Giuseppe Di Benedetto

Surgical results of aortic valve replacement via partial upper sternotomy: comparison with median sternotomy

BACKGROUND the theoretical advantages of mini-invasive cardiac surgery are shorter hospitalisation, better surgical results and costs reduction. In November 1997 we started a non-coronary mini-invasive surgery program using a partial upper median sternotomy. This study has been conceived to retrospectively compare two groups of patients who underwent isolate aortic valve replacement using the conventional and the mini-invasive technique. MATERIAL AND METHODS in Group A 100 patients (mean age 62+/-12 years; 58 male) underwent isolated aortic valve replacement through a partial upper median sternotomy. Group B was composed by the last 100 patients (mean age 63+/-8 years; 56 male) who underwent the same operation through a conventional median sternotomy. For both groups we recorded the ECC and ischaemic times, postoperative intubation time, total postoperative bleeding, intensive care unit length of stay and total hospitalisation time. Major and minor complications were reported. RESULTS operating times, were significantly longer in Group A (p<0.001). Mechanical ventilation time, ICU and total hospital stay, and total postoperative bleeding showed no significant difference. Adjunctive statistical evidenced the absence of learning curve. Mortality and other complications failed to reveal any significant difference between the two groups. CONCLUSIONS in our experience, partial upper median sternotomy does not increase surgical risks but failed to demonstrate clear advantages. Apart for an increase in operating times, the surgical results are similar to those of a conventional median sternotomy with only improvement in the aesthetical aspect. In our opinion, this supports the conviction that this approach can be proposed to selected patients, to obtain a better cosmethical result for the same given risk.

Echocardiographic assessment of regional left ventricular wall motion abnormalities in patients with tako-tsubo cardiomyopathy: comparison with anterior myocardial infarction

AIMS The aim of this study was to assess the echocardiographic distribution of regional wall motion abnormalities (RWMA) in patients with tako-tsubo cardiomyopathy (TTC) compared with anterior ST-elevation myocardial infarction (ant-STEMI). METHODS AND RESULTS Thirty-seven TTC and 37 ant-STEMI patients underwent standard echocardiographic examination at the time of hospital admission. RWMA and the involvement of the left ventricular territories supplied by each coronary artery according to the American Society of Echocardiography classification were reported. TTC patients showed a lower left ventricular ejection fraction (37.6 ± 5.1 vs. 40.9 ± 3.7%; P = 0.002) and a higher wall motion score index (WMSI; 1.98 ± 0.2 vs. 1.51 ± 0.14; P < 0.001) compared with ant-STEMI patients. No significant differences were observed between groups with regard to detection of RWMA in the territory supplied by the left anterior descending coronary artery (LAD) (37 vs. 37; P = 1). Conversely, in TTC patients, the territories supplied by the LAD/left circumflex coronary artery (LCX) (37 vs. 31; P = 0.011), LAD/right coronary artery (RCA) (34 vs. 13; P < 0.001), RCA (33 vs. 5; P < 0.001), and RCA/LCX (31 vs. 2; P < 0.001) were more frequently involved. A cut-off value of WMSI ≥1.75 (area under the curve 0.956) and for the number of territories with RWMA ≥4 (AUC = 0.928) predicted TTC with a sensitivity of 83 and 84% and a specificity of 100 and 97%, respectively. CONCLUSION Echocardiography revealed a distinctive pattern of contractility in TTC patients, characterized by symmetrical RWMA extending equally into the territory of distribution of all coronary arteries.

Giant Left Atrial Myxoma: An Unusual Cause of Acute Pulmonary Edema

We report a case of a huge left atrial myxoma with an unusual clinical presentation characterized by acute pulmonary edema. The possible pathophysiologic mechanism has been discussed.

Type B Aortic Dissection Involving an Isolated Right-Sided Aortic Arch

We report a case of a 48-year-old man in whom type B aortic dissection in the right aortic arch and right descending aorta was diagnosed by transesophageal echocardiography and computed tomographic scan. Angiography was necessary to define the anatomy of the branching vessels. The patient was successfully treated by interposition of a Vascutek 24-mm Dacron woven tube with a right posterolateral thoracotomy approach. Circulatory arrest in profound hypothermia and cerebral retroperfusion were used.

Surgical treatment of impending paradoxical embolization associated with pulmonary embolism in a patient with heterozygosis of factor V Leiden.

We report an unusual case of impending paradoxical embolization in a 69-year-old woman heterozygote carrier of factor V Leiden mutation. The patient presented to the emergency room with the clinical scenario of massive pulmonary embolism. Serial echocardiographic examinations revealed a large thrombus in the right atrium floating via a patent foramen ovale into the left atrium. Anticoagulation therapy was started. After 72 h, due to the unresolved thrombus, the patient underwent surgical treatment consisting of complete excision of the thrombus, closure of the foramen ovale, and pulmonary embolectomy. No in-hospital complications were noted. At 1-year follow-up, the patient is doing well on long-term anticoagulation treatment free of thromboembolic events.

Giant Candida mycetoma in an ascending aorta tubular graft.

