Salvatore Lentini

Prognostic Significance of Valvuloarterial Impedance and Left Ventricular Longitudinal Function in Asymptomatic Severe Aortic Stenosis Involving Three-Cuspid Valves

The purpose of the present study was to evaluate the role of left ventricular global afterload and various echocardiographic parameters of systolic function in a prospective cohort of 52 asymptomatic patients with severe aortic stenosis (indexed aortic valve area 0.4 ± 0.1 cm²/m²) and normal left ventricular ejection fraction (61 ± 5%). Using 2-dimensional speckle tracking echocardiography, myocardial strain, rotation, and twist were evaluated. The valvuloarterial impedance (Zva) was calculated as a measure of left ventricular global afterload. The predefined end points were the occurrence of symptoms (dyspnea, angina, syncope), aortic valve replacement, and death. At study entry, all patients had decreased longitudinal strain (LS) (-15 ± 4%) and increased circumferential strain (-22 ± 5%), twist (24 ± 7°), and Zva (5.8 ± 2 mm Hg/ml/m²). Increased Zva was closely associated with the circumferential strain increase (r = 0.59, p = 0.02) and LS decrease (r = -0.56, p = 0.016). In contrast, no relation was found between myocardial function and transaortic gradients. During follow-up (11 ± 7.5 months), on univariate Cox regression analysis, the predictors of events were the left ventricular ejection fraction (p = 0.02), mass index (p = 0.01), LS (p < 0.0001), radial strain (p = 0.04), and Zva (p = 0.0002). On multivariate Cox regression analysis, only the global LS (p = 0.03) and Zva (p = 0.03) were independently associated with the combined end point. Using receiver operating characteristic curve analysis, a LS of ≤-18% (sensitivity 96%, specificity 73%) and a Zva of ≥ 4.7 mm Hg/ml/m² (sensitivity 100%, specificity 91%) were identified as the best cutoff values to be associated with events. In conclusion, in asymptomatic patients with severe aortic stenosis, the degree of global afterload and its consequences on longitudinal function might play a role in clinical practice.

Ministernotomy approach for surgery of the aortic root and ascending aorta

Different minimally invasive approaches have been proposed for cardiac surgery. Between those, the ministernotomy finds wide consensus for the treatment of the aortic disease, being both the upper reversed T and the upper J the mostly used type of incisions. The authors review the literature on the use of ministernotomy in the treatment of the ascending aorta and arch pathology. The scientific literature was reviewed by searching Medline, the Cochrane Library and the CINAHL database. A total of 1411 papers were found in Medline, 186 in the Cochrane database and 514 in CINAHL database; 50 papers were used to write the article; of which seven represent the most significant papers on the subject. The authors, journal, date and country of publication, patients group studied, relevant outcomes, and the results of these papers are tabulated. The ministernotomy is gaining consensus among surgeons. The indication to surgery, initially restricted only to selected elective patients, is now extended to more complex surgeries, including both the aortic root and aortic arch, redo-operations and, in minor cases, to emergency patients. Furthermore, the use of ministernotomy in redo aortic surgery with patent left internal mammary artery (LIMA) to left anterior descending (LAD) artery is a promising alternative. However, the use of this technique is still limited to few institutions and there are still a limited number of studies comparing this approach to full sternotomy in a prospective, randomized fashion. Even with those limitations, from the review of the literature, it seems that ministernotomy approach for aortic root and ascending aorta surgery is a feasible alternative, showing some advantages compared to full sternotomy. Those advantages include: reduced postoperative bleeding and pain, lower risk of mediastinitis, better aesthetic results, and faster respiratory function recovery. This is true not only for first time surgery, but also, and especially, for redo cases, where the limited exposure will reduce risks correlated to the surgical dissection of redo surgery. The ministernotomy approach for aortic root and ascending aorta surgery could in the future be more extensively used, offering greater benefits to cardiac surgical patients.

