Giuseppe Rescigno

Prosthetic valve endocarditis.

Prosthetic valve endocarditis (PVE) is associated with a high mortality during the early and midterm follow-up despite diagnostic and therapeutic improvements; its incidence is increasing and reaches 20–30% of all infective endocarditis episodes. In this review, changes in epidemiology, microbiology, diagnosis and therapy that have evolved in the past few years are analyzed. Staphylococci (both Staphylococcus aureus and coagulase-negative Staphylococcus) have emerged as the most common cause of PVE and are associated with a severe prognosis. Moreover, diagnosis may often be difficult because of its complications and extracardiac manifestations; thus, a comprehensive assessment of the clinical, echocardiographic and laboratory data must be performed. Early PVE, comorbidity, severe heart failure and new prosthetic dehiscence are predictors of mortality. Therapy is not indicated by evidence-based recommendations but mostly on identification of the high-risk conditions. A PVE is a common indication for surgery, whereas medical treatment alone may be achieved in a few instances. Systematic prophylaxis should be used to prevent this severe complication of cardiac valve replacement.

Atrial myxoma: a 25-year single-institutional follow-up study.

Objective A single-institutional study on atrial myxoma. Patient data and data obtained from the survivors during follow-up were reviewed. Methods We studied 109 patients (61.5% female) who underwent surgical excision of atrial myxoma between January 1980 and December 2005. Mean age at the time of surgery was 60 ± 14 years (range 1–83 years). Overall survival and atrial myxoma recurrence were determined by Kaplan–Meier analysis. Linearised rates of recurrence at follow-up are reported. Results One hundred and two (93.6%) of the 109 tumours were found in the left atrium. Comparative mean age distribution revealed a significant difference between patients operated on between 1980 and 1992 and patients operated on between 1993 and 2005 (55 ± 15 and 63 ± 13 years, respectively; P < 0.05). All patients survived the operation. Three patients were lost to follow-up. The 15-year and 25-year survival rates were 91 ± 4% and 72 ± 12%, respectively. Survival of patients after myxoma removal did not significantly differ from the expected survival of the general population. Recurrent myxomas developed in two patients (mean age 50 ± 7 years) with a 25-year freedom from reoperation of 96 ± 3% and a linearised rate of 0.17 ± 0.12%/year. Conclusions Myxomas tend to be observed in a more elderly and higher-risk population, often at an early stage. The extended follow-up of patients with intracardiac myxomas shows that surgical excision of such tumours is curative with low mortality and good long-term outcome.

Saphenous Vein Graft Wrapping by Nitinol Mesh: A Word of Caution

BACKGROUND Saphenous vein conduits are still used in a large proportion of coronary artery bypass graft (CABG) operations. A recently commercialized nitinol mesh seems to improve venous graft patency. The aim of this study was to control nitinol mesh vein graft patency in a series of isolated CABG patients by computed tomographic (CT) scan. METHODS In 25 patients (mean age: 61.0 ± 9.65 years), operated for isolated CABG, the eSVS nitinol mesh (Kips Bay Medical Inc., Minneapolis, Minnesota, United States) was used to wrap one vein graft in each patient. Nitinol mesh vein graft was used to revascularize the right coronary (4 patients; 16%), the posterior descending (18 patients; 72%), and the obtuse marginal (3 patients; 12%) arteries. CT scans were performed at 1, 6, and 12 months postoperatively. RESULTS The procedure was uneventful in all patients. CT controls showed an overall patency rate of 86.9, 42.7, and 34.1% at 1, 6, and 12 months, respectively. The 4 mm mesh had a significantly higher patency rate at 12 months (83.33%) than the 3.5 mm one which showed quite unsatisfactory results (20%) (p = 0.02). Patients with graft occlusion underwent stress testing which was mildly positive in two cases. One of them underwent a percutaneous revascularization. CONCLUSION Despite promising early results, use of nitinol mesh for saphenous veins was disappointing in our experience. Further refinements are probably needed.

Coronary graft use of a new external mesh support

Poor quality veins may result in early graft failure after coronary artery bypass grafting. Vein remodelling by means of external scaffolds has been attempted by various products. Here, we describe our use of a new external mesh support that is generally used in peripheral vascular bypasses in order to remodel a poor quality vein used in coronary revascularization. Early CT control demonstrated a good result.

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.

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

(J Card Surg 2011;26:383‐384)

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,

Continuous high vacuum and primary skin closure in sternotomy wound infection

An important message in the report of A.T.M. Tang and associates [1] concerns the essential role of continuous vacuum in sternotomy wound infections healing process. Dressings by polyurethane foam sealed by transparent adhesive drape in fact are changed only once every 48 h, since wound toilette and purulent material removal actually relies on a sophisticate intermittent high suction vacuum system. We have adopted a conceptually similar, closed technique for superficial wound infections. After a favourable experience with a two stage approach [2], consisting in preliminary debridement, followed, a few days later, by a surgical closure by means of advancement flaps and multiple high suctions drains, we now carry out primary closure of the infected superficial tissues. When a superficial sternal wound infection is diagnosed, surgical debridement is carried out; a sufficient number of small high suction drains (Riplast; Neukirchen-Saar, Germany) are positioned and the skin is immediately closed by means of a continuous monofilament suture. High suction is continued until no more material is drained, usually after 7‐8 days. We have treated 15 patients by this method with good results; only in one case a further debridement was necessary with second intention healing. Cosmetic results were very satisfactorily in the remaining 14 patients. Mean hospital stay after infection diagnosis was 9 ^ 2 days. We believe that, when possible, immediate skin closure after debridement over an efficient and continuous vacuum system, may be in most cases as effective as the polyurethane foam and adhesive sealant drape medication, offering better cosmetic results.