The case presents a traumatic ventricular perforation of a girl, accidentally felt on a sharp instrument. The uniqueness of the case presented is due to the very high infrequency of injuries with this type of sharp object. The 7-year-old girl was transported to the hospital after accidentally falling on a sharp instrument. The child had no signs of heart failure. On opening the chest, it was found that the metal object was lodged in the right ventricle. Quickly proceeded to remove the object and suture the entry hole. After a short hospitalization, the child was discharged completely cured.

Transfemoral transcatheter aortic valve replacement (TAVR) is currently the standard catheter-based treatment of severe aortic stenosis patients. Being the transfemoral route not feasible, other access sites could be chosen. Transaortic TAVR via either a J mini-sternotomy or a right anterolateral mini-thoracotomy is a good option for patients having tricky thoracoabdominal aorta. Some tips and tricks may help in getting a fast and safe transaortic procedure.

Abstract Introduction Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is an appealing treatment option for patients with degenerated aortic bioprosthetic valves. However, high post-procedural transprosthetic gradients are very common after ViV-TAVI than after TAVI for native-valve aortic stenosis. Aim We sought to evaluate transprosthetic gradients (ΔP) and hemodynamic outcome in patients undergoing ViV-TAVI according to valve type and balloon post-dilation (balloon-expandable vs self-expandable with and without post-dilation). Material and methods We retrospectively analyzed 111 patients undergoing ViV-TAVI. A balloon-expandable valve was used in 35 patients (32%, Group 1), a self-expandable valve in 76 cases of which 39 (35%, Group 2) without balloon post-dilation and 37 (33%, Group 3) with balloon post-dilation. A comprehensive transthoracic echocardiography (TTE) was performed in all patients at baseline, at discharge and at 6-months follow-up. Results Successful ViV-TAVI was performed in 110 patients (99%). Baseline peak and mean ΔP, left ventricular volumes, ejection fraction, and pulmonary artery systolic pressure were similar among groups. A significant improvement in all echocardiographic parameters was observed in all groups over time (Table 1). In particular, a significant reduction in postprocedural gradients was observed at discharge and at 6-months follow-up compared to baseline in all groups. Immediately after ViV-TAVI procedure, the lowest value of mean ΔP was observed in Group 3 (12±7 mmHg) compared to both Group 1 (20±9 mmHg) and Group 2 (17±8 mmHg, p=0.001). This result was confirmed at 6-months follow-up (p=0.012). Rate of small valve size (≤23 mm) implanted was similar among groups (Group 1: 78%, Group 2: 60%, Group 3: 62%, p=0.123). Similar 1-year all-cause mortality was observed among groups (9%, 13%, 0%, respectively, p=0.135). Conclusions In patients with failed surgical aortic prosthesis, ViV-TAVI is an effective option and is associated with sustained improved hemodynamics in all patients. Anyway, the choice of prosthetic valve type and implantation technique are relevant on residual transprosthetic gradients and should be taken into account for a better long-term outcome. Funding Acknowledgement Type of funding sources: None.