Aortic dissection with concomitant acute myocardial infarction: From diagnosis to management

Acute aortic dissection an extremely severe condition having a high risk of mortality. The classic symptom may mimic other conditions such as myocardial ischemia, leading to misdiagnosis. Coronary malperfusion associated with aortic dissection is relatively rare, but when it occurs, it may have a fatal result for the patient. The diagnosis of acute coronary syndrome may lead to the inappropriate administration of thrombolytic or anticoagulant treatment resulting in catastrophic consequences. Emergency imaging techniques help to guide the correct diagnosis. Transthoracic echocardiography is useful as a first imaging test, and may be followed by transesophageal echocardiography, or other imaging techniques. Surgery represents the treatment for these patients. However, with the aim to stabilize the patient and to reduce myocardial damage, initial preoperative endovascular coronary intervention has been reported.

A retrospective analysis of terlipressin in bolus for the management of refractory vasoplegic hypotension after cardiac surgery

Cardiac surgery performed with cardiopulmonary bypass (CPB) may be complicated by hypotension due to low systemic vascular resistance (SVR). Often in those cases, hypotension is resistant to pressor catecholamines. We report six cases of norepinephrine-resistant postcardiotomy hypotension, treated by terlipressin (TP), a potent vasopressor agent. Between May 2007 and May 2008, we treated six patients with TP administration (1 mg bolus) for post CPB refractory vasodilatory hypotension. Analyzed parameters were: mean arterial pressure (m-AP), SVR, cardiac output index (CI), mean pulmonary pressure (m-PP), and lactate, at baseline (before TP bolus) and 3 h after injection. Before TP bolus, the average m-AP was 53.32+/-8.86 mmHg, the CI was 3.45+/-0.24 l/min/m(2), the SVR was 650+/-62.03 dyne*s/cm(5) and the arterial lactate level was 4.6+/-0.95 mmol/l. Three hours after the TP bolus, the m-AP increased to 81.83+/-9.71 mmHg (P=0.002), the CI decreased to 2.88+/-0.14 l/min/m(2) (P=0.002), the SVR increased to 1154+/-116 dyne*s/cm(5) (P=0.002), and arterial lactates decreased to 3.13+/-0.78 mmol/l (P=0.015), without significant modification of m-PP and CVP. We treated postoperative refractory low SVR hypotension by TP administration in bolus. Exogenous administration of TP normalized SVR and increased the systemic arterial pressure with a minimum effect on pulmonary pressure. Subsequently, the effect on systemic blood pressure enhanced urine output. No major collateral effects were observed. The administration of TP in bolus may result as a useful alternative for treating refractory low SVR hypotension post CPB.

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.

Myocardial deformation and rotational mechanics in revascularized single vessel disease patients 2 years after ST-elevation myocardial infarction.

Objective We sought to characterize the left ventricular strains and rotational mechanics in the infarct-related and remote regions of dilated heart following an ST-elevation myocardial infarction (STEMI) to understand the adaptive changes in global left ventricular function that develop several months after percutaneous coronary revascularization. Methods Forty-six patients with STEMI (66.6 ± 11 years, 29 men) 2 years after coronary revascularization were enrolled. Longitudinal, circumferential, radial and rotational mechanics of the left ventricle were evaluated by speckle tracking echocardiography in 39 (84.8%) of them, after excluding seven patients with multivessel coronary disease. Forty-one asymptomatic volunteers without a history of coronary artery disease (65 ± 9 years, 23 men) served as controls. Results There was no difference, between groups, regarding the prevalence of cardiovascular risk factors, whereas patients had significantly reduced left ventricular strains (P < 0.001), rotations (P < 0.001), twist (P < 0.001), torsion (P < 0.001) and untwisting rates (P < 0001) in comparison with controls. Furthermore, reduction in regional strains was observed both in infarct and remote regions of the left ventricle and correlated with the changes in ejection fraction. On logistic regression analysis, only global circumferential strain was independently related (odds ratio 4.28; 95% confidence interval 1.11–16.4; P = 0.034) with left ventricular dilation, defined as an indexed end-diastolic left ventricular volume more than 75 ml/m2. Conclusion Reduction in regional strains and rotational mechanics are detectable in both the infarct-related and remote regions of dilated left ventricle. Attenuation of global circumferential strain, rather than isolated changes in the mechanics of the infarct region might contribute to determine the extent of left ventricular dilation, independent of the presence of multiple risk factors for left ventricular dysfunction. These findings might have important clinical implications regarding novel therapeutic approaches for counteracting left ventricular remodeling.

