Giampaolo Zoffoli

Diagnosing left ventricular aneurysm from pseudo-aneurysm: a case report and a review in literature

Rupture of the free wall of the left ventricle (LV) is a catastrophic complication occurring in 4% of patients after myocardial infarction (MI) and in 23% of those who die of MI. Rarely the rupture is contained by an adherent pericardium creating a pseudo-aneurysm. This clinical finding calls for emergency surgery. If no ruptures are detectable and myocardium wall integrity is confirmed, we are in the presence of a true aneurysm, which can be treated by means of elective surgery. Differentiation between these two pathologies remains difficult. We report the case of a patient with a true aneurysm, initially diagnosed as pseudo-aneurysm at our institution; we have reviewed the literature on this difficult diagnosis and outlined characteristic findings of each clinical entity.

The TRIBECA study: (TRI)fecta (B)ioprosthesis (E)valuation versus (C)arpentier Magna-Ease in (A)ortic position

OBJECTIVE To determine whether the Trifecta bioprosthetic aortic valve produces postoperative haemodynamic results comparable with or better than those of the Magna Ease aortic valve bioprosthesis. METHODS We retrospectively reviewed the medical records of patients who had undergone aortic valve replacement with Trifecta or Magna Ease prostheses at eight European institutions between January 2011 and May 2013, and analysed early postoperative haemodynamic performance by means of echocardiography. RESULTS A total of 791 patients underwent aortic valve replacement (469 Magna Ease, 322 Trifecta). Haemodynamic variables were evaluated on discharge and during the follow-up (minimum 6 months, maximum 12 months). The mean gradient and the indexed effective orifice area (IEOA) were as follows: 10 mmHg [interquartile range (IQR): 8-13] and 1.10 cm(2)/m(2) (IQR: 0.95-1.27) for Trifecta; 16 mmHg (IQR: 11-22) and 0.96 cm(2)/m(2) (IQR: 0.77-1.13) for Magna Ease (P < 0.001). These significant differences were maintained across all valve sizes. Similar statistically significant differences were found when patients were matched and/or stratified for preoperative characteristics: body-surface area, ejection fraction, mean gradients and valve size. Severe prosthesis-patient mismatch (IEOA: <0.65 cm(2)/m(2)) was detected in 2 patients (0.6%) with Trifecta and 40 patients (8.5%) with Magna Ease (P < 0.001). CONCLUSIONS The haemodynamic performance of the Trifecta bioprosthesis was superior to that of the Magna Ease valve across all conventional prosthesis sizes, with almost no incidence of severe patient-prosthesis mismatch. The long-term follow-up is needed to determine whether these significant haemodynamic differences will persist, and influence clinical outcomes.

A Novel Approach to Ventricular Rupture: Clinical Needs and Surgical Technique

Cardiac rupture is a life-threatening event that often occurs after myocardial infarction and is often associated with significant death. Pericardiocentesis provides hemodynamic short-term improvement; however, patients with cardiac rupture require an emergency operation. This report describes a new procedure used to repair left ventricle free wall rupture after myocardial infarction. The technique described repairs the rupture off-pump and without the need for suturing. Midterm results demonstrate the feasibility and durability of this procedure.

Mitral valve annuloplasty and myocardial revascularization in the treatment of ischemic dilated cardiomyopathy.

The aim of this study was to examine perioperative mortality and morbidity and midterm results in patients undergoing coronary bypass graft and mitral valve annuloplasty with advanced dilated cardiomyopathy. Sixty-one patients with ischemic dilated cardiomyopathy underwent coronary artery bypass grafting and mitral valve annuloplasty between January 1998 and December 2003. Patients eligible for revascularization that presented a mild or more severe mitral valve regurgitation at echocardiography (effective regurgitant orifice > 0.2 cm2) were considered for annuloplasty with a Cosgrove ring. New York Heart Association class (NYHA) III/IV was present in 40 patients (66%) and Canadian Cardiovascular Society class III–IV in 19 (31%). A previous acute myocardial infarction was reported in 48 patients (79%). The mean number of graft anastomoses was 2.5 ± 0.7 and the left internal mammary artery was used in 49 patients (80%). In-hospital mortality was 4.9% (3 patients), due to unsuccessful weaning from cardiopulmonary bypass, multiple organ failure, and stroke, respectively. Left ventricle ejection fraction improved from 28.9% ± 5.2% preoperatively to 35.4% ± 8.1% at follow-up (P = 0.0001) and a significant reduction in NYHA III/IV was detected: from 40 patients preoperatively (66%) to 14 (31%) at follow-up (P = 0.031). Midterm cardiac-related mortality rate was 3.4%. In our experience combined coronary artery bypass grafting and ring annuloplasty for ischemic dilated cardiomyopathy can be performed with acceptable risks for in-hospital mortality and morbidity. Midterm results show a good survival rate and a durable functional improvement in this subset of patients.