Abstract Introduction In the last years, genetic testing for inherited cardiac conditions (ICCs) is expanded and evolved at an incredible rate. This tool may inform treatment options and lifestyle choices to avoid arrhythmia triggers. Furthermore, identifying the genetic underpinning of the disorder improves risk assessment for asymptomatic or pre-symptomatic family members. However, despite the large numbers of disease-causative genes identified in the last years, only 60% of the patients with a clinical diagnosis of ICCs carry a pathogenic or likely pathogenic variant. The remaining 40% of the cases have an inconclusive or ambiguous test caused by negative results or mainly by the identification of one or more variants of unknown significance (VUS). In this case, the test results are uninformative and clinically irrelevant, increasing uncertainty about medical management. Purpose We investigated whether a periodic re-evaluation of the detected VUS, using the American College of Medical Genetics and Genomics (ACMG) criteria, may impact the clinical setting of patients with suspected ICC and their family members. Methods We reevaluated 306 consecutive probands with suspected ICC undergoing genetic testing by next-generation sequencing using the Illumina TruSight Cardio Sequencing panel, from 2017 to 2021. Results Thirty-five percent of patients carried at least one variant in a gene associated with the phenotype. Of these, 94 had been previously classified as VUS and were not considered clinically actionable. After an average time of 36 months, they were reevaluated and 26.6% of the VUS were reclassified. In particular, 1 was downgraded to Benign and 24 were upgraded to Likely Pathogenic (16) or Pathogenic (8). According to the different phenotypes, the reclassification rate was 45.8% in Hypertrophic cardiomyopathy, 33.3% in Dilated cardiomyopathy, 27.3% in Arrhythmogenic cardiomyopathy, 12.5% in Brugada syndrome, and 50% in Long QT syndrome patients. This reclassification process allowed to recategorize 24 probands as clinically and molecularly diagnosed and to extend the genetic screening to their at-risk family members. Conclusions Given the extent of the clinical impact that genetic testing can have, these findings suggest that a periodic reevaluation of genetic test results, particularly VUS, should be a mandatory step in the ICC diagnostic workflow.

Abstract Background Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (EF), and both situations represent the most challenging subset of patients with AS to manage and generally have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Few and controversial data exist on the outcomes of these patients compared to normal-flow high-gradient (NF-HG) AS following transcatheter aortic valve replacement (TAVR). Purpose This study aims to better characterize patients with different transvalvular flow-gradient patterns undergoing TAVR and to examine the prognostic value of these flow state. Methods Overall, 1208 patients with severe symptomatic AS undergoing TAVR were categorized according to flow-gradient patterns as follow: 976 patients NF-HG (DPmean >40 mmHg), 107 paradoxical LF-LG (pLF-LG: DP mean <40 mmHg, EF >50%, and SVi <35 mL/m2), and 125 classical LF-LG (DP mean <40 mmHg, EF <50%, SVi <35 mL/m2). Results TAVR was feasible in all AS subtypes. When compared with NF-HG and pLF-LG, LF-LG had a worse symptomatic status (NYHA III–IV 86% vs 62% and 67%, respectively, p<0.001), a higher prevalence of eccentric hypertrophy (Figure 1, left), a higher level of LV global afterload reflected by a higher valvuloarterial impedance and a higher pulmonary pressure (Table). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group. While intraoperative (p=0.935) and 30-day mortality (p=0.911) did not differ significantly among the 3 groups, LF-LG had a lower overall 5-year survival (LF-LG 50%, pLF-LG 65%, NF-HG 84%, p<0.001) (Figure 1, right). LF-LG AS was associated with a hazard ratio for 5-year mortality of 2.416 (95% CI: 1.658–3.520, p<0.001). Conclusions TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rate than patients with NF-HG, whereas survival in LF-LG patients was 2-fold higher. Therefore, being able to identify patients less likely to improve after TAVR may help to guide treatment decision. Funding Acknowledgement Type of funding sources: None.

