An 86-year-old lady with severe aortic stenosis and interventricular membranous septal aneurysm underwent transfemoral transcatheter aortic valve implantation (TAVI). A balloon-expandable valve was deployed after a difficult native valve crossing. Transesophageal echocardiography showed a rapidly accumulating pericardial effusion, with pericardial thrombus and subsequent cardiac tamponade. The angiographic views raised suspicion of aortic root perforation. Median sternotomy was performed because of sudden hemodynamic collapse.The report presents the uncommon association between severe aortic stenosis and interventricular membranous septal aneurysm in an octogenarian and discusses its impact on the development of a post-TAVI major complication.

Introduction: Balloon-expandable (BE) and self-expandable (SE) prostheses are the main types of devices currently used in transcatheter aortic valve implantation (TAVI). Despite the different designs, clinical practice guidelines do not make any specific recommendation on the selection of one device over the other. Most operators are trained in using both BE and SE prostheses, but operator experience with each of the two designs might influence patient outcomes. The aim of this study was to compare the immediate and mid-term clinical outcomes during the learning curve in BE versus SE TAVI. Methods: The transfemoral TAVI procedures performed in a single center between July 2017 and March 2021 were grouped according to the type of implanted prosthesis. The procedures in each group were ordered according to the case sequence number. For each patient, a minimum follow-up time of 12 months was required for inclusion in the analysis. The outcomes of the BE TAVI procedures were compared with the outcomes of the SE TAVI procedures. Clinical endpoints were defined according to the Valve Academic Research Consortium 3 (VARC-3). Results: The median follow-up time was 28 months. Each device group included 128 patients. In the BE group, case sequence number predicted mid-term all-cause mortality at an optimal cutoff value ≤58 procedures (AUC 0.730; 95% CI: 0.644–0.805; p < 0.001), while in the SE group, the cutoff value was ≤85 procedures (AUC 0.625; 95% CI: 0.535–0.710; p = 0.04). A direct comparison of the AUC showed that case sequence number was equally adequate in predicting mid-term mortality, irrespective of prosthesis type (p = 0.11). A low case sequence number was associated with an increased rate of VARC-3 major cardiac and vascular complications (OR 0.98 95% CI: 0.96–0.99; p = 0.03) in the BE device group, and with an increased rate of post-TAVI aortic regurgitation ≥ grade II (OR 0.98; 95% CI: 0.97–0.99; p = 0.03) in the SE device group. Conclusions: In transfemoral TAVI, case sequence number influenced mid-term mortality irrespective of prosthesis type, but the learning curve was longer in the case of SE devices.

In the presence of both oxidizable substrate and phosphate, low concentrations of sporidesmin produced rapid swelling of mitochondria isolated from guinea-pig liver. There is no requirement for alkali metal ions. Uncoupling agents or respiratory inhibitors inhibited the swelling. Mitochondria that had been swollen in the presence of sporidesmin could be contracted by addition of ATP, magnesium ions and bovine serum albumin. The rate of swelling was dependent on the concentration of both sporidesmin and mitochondrial protein and half-maximum effect was observed at 140 nmoles of sporidesmin per mg of protein. A lag period occurred before the maximal effect of sporidesmin and this period was also dependent on the concentration of both sporidesmin and mitochondrial protein. Sporidesmin decreased the respiratory control index of mitochondria by increasing the rate of state 4 respiration and decreasing that of state 3. As sporidesmin had no effect on the respiration of mitochondrial preparations that had either been treated with Triton X-100 or been subject to sonication, the toxin does not directly inhibit the respiratory chain. It is suggested that sporidesmin produces the effects described above by altering the permeability of the mitochondrial membrane.

