR) through transapical approach, including annuloplasty and chordal-repair options. ANNULOPLASTY: To date, Valcare Amend is the only transapical MV ring to have been implanted in patients. The device allows for stabilization of the annulus through a complete semirigid d-shaped ring. The first-in-human successful procedure was performed in 2016 by our Group and subsequent clinical experience included a total of 14 implanted patients. Currently, the technology is under clinical trial evaluation to validate the efficacy and safety profile of the device. CHORDAL REPAIR: Beating-heart chordal implantation via transapical approach is a current feasible, safe and reproducible option. Neochord DS1000 is the most widely used technology in the field, with a solid procedural experience and good results in well-selected patients. Its clinical use has been validated in Europe since 2012, while it is still under clinical investigation in the United States. Harpoon MVRe system is a novel technology, recently CE-mark approved for clinical use. DISCUSSION AND CONCLUSIONS: Transapical micro-invasive technologies are current viable therapies to treat MR in selected patients. Although there are still several limitations that preclude an extensive use of such procedures, their results are promising in well-selected patients. Embracing transcatheter MVRe therapies should guide the cardiac surgeon through the new revolution of micro-invasive MV tailored repair.

Infectious complications following contemporary left ventricular assist device implantation.

BACKGROUND: The aim of this study is to evaluate the source of infectious complications following contemporary left ventricular assist device (LVAD) implantation and to determine the impact of infections on patient outcomes. METHODS: All patients who underwent centrifugal LVAD implantation between 2014 and 2020 at a single center were retrospectively reviewed. Postimplant infections were categorized as VAD-specific, VAD-related, or non-VAD according to previously published definitions. Postoperative survival and freedom from readmission were assessed using Kaplan-Meier analysis. Univariable and multivariable analyses were performed to determine the risk factors for postoperative infectious complications. RESULTS: A total of 212 patients underwent centrifugal LVAD implantation (70 HeartMate 3, 142 HeartWare HVAD) during the study period. One hundred and two patients (48.1%) developed an infection, including 34 VAD-specific, 11 VAD-related, and 57 non-VAD. Staphylococcus species were the most common source of postoperative infection (n = 57, 33.7%). In multivariable analysis, diabetes significantly impacted overall postoperative infection rate. At 12 and 24 months, respectively, Kaplan-Meier survival was 81.1% and 61.6% in the infection group and 83.4% and 78.1% in the noninfection group (p = 0.006). Within the total cohort, 12- and 24-month freedom from infection were 46.2% and 31.9%, respectively. Patients with infectious complication had significantly lower rate of transplantation (16.4% vs. 43.6%; p < 0.001), increased overall mortality (46.3% vs. 17.3%, p < 0.001), and increased rates of noncardiac readmission (58.2% vs. 37.3%, p = 0.007). CONCLUSIONS: Infections are common following contemporary LVAD implantation and are most commonly non-VAD related. Patients with postoperative infectious complications have significantly reduced rates of transplantation, survival, and freedom from noncardiac readmission.

Successful recovery with venovenous ECMO for ARDS after LVAD HeartMate 3 implantation: A case report.

Acute respiratory distress syndrome (ARDS) following left ventricular assist device (LVAD) implantation is a rare complication. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is used as a treatment for severe ARDS and pneumonia. We report the successful use of VV ECMO for ARDS Klebsiella pneumonia following urgent LVAD HeartMate 3 implantation.

Extracorporeal membrane oxygenation support in the setting of penetrating traumatic injuries.

BACKGROUND: Currently, no absolute contraindications to the use of extracorporeal membrane oxygenation (ECMO) support exist. However, the presence of penetrating traumatic injuries is often considered a relative contraindication to ECMO support. In this study, we aim to assess whether penetrating traumatic injuries should be considered a contraindication to the use of ECMO support, and how to better select patients who may benefit from this therapy. MATERIALS AND METHODS: In this paper, we present the findings of a retrospective review of all patients at a large, level 1 trauma center who received ECMO support following penetrating traumatic injuries. We describe the use of ECMO in these patients along with the complications associated with this therapy. CONCLUSION: In this study we show penetrating traumatic injuries should not be considered a contraindication to ECMO support, and how ECMO can be a useful treatment strategy in selected patients with these injuries.

