Filippo Capestro

Syncope triggered by a giant unruptured sinus of Valsalva aneurysm

Sinus of Valsalva aneurysms are rare anomalies, most often caused by congenital absence of muscular and elastic tissue in the aortic wall of the sinus. The indication for surgical repair is controversial at the time of diagnosis. As well, the repair technique depends on how many sinuses are dilated, whether the aneurysm is ruptured and whether the aneurysm is symptomatic. We report a case of a single unruptured sinus of Valsalva aneurysm of a 54-year-old woman.

Cardiac Paraganglioma Arising From the Right Atrioventricular Groove in a Paraganglioma-Pheochromocytoma Family Syndrome With Evidence of SDHB Gene Mutation: An Unusual Presentation

Primary cardiac paragangliomas are extremely rare. Recently this neoplasm has been associated with a familiar syndrome as a result of mutation of genes that encode proteins in the mitochondrial complex II. We report a case of a 46-year-old woman having cases of vertebral paraganglioma in her family showing an unusual anatomic and clinical presentation of cardiac paraganglioma and expressing a genetic mutation never associated before with cardiac localization of this neoplasm.

Sutureless aortic valve prosthesis in a calcified homograft

Surgical aortic valve replacement (AVR) is the treatment of choice for severe aortic valve regurgitation. In patients undergoing reoperation with a severe calcified homograft AVR is a challenging operation, and alternative solutions are prompted for the high surgical risk. Predominant aortic valve regurgitation remains a relative contraindication for transcatheter aortic valve implantation. The use of sutureless aortic valves offers a viable option for these patients at high risk with conventional approaches. The potential clinical advantages are related to the easier implantation, specifically in completely calcified aortic roots, with reduced extracorporeal circulation and aortic crossclamp times. We report a case of sutureless aortic valve implantation within a calcified aortic root homograft.

Delayed Left Ventricle Posterior Wall Rupture Following Mitral Replacement Detected by Multislice CT-Scan

(J Card Surg 2011;26:383‐384)

Cardiopulmonary bypass line sternal wrapping: technical tips

Cardiopulmonary bypass line sternal wrapping (SW) is a new approach to sternal care which avoids bone wax and offers mechanical protection and a shield from bacterial contamination, with beneficial effects on sternal healing. Since its introduction in February 2008, the technique has undergone some developments: it is possible to harvest internal thoracic arteries with SW in place and its haemostatic properties have improved.

Risk Factors and Impact on Clinical Outcome of Multidrug-Resistant Acinetobacter Baumannii Acquisition in Cardiac Surgery Patients.

OBJECTIVES Acinetobacter baumannii recently has emerged as an important nosocomial pathogen. The aim of this study was to assess the impact on mortality of multidrug-resistant A. baumannii (MDR-AB) infection/colonization in patients undergoing cardiac surgery and to investigate microbiologic characteristics, epidemiologic spread of this pathogen, and the relative containment measures. DESIGN Single-center, retrospective cohort study of prospectively collected data. SETTING Cardiac surgery tertiary-care center. PARTICIPANTS Patients with positive MDR-AB cultures from September 1, 2009 to December 31, 2011. INTERVENTIONS Bivariate and multivariate analyses were performed to individualize the risk factors for MDR-AB-infections in cardiac surgery patients. To evaluate the MDR-AB attributable mortality, a retrospective matched cohort study was performed. Incidence density ratio (IDR) was calculated to compare the MDR-AB infection/colonization before and after the introduction of preventive measures adopted following the first cases. MEASUREMENTS AND MAIN RESULTS MDR-AB acquisition occurred in 14 patients (0,6%) of 2385 patients. At the multivariate analyses, preoperative use of inotropic drugs (OR 18.2, 95% CI 4.6-71.9) and logistic EuroSCORE (OR 1.09, 95% CI 1.06-1.13) were found as independent risk factors. Patients with MDR-AB had 57% cumulative in-hospital mortality; no statistical differences in mortality were observed in the matched group. IDR revealed a significantly decreased incidence of infection/colonization (0.3 per 1,000 days of stay compared with 0.03/1,000 days of stay, p = 0.0001) after the containment measures became effective. CONCLUSIONS Sicker patients are more susceptible to be infected by A. baumannii, but mortality is not significantly higher compared with other patients with similar characteristics. Adequate measures are fundamental to control the spread of the infection.