A 67-year-old man had angina and dyspnea for several weeks during exercise and rest, and he came to our hospital for coronary angiography. He had mild ST-segment variability, without necrosis markers. Cardiac ultrasonograms revealed moderate mitral regurgitation, preserved ejection fraction, and a posterior-wall infarction scar despite no history of infarction.Coronary angiograms, which revealed no obvious culprit lesion, showed mild focal stenosis in the proximal right coronary artery, distal chronic occlusion of a small left circumflex coronary artery, and mild stenosis and haziness in the mid left anterior descending coronary artery (LAD) (Fig. 1). Suspecting thrombus in the mid LAD, we performed optical coherence tomography (OCT) (Fig. 2A). The OCT showed irregular honeycomb-like channels connecting the proximal and distal lumina, smooth appearance of the channels' inner surface and the separating septa, no visible fresh thrombus, and only a small plaque burden at the lesion site (Fig. 2B–E). We thought that the guidewire might have passed into a false lumen of a spontaneous dissection, so we advanced another guidewire, parallel to the first, to ensure entry into the distal true lumen.Given the patient's clinical instability, we performed angioplasty and implanted a bare-metal stent. Afterwards, OCT confirmed good distal flow without residual stenosis and showed a well-apposed stent, mild intima prolapse through the struts (Fig. 3A), and almost complete collapse of the parallel channels (Fig. 3B). Two years later, the patient was asymptomatic and well.Lesions of this type were previously associated with recanalized thrombus.1,2 They were compared with Swiss cheese,1 or, when channels were spread over a larger area, with a honeycomb—a term coined by Toutouzas and colleagues.2In our patient, the small plaque burden at the lesion site seen on coronary angiography suggested an organized coronary embolus, but OCT revealed a recanalized thrombus. This rare case highlights the need to recognize the limits of angiography and to use complementary imaging methods, especially when angiographic appearance is discordant with clinical status.

Background: Neutrophil-to-lymphocyte ratio (NLR) has recently emerged as a useful predictor of cardiovascular risk and adverse outcomes. According to previous studies, an NLR > 5 has the highest sensitivity and specificity for postoperative morbidity and mortality in cardiovascular disease. This study aims to evaluate the NLR in cases of infrarenal unruptured abdominal aortic aneurysm (uAAA) and ruptured abdominal aortic aneurysm (rAAA) and to assess the role of NLR as a prognostic marker of 30-day mortality in patients with uAAA and rAAA who underwent surgical repair. Methods: This retrospective cohort study examined 255 consecutive patients with intact or ruptured infrarenal AAA who underwent elective or urgent open repair surgery within our clinic in a 10-year period. Differences in prevalence were assessed using chi-squared calculations and values greater than 5 and a P-value less than 0.05 were considered significant. The averages were compared using the ANOVA parameter test when the Bartlett P-value was greater than 0.05. Results: The average NLR appeared to be significantly higher in the group of patients with rAAA (9.3 vs. 3.39, respectively P < 0001). Furthermore, NLR > 5 occurred in 77.6% of patients with rAAA but only 32.5% in patients with uAAA (odds ratio 5.085; 95% confidence interval [CI]: 3.0025-8.6145; P < 0000.1). In terms of the postoperative prognosis in patients with uAAA, mortality after 30 days postoperatively was considerably higher at 16.6% in patients with NLR > 5 compared with 6% for patients with NLR < 5 (RR: 2.77; 95% CI: 1.020-7.55; P < 0.045). In the case of rAAA, mortality after 30 days was higher in patients with NLR > 5 (61.44%) than those with NLR < 5 (45.83%). There was no relationship between NLR and length of hospital stay or between NLR and the maximum diameter of the AAA. There was also no difference in the NLR between genders or age groups. Conclusions: The main findings of this study were the poor outcomes in terms of 30-day mortality for the patients presenting NLR values greater than 5 undergoing open surgical repair in both categories: infrarenal uAAA and rAAA. We also show that NLR is significantly higher among patients with rAAA and that an NLR > 5 indicates a 5 times greater possibility of AAA being ruptured. We can use this easily determinable, broadly available, and inexpensive marker to identify high-risk patients, individually, or integrated into a risk-stratification system for patients diagnosed with AAA. This would help in the therapeutic management of AAA, including the avoidance of open surgery when there are prohibitive risks, instead opting for an endovascular approach.

Objectives . The study evaluated the correlation between baseline SYNTAX Score, Residual SYNTAX Score, and SYNTAX Revascularization Index and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) on an unprotected left main coronary artery lesion (UPLMCA). Background . Previous studies on primary PCI in UPLMCA have identified cardiogenic shock, TIMI 0/1 flow, and cardiac arrest, as prognostic factors of an unfavourable outcome, but the complexity of coronary artery disease and the extent of revascularization have not been thoroughly investigated in these high-risk patients. Methods . 30-day, 1-year, and long-term outcomes were analyzed in a cohort of retrospectively selected, 81 consecutive patients with STEMI, and primary PCI on UPLMCA. Results . Cardiogenic shock (p=0.001), age (p=0.008), baseline SYNTAX Score II (p=0.006), and SYNTAX Revascularization Index (p=0.046) were independent mortality predictors at one-year follow-up. Besides cardiogenic shock (HR 3.28, p<0.001), TIMI 0/1 flow (HR 2.17, p=0.021) and age (HR 1.03, p=0.006), baseline SYNTAX Score II (HR 1.06, p=0.006), residual SYNTAX Score (HR 1.03, p=0.041), and SYNTAX Revascularization Index (HR 0.9, p=0.011) were independent predictors of mortality at three years of follow-up. In patients with TIMI 0/1 flow, the presence of Rentrop collaterals was an independent predictor for long-term survival (HR 0.24; p=0.049). Conclusions . In this study, the complexity of coronary artery disease and the extent of revascularization represent independent mortality predictors at long-term follow-up.