Survival following lung transplantation: A population-based nested case-control study.

BACKGROUND: Lung transplantation is the mainstay of treatment for patients with end-stage respiratory failure. This study sought to evaluate survival following transplantation compared to the general population and quantify standardized mortality ratios (SMRs) using a nested case-control study design. METHODS: Control subjects were nonhospitalized inhabitants of the United States identified through the National Longitudinal Mortality Study. Case subjects were adults who underwent lung transplantation between 1990 and 2007 and identified through the Organ Procurement and Transplantation Network. Propensity-matching (5:1, nearest neighbor, caliper = 0.1) was utilized to identify suitable control subjects based on age, sex, race, and location of residency. The primary study endpoint was 10-year survival. RESULTS: About 14,977 lung transplant recipients were matched to 74,885 nonhospitalized US residents. The 10-year survival rate of lung transplant recipients was 28% (95% confidence interval [CI] = 27%-29%). The population expected mortality rate was 19 deaths/100 person-years while the observed ratio was 104 deaths/100 person-years (SMR = 5.39, 95% CI = 5.35-5.43). The largest discrepancies between observed and expected mortality rates were in females (SMR = 5.97), Hispanic (SMR = 10.70), and single lung recipients (SMR = 5.92). SMRs declined over time (1990-1995 = 5.79, 1996-2000 = 5.64, and 2001-2007 = 5.10). Standardized mortality peaks in the first year after transplant and decreases steadily over time. CONCLUSIONS: Lung transplant recipients experience a fivefold higher SMR compared to the nonhospitalized population. Long-term mortality rates have experienced consistent decline over time.

Variable definitions and treatment approaches for atrial functional mitral regurgitation: A scoping review of the literature.

OBJECTIVES: Atrial functional mitral regurgitation (AFMR) is a subtype of functional mitral regurgitation due to longstanding atrial fibrillation (AF) or heart failure with preserved ejection fraction. The variation in AFMR' definition and the common mode of treatment described in the literature remain unknown. METHODS: We performed a scoping review of studies that surgically treated AFMR to characterize the existing variability in the definition of AFMR, the type of operations performed for AFMR valvulopathy, and the treatment for the chronic AF. We searched Medline, EMBASE, Cochrane Library, Scopus, and Web of Science since their inceptions for studies of patients affected by AFMR and surgically treated for their valvulopathy. RESULTS: Twelve studies (n = 494 patients) met eligibility criteria. All studies excluded patients with signs of left ventricular (LV) dysfunction, but the way additional parameters were used to define AFMR at a more granular level varied across studies: nine studies (75%) used the presence of AF to define their AFMR cohorts, with five (41.2%) requiring a history of AF of >1 year; additionally, the threshold values for the LV ejection fraction differed (45%-55%). Isolated mitral annuloplasty was performed in 96.2% of patients. Broad variability was detected in the proportion of patients undergoing the Cox-Maze procedure (range, 17.8%-79.5%), pulmonary vein isolation (0.0%-66.7%), and left atrial appendage ligation (0.0%-100.0%). CONCLUSIONS: AFMR remains variably defined in surgical studies, making comparisons across studies difficult. Mitral annuloplasty was most commonly performed. The proportion of AFMR patients undergoing concomitant procedures for AF varied substantially.

Cutting the second order chords during mitral valve repair.

The chordae tendinae connect the papillary muscles (PMs) to the mitral valve. While the first-order chordae serve to secure the leaflets to maintain valve closure and prevent mitral valve prolapse, the second-order chordae are believed to play a role in maintaining normal left ventricle size and geometry. The PMs, from where the chordae tendinae originate, function as shock absorbers that compensate for the geometric changes of the left ventricular wall. The second-order chordae connect the PMs to both trigons under tension. The tension distributed towards the second-order chordae has been demonstrate to be more than threefold that in their first-order counterpart. Cutting the second-order chordae puts all the tension on the first-order chordae, which are then closer to their rupture point. However, it has been experimentally demonstrated that the tension at which the first-order chordae break is 6.8 newtons (N), by far higher than the maximal tension reached, that is 0.4 N. Even if the clinical reports have been favorable, the importance of cutting the second-order chordae to recover curvature of the anterior leaflet and increase the coaptation length between the mitral valve leaflets has been slowly absorbed by the surgical world. Nevertheless, there are progressive demonstrations that chordal tethering affects the anterior leaflet not only in secondary, but also in primary mitral regurgitation, having a not negligible role in the long-term outcome of mitral repair.