A new subspecialty in cardiac surgery: Scrap metal merchant

Valve Stability and Pseudoendothelialization Fears of calcium resorption leading to loss of valve fixation over the intermediate term are likely unfounded. In this patient, despite minimal initial native aortic cusp calcification, the valve was tenaciously fixed. Whether tissue in-growth contributed is unclear. This valve, particularly the uncovered upper stent cells, was not fully covered in pseudoendothelium 11 months later. Although beneficial near the coronary ostia (possibly caused by high flow), retarded pseudoendothelialization might require antiplatelet therapy postoperatively. Paravalvular leak might further disrupt tissue coverage. Finally, cusp integrity was lost early, probably accelerated by infection and high flow with (paravalvular) AR. Further evaluation of long-term durability, function, and tissue coverage is needed.

A simplified technique for caval occlusion in reoperative small thoracotomies

gained wide popularity because of the lack of clinical evidence. Tracheal wound closure requires meticulous training and can be difficult with recently reported endoscopic devices. In contrast, BioGlue has the characteristic of facilitating wound sealing immediately after application. BioGlue has been used to treat postoperative bronchopleural fistula after surgery for lung cancer and to seal the tracheal and bronchial anastomoses after segmental resection. The tracheal wound cannot be left to heal spontaneously because of complications such as massive air leaks and tension pneumothorax. The BioGlue technique was successful in that it provided an effective and quick method of tracheal incision closure and obviated the need of removal of any wound closure device. The potential benefits of NOTES include minimizing wound discomfort and improving cosmetic effect. Once the technique matures in the future, the application may further include lung cancer staging, mediastinal masses biopsy, and diffuse lung disease biopsy. However, potential shortcomings of this approach include mediastinitis and emphysema. It is essential to ensure tracheal wound healing with this approach. In future studies, wewould carefully examine the trachea wound tissue after the NOTES approach in different stages. Ensuring that the trachealwound has a smooth healing process is essential before introducing the new approach into clinical application. According to our previous experience,

Mini Bentall operation: technical considerations

Bentall operation via median sternotomy has been largely shown to be safe and long-term efficacious and currently represents the “gold standard” intervention in patients presenting with aortic valve and root disease. However, over the last years, minimally invasive techniques have gained wider clinical application in cardiac surgery. In particular, minimally invasive aortic valve replacement through ministernotomy has shown excellent outcomes and becomes the first choice approach in numerous experienced centers. Based on these favorable results, ministernotomy approach has also been proposed for complex cardiac procedures such as aortic root replacement and arch surgery. Herein, we present our technique for minimally invasive Bentall operation using a ministernotomy approach.

Left ventricular function after mitral surgery: Time to focus on intraoperative management?

The Editor welcomes submissions for section that consist of commentary o vant issues. Authors should: Includ and five references. Type with dou misc/ifora.shtml for detailed submis cally via jtcvs.editorialmanager.com in the JTCVS will be considered if the article was published. Authors o an opportunity of offer a timely res will be notified that the letter has b turned. We read with interest the article by Quintana and colleagues and a letter to the Editor by Buckberg and Athanasuleas about this article published in the Journal in December 2014 and March 2015, respectively. We have some observations for the authors. We focused our attention on Table 2, ‘‘Comparison of Postoperative Clinical Course Stratified by Early Predismissal LVEF,’’ in the article by Quintana and colleagues. In the footnotes of the table, it is clear that the data are presented as median (interquartile range) or n (%), but looking carefully at the line ‘‘Need for inotropic support,’’ we found 2 mistakes: If 136 patients in the first group of 1391 (ejection fraction [EF] 50) required inotropic support, they do not represent 28% but 9.77%. The same applies to the second group (EF 50) of 50 patients of 314. They do not represent 37.3% but 15.9%. This error is reported in the results: ‘‘As expected, patients with early dysfunction required more frequently postoperative inotropic support (28% vs 37.3%, P 1⁄4 .04),’’ but in the light of the wrong percentage calculation, the P value may be incorrect. The second observation is related to the need of intraaortic balloon pump (IABP). The authors report the same incidence of IABP use in the 2 groups. This event could be explained assuming that patients in the first group (EF> 50%) have had a transitory left ventricular dysfunction (stunning) requiring IABP support, which quickly resolved without leaving any sign at predismissal echocardiographic evaluation. This hypothesis strongly strengthens the suspicion of an inadequate intraoperative protection in these groups of patients. Finally, the authors give no definition for ‘‘Need for inotropic support,’’ especially regarding the duration (>6 hours, >12 hours, >24 hours). These data support the need to expand our research not only in the preoperative evaluation of patients with mitral