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Contact address: Claudia Matei, Department of Cardiology, “Dr. Constantin Opris” Emergency County Hospital, George Cosbuc Street, no 31, Baia Mare, Romania. E-mail: cabdia@yahoo.com 1 “Dr. Constantin Opris” Emergency County Hospital, Baia Mare, Romania 2 “Vasile Goldis” West University, Arad, Romania 3 “Niculae Stancioiu” Heart Institute, Cluj-Napoca, Romania Abstract: Introduction – Atrial fi brillation (AF) accounts for over 50% of strokes, also known as cerebrovascular accidents (CVAs). We report a case of a right atrial (RA) myxoma presenting as paroxysmal AF, syncope and acute chest pain, in a patient with previous CVA. Description of the problem. A 62-year-old Caucasian woman was admitted for an episode of syncope and acute chest pain. Two years earlier she had suffered a CVA. Paroxysmal AF was noted at that time. At current presentation pulmonary thromboembolism (PE) was ruled out by pulmonary CT. TTE combined with TOE showed a large moving mass in the RA, prolapsing through the tricuspid valve into the right ventricle. The coronary arteries were normal. The patient underwent surgical treatment. The histopathological study confi rmed diagnosis of myxoma. Questions, problems. Up to 25% of myxomas are found in RA. Chest pain is infrequent. Syncope is experienced by approximately 20% of patients. Our patient had confi rmed TTE obstruction of the tricuspid valve and PE was ruled out by CT pulmonary scan. Conclusions – TTE must be considered at admission to clarify etiology in all AF and stroke patients. Although TOE is more sensitive, TTE is usually adequate for the diagnosis of cardiac myxomas.

This report presents the surgical repair and postsurgical outcomes following a ruptured infrarenal aortic aneurysm with a maximum transverse diameter of 20 cm. Its association with acute lower limb motor deficit is rare. Open surgery of giant abdominal aortic aneurysms is often the only available treatment, favored over an endovascular approach in the presence of increased aneurysm size with dislodged abdominal organs, adhesions, and short and angled proximal infrarenal aortic neck, presenting significant additional surgical and anesthesiological challenges.

BACKGROUND: A 68-year old man with a history of prior endovascular abdominal aortic aneurysm repair, with recurrent flash pulmonary oedema and renal artery revascularisation including redo renal artery interventiions for in-stent restenosis, presented to our department with renal failure, severe uncontrolled high blood pressure and left renal stent fracture. The patient was prepared for a third renal revascularisation procedure.INVESTIGATION: Renal angiography, intravascular ultrasound, renal duplex imaging.DIAGNOSIS: Renal artery in-stent restenosis and stent fracture after endovascular abdominal aortic aneurysm repair.MANAGEMENT: Left renal artery stenting was performed using a Hippocampus 6*24 mm renal stent which was preferred to a drug-eluting stent.

Coronary subclavian steal syndrome (CSSS) is a relatively uncommon entity, and its clinical spectrum is characterized by stable exertional angina and rarely as acute coronary syndrome. The diagnosis can be established easily by angiography. We report a case series of three patients with CSSS and acute coronary syndrome and we review the literature in the attempt to understand the nature of symptomatology and the mechanisms of ischemia in this condition. Our study raised some questions about the correct definition of this entity, the pathophysiology of coronary steal and the mechanisms of ischemia, in the setting of unstable angina and acute myocardial infarction.

Contact address: Dan Bindea MD, PhD “Niculae Stăncioiu” Heart Institute Motilor Street, No. 19-21, 400001, Cluj-Napoca, Romania E-mail: bindea_dan_ch@yahoo.com INTRODUCTION The ventricular septal rupture is a rare complication (1-2% of all patients with myocardial infarction), with a decreasing incidence (0.2%)1, due to increased early myocardial revascularization possibilities. In the absence of an adequate surgical treatment, mortality is extremely high, being about 25% on the fi rst day, 50% in the fi rst week and 80% in the fi rst month2. This is due to the syndrome of cardiac insuffi ciency and to quickly installed multiple organs failure.