Acute iatrogenic complications after mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair is the procedure of choice to correct mitral regurgitation. However, some dangerous iatrogenic complications can occur at the end of the procedure. Therefore, we sought to review the most frequent and clinically relevant acute iatrogenic complication following mitral valve repair. METHODS: A thorough review of the literature has been performed. Criteria for considering studies for this non-systematic review were as follows: observational and interventional studies investigating the acute iatrogenic complications following mitral valve repair, and essential review studies pertinent to the topic. RESULTS: The most frequent is the systolic anterior motion. Due to a systolic dislocation of the anterior leaflet toward the outflow tract, it causes both obstruction of the outflow tract and mitral regurgitation. Often it is due to excess of catecholamines or to reduced filling of the left ventricle but sometimes needs further surgical maneuvers, focused on moving posteriorly the coaptation line. It can be obtained by shortening the posterior leaflet or increasing the size of the ring or applying an Alfieri stitch to limit the movements of the anterior leaflet. Another complication, often underdiagnosed and potentially lethal, is the injury of the circumflex artery that happens at the level of the anterolateral commissure or P1 zone. Two mechanisms are involved. The first one is the direct injury of the artery by a stitch (roughly 25% of the patients present a distance artery-annulus <3 mm. The second one is the distortion of the artery, attracted toward the annulus by a misplaced stitch. The attraction causes kinking with stenosis of different degrees till functional occlusion. However, the artery has to be far from the annulus and the atrial tissue has to be stiff and resistant, as after an infective process, to move the circumflex artery toward the annulus without tearing. Positioning the stitches very close to the mitral leaflets in the dangerous area is the only prevention to the complication. The treatment in the operating theater is partial or total removal/reimplantation of the annular sutures or coronary artery bypass grafting to the circumflex area. If the injury is demonstrated only after coronary angiography, percutaneous revascularization can be attempted before further surgical treatment. CONCLUSIONS: Acute iatrogenic complication after mitral repair exists and may compromize patient outcome. Raising awareness about these issues, the precautions to prevent them, and the manners of resolution is therefore mandatory.

Surgery for complications after thoracic endovascular aortic repair with arch vessel debranching: Role of imaging in preoperative planning.

We describe here a series of patients who presented with failed hybrid arch and descending thoracic aortic aneurysm repairs, while highlighting the instrumental role that advanced medical imaging played in formulating an operative plan. Each case involved persistent 1A endoleaks and aneurysm sac growth after hybrid arch repairs tackled by arch debranching followed by thoracic endovascular aortic repair. Two open cases were described as well as one endovascular case. Imaging played a key role in elucidating the site of endoleak and in operative planning. These cases highlight the importance of multidisciplinary input between cardiac surgery, vascular surgery and radiology in management of complex aortic patients.

Mitral valve repair with artificial chords: Tips and tricks.

Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore-Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD-5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real-world surgery, summarizing all the tips and tricks.

Mitral valve repair: Regulatory or ethical problem?

The long-term outcome of patients undergoing mitral valve repair (MVr) is based on what happens during the more or less 60 min of aortic cross-clamping necessary to transform a leaking valve into a well-functioning one. As a consequence, the experience of the surgeon performing the procedure is the only determinant of the success rate that deserves to be taken into account. It is clear from the literature that the number of cases/year is inversely related to the number of early and late deaths, repair failures, and reoperations. However, there is no agreement on the minimum caseload/year that represents the threshold to identify surgeons that can perform or not MVr. This problem then cannot be regulated by specific guidelines of Scientific Societies, but only by the ethical perception, we have of our profession.

Frozen elephant trunk procedure for complex aortic arch surgery: The Salerno experience with Thoraflex hybrid.