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.

Aortic valve replacement with pulmonary autograft in children and adults

Aortic valve replacement with a conventional prosthesis is still flawed with complications, especially in children and young adults. Complex aortic root enlargement (Konno) is often needed because of small aortic diameter. The poor compliance with anticoagulation by teenagers and the risks associated with this made us look at alternative techniques. From November 1990 to June 1994, 70 patients were considered for pulmonary autografts in our institution; 64 underwent the procedure with one death and one failure to implant. Short-term results are excellent, with minimal gradient in 90% and minimal regurgitation in 96% of the patients. The long-term follow-up, hopefully, will confirm the superiority of this procedure over more conventional replacement.

In Patients with Post-Infarction Left Ventricular Dysfunction, How Does Impaired Basal Rotation Affect Chronic Ischemic Mitral Regurgitation?

BACKGROUND The aim of this study was to explore the contribution of left ventricular (LV) basal rotation to the mechanism of chronic ischemic mitral regurgitation (MR). METHODS Fifty-seven patients (52 men; mean age, 68.3 ± 11.8 years) with postinfarction LV dysfunction (defined as an ejection fraction ≤ 45%) were prospectively enrolled. Each invariably had functional MR. To assess MR degree, the effective regurgitant orifice area (EROA) was quantified by echocardiography using the proximal isovelocity surface area method. Furthermore, mitral valve deformation (valve tenting and annular function) and LV global (systolic and diastolic volumes, function, and sphericity) and local remodeling (displacement of papillary muscles, regional strain, and rotation by speckle-tracking) were assessed. The patients were subsequently subdivided into two groups according to the absence (group A) or presence (group B) on transthoracic echocardiography of infarct area in the inferior and/or posterior basal segments. RESULTS A larger EROA was found in group B than in group A (P = .034) and in subjects with asymmetric rather than symmetric tethering in either group (P = .036 and P = .040 for groups A and B, respectively). Basal radial (P = .009), circumferential (P = .042), and longitudinal (P = .005) strain and rotation (P = .021) were lower in group B than in group A. There was also a significant inverse correlation between EROA and basal rotation in group B (r = -0.75, P < .001). Furthermore, using multivariate linear regression analysis, we found that the independent determinants of EROA were end-diastolic volume (P < .001) and tenting area (P = .004) in group A and asymmetric tethering (P = .029) and basal rotation (P < .001) in group B. CONCLUSIONS Impaired basal rotational mechanics occurring after an inferior-posterior myocardial infarction is associated with increased MR.

Giant endobronchial hamartoma resected by fiberoptic bronchoscopy electrosurgical snaring

Less than 1% of lung neoplasms are represented by benign tumors. Among these, hamartomas are the most common with an incidence between 0.025% and 0.32%. In relation to the localization, hamartomas are divided into intraparenchymal and endobronchial.Clinical manifestation of an endobronchial hamartoma (EH) results from tracheobronchial obstruction or bleeding. Usually, EH localizes in large diameter bronchus. Endoscopic removal is usually recommended. Bronchotomy or parenchimal resection through thoracotomy should be reserved only for cases where the hamatoma cannot be approached through endoscopy, or when irreversible lung functional impairment occurred after prolonged airflow obstruction. Generally, when endoscopic approach is used, this is through rigid bronchoscopy, laser photocoagulation or mechanical resection. Here we present a giant EH occasionally diagnosed and treated by fiberoptic bronchoscopy electrosurgical snaring.