Coronary-subclavian steal syndrome is a rare clinical entity, which results from the atherosclerotic disease of the origin of the subclavian artery in patients in which the internal mammary artery was used as a conduit for coronary artery by-pass. This complication causes reversal of the flow in the internal mammary artery and the recurrence of myocardial ischemia. The therapeutic options are angioplasty and stent of the subclavian artery or, in a rare case of occlusion, surgical treatment. This case report describes the use of the carotid to subclavian artery by-pass for the treatment of coronary-subclavian steal syndrome due to the occlusion of the subclavian artery.

Assessment of the left internal mammary artery (LIMA) graft patency currently requires invasive investigation through coronary angiography. In the last years the successful application of noninvasive Doppler spectrum analysis has been reported for patency assessment of the LIMA graft after myocardial revascularization. Echocardiography is considered to be a sensitive noninvasive screening modality to diagnose critical narrowing of LIMA grafts and angiography should be reserved for cases in which Doppler echocardiography fails to visualize the LIMA or reveals an abnormal flow pattern.

Transthoracic Doppler echocardiography (TDE) is a non-invasive and easy reproducible method to assess the left internal mammary artery (LIMA) graft patency after coronary artery bypass graft surgery (CABG). LIMA graft dysfunction is rare, its rate being 10% at 10 to 15 years after revascularization. The most common cause of graft dysfunction is the competitive flow with the native coronary artery, when the stenosis of the bypassed vessels is not severe. We present two cases of LIMA graft dysfunction diagnosed by TDE and confirmed by angiography, with two particular pulsed-wave color Doppler flow signals.

REZUMAT Pacienta L.M. in vârsta de 53 ani a fost internata de urgenţa in Serviciul nostru cu diagnosticul de disecţie de aorta (Ao) tip A cu interesarea porţiunilor iniţiale a trunchiului arterial brahiocefalic (TABC) si a arterei carotide comune (ACC) stângi (confirmat prin CT in Spitalul teritorial). Ecografia cardiaca confirma diagnosticul si arata prezenţa unei colecţii pericardice cu semne de tamponada si a insuficienţei aortice severe. In aceste condiţii, pacienta este supusa de urgenţa unei intervenţii chirurgicale complexe: protezarea valvei aortice, inlocuirea Ao ascendente si a 2/3 proximale din arcul aortic, reimplantarea arterelor coronare prin interpoziţia a doua segmente de proteza scurte si reimplantarea TABC si a ACC stângi, de-asemenea prin intermediul unor segmente de proteza. Pentru refacerea porţiunii iniţiale a aortei s-a utilizat procedeul Bentall si tehnica Mills. Pe perioada arestului cardiocirculator (53 min) perfuzia cerebrala a fost asigurata prin incanularea directa a TABC. Evoluţia postoperatorie a fost marcata de prezenţa unui sindrom de insuficienţa respiratorie acuta (ARDS), care a necesitat ventilaţia mecanica prelungita a pacientei. In ziua a 14-a postoperator a fost necesara evacuarea unei colecţii pericardice compresive prin abord chirurgical subxifoidian. Ulterior, evoluţia a fost fara alte evenimente. Consideram ca, chirurgia arcului aortic ramâne o provocare pentru chirurgul cardiac; o tehnica chirurgicala excelenta alaturi de o protecţie cerebrala buna asigura premisele unei reusite. Cuvinte cheie: disecţie de Ao tip A, procedeul Bentall, tehnica Mills, protecţie cerebrala

REZUMAT Pacientul V.P., de 62 de ani, a fost internat in spitalul nostru cu diagnosticul de ruptura de sept ventricular si anevrism de ventricul stâng (VS) dupa un infarct miocardic vechi de trei saptamâni. Dupa investigaţii preoperatorii (echocardiografie si angiografie coronariana) pacientului i s-a propus intervenţia chirurgicala. Datorita disfuncţiei severe de VS si a imposibilitaţii de a asigura o protecţie miocardica adecvata (ocluzie a arterei coronariene stângi anterioare descendente) am decis realizarea intervenţiei chirurgicale cardiace fara clampaj aortic, cu asistarea circulaţiei extracorporeale. In acest fel s-a realizat inchiderea cu succes a rupturii de sept ventricular cu petec de Dacron si sutura liniara a anevrismului de VS. Consideram ca acest procedeu, chiar daca este mai dificil din punct de vedere tehnic, poate oferi rezultate foarte bune. Cuvinte cheie: post-infarct, ruptura de sept ventricular, anevrism de ventricul stâng