BACKGROUND AND AIM OF THE STUDY: To report early clinical outcomes of the frozen elephant trunk (FET) technique for the treatment of complex aortic diseases after transition from conventional elephant trunk. METHODS: A single-center, retrospective study of patients who underwent hybrid aortic arch and FET repair for aortic arch and/or proximal descending aortic aneurysms, acute and chronic Stanford type A aortic dissection with arch and/or proximal descending involvement, Stanford type B acute and chronic aortic dissections with retrograde aortic arch involvement. RESULTS: Between December 2017 and May 2020, 70 consecutive patients (62.7 ± 10.6 years, 59 male) were treated: 41 (58.6%) for emergent conditions and 29 (41.4%) for elective. Technical success was 100%. In-hospital mortality was 14.2% (n = 12, 17.1% emergent vs. 10.3% elective, P = NS); 2 (2.9%) major strokes; 1 (1.4%) spinal cord injury. Mean follow-up was 12.5 months (interquartile range, 3.7-22.3). Overall survival at 3, 6, 12, and 24 months was 90% (95% confidence interval [CI], 83.2-97.3), 85.6% (95% CI, 77.7-94.3), 79.1% (95% CI, 69.9-89.5), 75.6% (95% CI, 65.8-86.9) and 73.5% (95% CI, 63.3-85.3). There were no aortic re-interventions and no distal stent graft-induced new entry (dSINE); 5 patients with residual type B dissection underwent TEVAR completion. CONCLUSIONS: In a real-world setting, FET with Thoraflex Hybrid demonstrated feasibility and good clinical outcomes, even in emergent setting. Our implant technique optimize cerebral perfusion reporting good results in terms of neurological complications. Techniques to perfect the procedure and to reduce remaining risks, and consensus on considerations such as standardized cerebral protection need to be reported.

An abscess of mitral aortic intervalvular fibrosa mimicking an intracardiac mass.

BACKGROUND: Abscess of the mitral-aortic intervalvular fibrosa (MAIVF) is a rare occurrence, with its most frequently described causative associations being active or prior endocarditis, prosthetic valves, or native valves with anomalies. We report a case of infective endocarditis (IE) complicated by an abscess of the MAIVF without valvular involvement. This case highlights the importance of this rare clinical entity and of the multimodality imaging approach in reaching an accurate diagnosis and differential diagnosis. METHODS AND RESULTS: A 35-year-old male presented with fatigue and intermittent high-grade fever for a 2-week duration. IE was suspected based on a clinical exam. Transthoracic echocardiography (TTE) demonstrated heterogeneous mass with a size of about 2.9 cm × 2.3 cm coming from the MAIVF, mimicking an intracardiac mass. Color Doppler flow Imaging showed the mass without communication with the surrounding cardiovascular cavities. Cardiac computed tomography angiography (CCTA) revealed a large low-density mass without any enhancement, which was situated adjacent to the left ventricular tract with a severely compressed left atrial chamber. The patient underwent cardiac mass removal under extracorporeal circulation. During the procedure, a large abscess was found to be located in MAIVF. The postoperative course was uneventful. DISCUSSION: The abscess of MAIVF is a rare entity with a high risk of developing the pseudoaneurysm of MAIVF (p-MAIVF). The periaortic spread of the abscess is a dynamic process in which the inflammation of the deep tissue causes, in the first stage, a MAIVF thickening, which eventually progresses with the formation of an abscess, and subsequently, a pseudoaneurysm. Complications of p-MAIVF include rupture into the left atrium, aorta, or pericardial space leading to hemopericardium, tamponade, and death. The major differential diagnosis for abscess of MAIVF includes p-MAIVF an intracardiac mass. TTE plays a key role in the diagnosis and differential diagnosis of abscesses of MAIVF. CCTA can be a useful adjunct to further characterize abscess spread, three-dimensional spatial relationships with other cardiac structures for preoperative planning, as well as in the evaluation of potential complications such as coronary artery compromise and communication with the aorta, left atrium, or pericardial space. Surgical management is recommended in complicated, symptomatic patients to prevent further expansion of abscesses or pseudoaneurysms. CONCLUSION: The abscess of MAIVF is a rare complication of endocarditis and surgical trauma in the MAIVF area, TTE remains a first-line imaging modality for clinically suspected periaortic abscess or other IE complications. CCTA has a complementary role to echocardiography in identification, characterization, and preoperative planning.