Fabrizio Tancredi

Aortic Valve Infective Endocarditis: Could Multi-Detector CT Scan Be Proposed for Routine Screening of Concomitant Coronary Artery Disease Before Surgery?

Usefulness of the coronary artery study has been questioned in patients with infective valve endocarditis. Fatal events are reported in the literature due to embolization of endocarditic vegetations during cardiac catheterization. For this reason, many authors do not recommend preoperative invasive coronary studies in these patients. We report the case of a 56-year-old patient with prosthetic valve endocarditis with vegetations, and concomitant risk factors for coronary disease. We did preoperative coronary screening using multi-detector computed tomographic scan imaging, which may be useful for noninvasive imaging of the coronary arteries in these patients with high risk of embolization.

Type A aortic dissection involving the carotid arteries: carotid stenting during open aortic arch surgery

Aortic dissection involving the arch can be complicated by extension to the supra-aortic branches. Carotid dissection may be symptomatic or asymptomatic at the time of surgery. Dissection or re-dissection of repaired carotid may happen later, with symptoms occurring days after the surgical repair, increasing the morbidity and mortality of those patients. We report a case of a patient with type A aortic dissection involving the aortic arch and extending to the supra-aortic branches. During surgery the dissection was seen extending to the distal carotid arteries with tears in the inner wall. After use of surgical glue as a sealant, seeing the persistent fragility and the presence of spiral form tears in the internal wall of the carotid arteries, intraoperative stenting of the common carotid arteries was performed using two stents to prevent carotid re-dissection and ischemic stroke in the postoperative period. In patients with aortic dissection and extension into the carotid arteries, especially with presence of tears of the inner wall, after use of a glue as a sealant of the two dissected layers, if the repaired artery wall results are still fragile, use of intraoperative carotid stenting may be of help in preventing late re-dissection.

EndoClamp Aortic Catheter in the descending aorta for normothermic aortic arch replacement on the beating heart without circulatory arrest

Different surgical techniques and perfusion methodologies have been used for open aortic arch surgery, including deep or moderate hypothermic circulatory arrest with cerebral perfusion (antegrade or retrograde) and lower body perfusion.1 However, despite all the progress in this field, surgery of the aortic arch remains a challenging procedure, especially in high-risk patients. Here, we propose a perfusion methodology for the treatment of saccular aneurisms of the aortic arch under normothermic beating heart surgery, using an aortic endoclamp inflated in the descending aorta. With this technique, we recently treated a 79-year-old patient referred for a saccular aneurysm of the aortic arch (Figure 1). He underwent complete aortic arch replacement with supra-aortic vessel debranching.

Additive and independent prognostic role of abnormal right ventricle and pulmonary hypertension in mitral-tricuspid surgery

OBJECTIVE To evaluate the additive and independent prognostic value of abnormal right ventricle (aRV) and pulmonary hypertension (PH) in patients undergoing mitral-tricuspid surgery. METHODS From January 2009 to December 2012, 541 patients underwent mitro-tricuspid surgery. The entire cohort was divided into 6 subgroups: 63 cases had normal RV and no PH (Group A), 180 normal RV but moderate PH (Group B), 101 normal RV but severe PH (Group C), 15 abnormal RV and no-PH (Group D), 86 abnormal RV and moderate PH (Group E) and 96 abnormal RV and severe PH (Group F). RESULTS Forty-two (7.8%) patients died in hospital due to any cause: 1.6% in group A, 3.9% in group B, 8.9% in group C, 13.3% in group D, 9.3% in group E, 15.6% in group E, p = 0.005. Among 78 patients with no-PH, mortality was significantly higher in patients with aRV (1.6%vs 13.3%. p = 0.03). Among 344 patients with normal RV, mortality was significantly higher in patients with severe PH (1.6% vs 3.9% vs 8.9%. p = 0.03). Comparing the presence of both abnormal RV and severe PH with the remaining patients, mortality was significantly higher in the first group (15.6% 6.1%, p = 0.004). Multivariable analysis confirmed either the independent or the additive role of RV and PH. CONCLUSIONS In patients undergoing mitral-tricuspid valve surgery, the presence of either RV dysfunction/dilatation or severe pulmonary hypertension, might play an independent prognostic role for mortality. The worst scenario is surely the contemporary presence of both conditions.

Sutureless aortic valve prosthesis 44 years after implantation.

Sutureless percutaneous or transapical aortic valve prostheses are receiving considerable attention as the next generation of valves. At present, implantation is mainly for high-risk patients [1] or in particular clinical cases [2,3]. Improvements in existing sutureless prostheses are an area of interest for manufacturing companies. New sutureless mechanical devices and low-profile prostheses represent an important area of research. However, the first sutureless prosthesis was implanted at the beginning of the 1960s.

The Dark Side of the Moon: The Right Ventricle

The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.

Intraoperative imaging to detect coronary stenosis in no-angiography patients

Sometimes, patients scheduled for cardiac operations other than coronary artery bypass may be unsuitable for preoperative coronary angiography. We routinely use intraoperative high-resolution epicardial ultrasound to select the proper target for the graft and to check graft anastomosis integrity. We describe 3 patients who could not undergo preoperative coronary angiography for different reasons. In all cases, we discovered significant stenosis in the left anterior descending coronary artery, which required bypass grafting. Intraoperative verification by transit-time flow measurements confirmed the significant stenosis detected by imaging.

Surgery for Acute Aortic Dissection: An Easy and Cheap Method to Reinforce the Anastomosis

Abstract  Bleeding from the anastomotic site is a frequent complication of surgery for acute aortic dissection. Many methods have been devised in order to avoid this problem. We report a simple, easy technique to reinforce the anastomotic sites. One small 4‐mm‐high ring is cut from the same prosthesis and placed circumferentially inside the aorta edge. Another ring of the same width is opened in a “C” shape, and placed outside the aorta. The conduit was eventually sutured to the aorta in a standard fashion using a running 3‐0 polypropylene suture. The final result appeared good with no bleeding, and the rim lines appear clearer and the edges easier to suture because the Dacron is thinner than other used materials (that is, Teflon). In our opinion, this technique is a simple method to reinforce the anastomosis for both proximal and distal aorta.

A shot in the dark… the nth shot!

From the Cardiology and Cardiac Surgery, API Madonna del Ponte Institute, Lanciano; Cardiovascular Disease Department, SS Annunziata Hospital and University of Chieti, Chieti; and Cardiac Surgery, Pope John Paul II Foundation, Campobasso, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Oct 2, 2017; accepted for publication Oct 6, 2017. Address for reprints: Michele Di Mauro, MD, PhD, Cardiology and Cardiac Surgery, API Madonna del Ponte Institute, Viale Cappuccini 50, Lanciano (CH) 66034, Italy (E-mail: mdimauro1973@gmail.com). J Thorac Cardiovasc Surg 2017;-:1-2 0022-5223/

Transposition of the left carotid artery to the ascending aorta to repair aortic arch injury.

36.00 Copyright 2017 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2017.10.026