Periaortic Valve Abscess Presenting as Unstable Angina

An 82-year-old woman admitted to hospital for endocarditis caused by Staphylococcus aureus presented, after medical treatment, some episodes of angina. Echocardiography showed a mitroaortic junction abscess communicating with the left ventricle (Figures 1 and 2⇓). Figure 1. Echocardiography of a mitroaortic junction abscess. Figure 2. Echocardiography color Doppler …

Papillary fibroelastoma, unusual cause of stroke in a young man: a case report.

BackgroundPapillary fibroelastoma is the third most common primary benign tumor with an incidence of up to 0.33% in autopsy series; it accounts for approximately 75% of all cardiac valvular tumors.Case presentationWe describe a rare case of a 28-Year-old man that while playing football, had a sudden onset of neurological deficit: aphasia, right hemiparesis and right facial numbness. Transthoracic echocardiography (TTE) showed a 10x10 mm mass attached to the anterior mitral valve leaflet. The patient was treated surgically for the prevention of further embolic complications. Histologic examination of the resected mass revealed a papillary fibroelastoma. It is the third most frequent primary cardiac tumor, after myxoma and fibroma, and the most common primary tumor of heart valves. Despite the benign nature of this tumor, it carries very high risk of embolic complications. The successful complete resection of the papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent.ConclusionsDifferential diagnosis of cardiac masses requires clinical informations, laboratory tests, blood cultures and appropriate use of imaging modalities. Papillary fibroelastoma is a potential cause of embolic stroke in the young. The prompt surgical excision of papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent.

Commentary on video assistance in mitral surgery: reaching the “Thru” port access

Very interesting article (1) about minimally invasive mitral valve surgery. The port access is evolving in “video-port access”, it means smaller incision, video-guided mini-thoracotomy approach is about 4–6 cm, the view of the surgical field is achieved with 30° or even 120° camera, high definition and inclusive 3D visualization is used with 5 or 10 mm optics. The aim is reduction in surgical trauma, a major increase in patient comfort, faster recovery as well as better cosmetic results. It became even more an ultra-specialized field, in which is required a specific surgeon training and a rigorous team approach. The team approach, including surgeon, anaesthesiologist, nurse, cardiologist and perfusionist, is crucial for a safe and effective realization of this surgical strategy. In our experience we noticed that the learning curve in video assisted port access for mitral surgery is mandatory for the entire equipe. So we have dedicated some figures to this kind of operation, with the aim to reduce individual differences, accelerate learning and optimize the procedure. Direct heart visualization during MIMVS operation is impossible through such small access and TEE managed by anesthesiologist is vital. Any modification in ventricular size or performance need to be detected by TEE and proper management introduced. Viewing the video is clear that the approach is minimally but the field view is better than in open surgery, we are sure this is the goal of this technique.

Unexpected limited chronic dissection of the ascending aorta

We report a rare case of a limited chronic dissection of the ascending aorta that was accidentally discovered at operation performed for severe aortic stenosis and moderate to severe dilatation of the ascending aorta. Preoperative investigations such as transoesophageal echocardiography and cardiac catheterization missed the diagnosis of dissection. Intraoperative findings included a 3.5 cm eccentric bulge of the ascending aorta and a 5 mm circular shaped intimal tear comunicating with a limited hematoma or small dissection of the media layer. (The rarety of the report is that the chronic dissection is limited to a small area (approximatively 3.5 × 2.5 cm) of the ascending aorta).