We report the case of a 46‐year‐old male hospitalized for abdominal pain and fever with history of a David procedure followed by an aortic valve replacement due to severe aortic regurgitation. Transesophageal echocardiography (TEE) and computed tomography showed a large mass floating in the aorta. After surgical excision of the vegetation, attached to the Dacron prosthesis, histological examination revealed Candida hyphae and spores confirming the diagnosis of a mycetoma in an ascending aorta tubular graft. At six‐month follow‐up, the patient was in good clinical condition without recurrence of the fungal mass on TEE. doi: 10.1111/jocs.12193 (J Card Surg 2013;28:557–560)

Fibrous tissue ring : an uncommon cause of severe prosthetic valve stenosis

We describe here the case of a patient in whom severe mitral stenosis and periprosthetic leak developed 5 years after mitral valve replacement with a Medtronic Hall prosthesis (Medtronic, Inc., Minrie.apolis, Minn.). Mitral valve stenosis was attributed to the~formation of concentric dense fibrous tissue around the atrial side of the anulus. A 45-year-old woman underwent open mitral commissurotomy in 1979 for rheumatic mitral stenosis. Ten years later she underwent mitral valve replacement with a Medtronic Hall 27 mm prosthesis. In 1993 she had a fever of unknown origin. Subsequently her clinical status progressively worsened, with the onset of exertional dyspnea and fatigue. In March 1994 she was referred to us. On admission severe peripheral edema and jugular vein distention were present. The liver was palpable 6 cm below the costal border. A 2/6 to 3/6 soft holosystolic murmur was audible on the apex radiating to the axilla. Blood pressure was 130/80 mm Hg. The electrocardiogram showed sinus rhythm with a heart rate of 96 beats/min and signs of moderate right ventricular hypertrophy. The chest x-ray film revealed a slightly enlarged cardiac shadow and pulmonary congestion. A transthoracic two-dimensional and Doppler echocardiogram showed left atrial dilatation, normal opening of the prosthesis, reduction of diastolic flow through the prosthesis, and a mild periprosthetic leak. High pulmonary artery pressures were calculated and then confirmed by preoperative insertion of a thermodilution catheter (90/45 mm Hg, mean 60 mm Hg). A transesophageal echocardiogram revealed a periprosthetic leak and confirmed the transthoracic data. Mild aortic stenosis was present. The patient was operated on 2 days later and the mitral prosthesis was replaced through a vertical transseptal approach with a 27 mm CarboMedics prosthesis (CarboMedics, Inc., Austin, Tex.). The aortic valve was explored and subsequently a commissurotomy was made. The postoperative course was uneventful and the patient was discharged to her home on the ninth postoperative day. Postoperative transthoracic two-dimensional and Doppler echocardiography showed a dramatic drop in pulmonary artery pressure and a well-functioning prosthesis. Examination of the explanted valve revealed a ring of fibrosclerotic tissue, containing many inflammatory cells, surrounding the anulus on the atrial side. The movement of the disc was unimpeded but the fibrous tissue strongly reduced the valvular area, simulating mitral stenosis (Fig. 1, A and B).

Spontaneous coronary artery rupture presenting as an acute coronary syndrome evolved in pseudoaneurysm and cardiac tamponade: Case report and literature review:

Spontaneous coronary artery rupture is a rare disorder that may develop early into a sudden death due to the abrupt evolution of the associated cardiac tamponade. In some cases the rupture is contained and a false aneurysm develops with slower evolution of clinical signs. The correct diagnosis of spontaneous coronary artery rupture deserves a high level of suspicion; frequently it may be missed because the time window of its evolution seems to be very short or signs of acute coronary syndrome sometimes can prevail, leading to delays in diagnosis or to misdiagnosis. We report the case of a patient presenting a giant pseudoaneurysm of the right coronary artery due to spontaneous coronary artery rupture without any underlying disease. Moreover we present a review of the few cases in the literature, offering a pathophysiological hypothesis linking the site of rupture and clinical presentation.

Vascular Surgical Options

In the last decade, the surgical therapy for acute type A aortic dissections (AAAD) has been modified by new techniques that have improved the outcome. Continuous efforts have led to safer, more rapid, and more durable operations using new technology and new knowledge concerning the pathophysiology of the disease and the surgical long-term results. Some of these procedures (like the use of glue or other adjuncts to reinforce the aortic stumps) are already established techniques. Others “in progress” (like different modes of cerebral protection, sites of arterial cannulation, aortic valve management, and the extended aortic arch replacement) are still debated. Finally, procedures like the combined treatment of ascending aortic replacement associated with a stent graft positioned in the aortic arch and other endovascular techniques (hybrid procedures) seem to be the vascular surgical options for the future. These procedures appear as adjuncts to conventional surgical interventions but need to be evaluated for indications, feasibility, and long-term results.

Isolated atrial inversion in situs inversus: A rare anatomic arrangement

Isolated atrial inversion in situs inversus is a rare congenital cardiac malformation. Its physiology resembles transposition of great vessels, and the best option for its surgical treatment is the atrial switch operation. In this article, we present a case of isolated atrial inversion in concordance with visceral situs inversus diagnosed at birth by echocardiography and cardiac catheterization, which was successfully treated at 8 months of age by a Senning procedure.