Abstract Introduction In the last years, genetic testing for inherited cardiac conditions (ICCs) is expanded and evolved at an incredible rate. This tool may inform treatment options and lifestyle choices to avoid arrhythmia triggers. Furthermore, identifying the genetic underpinning of the disorder improves risk assessment for asymptomatic or pre-symptomatic family members. However, despite the large numbers of disease-causative genes identified in the last years, only 60% of the patients with a clinical diagnosis of ICCs carry a pathogenic or likely pathogenic variant. The remaining 40% of the cases have an inconclusive or ambiguous test caused by negative results or mainly by the identification of one or more variants of unknown significance (VUS). In this case, the test results are uninformative and clinically irrelevant, increasing uncertainty about medical management. Purpose We investigated whether a periodic re-evaluation of the detected VUS, using the American College of Medical Genetics and Genomics (ACMG) criteria, may impact the clinical setting of patients with suspected ICC and their family members. Methods We reevaluated 306 consecutive probands with suspected ICC undergoing genetic testing by next-generation sequencing using the Illumina TruSight Cardio Sequencing panel, from 2017 to 2021. Results Thirty-five percent of patients carried at least one variant in a gene associated with the phenotype. Of these, 94 had been previously classified as VUS and were not considered clinically actionable. After an average time of 36 months, they were reevaluated and 26.6% of the VUS were reclassified. In particular, 1 was downgraded to Benign and 24 were upgraded to Likely Pathogenic (16) or Pathogenic (8). According to the different phenotypes, the reclassification rate was 45.8% in Hypertrophic cardiomyopathy, 33.3% in Dilated cardiomyopathy, 27.3% in Arrhythmogenic cardiomyopathy, 12.5% in Brugada syndrome, and 50% in Long QT syndrome patients. This reclassification process allowed to recategorize 24 probands as clinically and molecularly diagnosed and to extend the genetic screening to their at-risk family members. Conclusions Given the extent of the clinical impact that genetic testing can have, these findings suggest that a periodic reevaluation of genetic test results, particularly VUS, should be a mandatory step in the ICC diagnostic workflow. Funding Acknowledgement Type of funding sources: None.

Aims Patients with coronary heart disease (CHD) are at very high risk of recurrent events. A strategy to reduce excess risk might be to deliver structured secondary prevention programmes, but their efficacy has been mostly evaluated in the short term and in experimental settings. This is a retrospective case–control study aimed at assessing, in the real world, the efficacy of a secondary prevention programme in reducing long-term coronary event recurrences after coronary artery bypass surgery (CABG). Methods and results Programme participants (henceforth ‘cases’) were men and women aged <75 years subjected to CABG between 2002 and 2014, living within 100 km of the hospital. Key programme actions included optimization of treatments according to the most updated European preventive guidelines, surveillance of therapy adherence, and customized lifestyle counselling. Controls were analogous patients not involved in the programme because living farther than 100 km away, matched 1:1 with cases for gender, age at CABG, and year of CABG. Both groups (n = 1248) underwent usual periodic cardiology follow-up at our centre. Data on symptomatic or silent CHD recurrences were obtained from the hospital electronic health records. Cox analysis (adjusted for baseline differences between groups) shows that programme participation was associated with a significantly lower incidence throughout 5 years post-CABG of symptomatic [hazard ratio (95% confidence interval): 0.59 (0.38–0.94)] and silent [0.53 (0.31–0.89)] coronary recurrences. Conclusion In a real-world setting, taking part in a structured longstanding secondary prevention programme, in addition to usual cardiology care, meaningfully lowers the risk of coronary recurrences.

In the clinical practice a noteworthy proportion of severe symptomatic aortic stenosis patients presents with low-flow low-gradients features, these having reported a less favorable prognosis even when surgically or transcatheter treated. We retrospectively analyzed the prospectively collected data on 1051 consecutive patients undergone balloon-expandable transcatheter aortic valve replacement at our Institution from January 2008 to January 2020. We divided the population according with a mean aortic gradient (MAG) < or ≥40 mmHg and we performed a propensity-matched analysis based on the Society of Thoracic Surgery Score and age, obtaining two homogeneous groups of 314 patients each (Groups A and B, respectively). We then analyzed the outcomes of the two groups by implementing adjusted Cox models adjusted for significant clinical differences between the two groups, such as sex, ejection fraction, comorbidities and other variables not included in the propensity-matched analysis. The only variable associated with both cardiovascular and all-cause events was an ejection fraction ≤35%. Finally, a sensitivity analysis found that an ejection fraction ≤35% was associated with an increase cardiovascular and all-cause mortality only in patients with an indexed end-diastolic volume >97 ml/m 2 ( p = .0438 and .3363, respectively). In our series a MAG <40 mmHg was not found to be per se an independent risk factor for cardiac and all-cause mortality after transcatheter aortic valve replacement. The ejection fraction was found to be an independent risk factor only in the context of enlarged left ventricular dimensions.

The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5–51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes.

Abstract Aims Haemodynamic classifications of severe aortic stenosis (AS) have important prognostic implications, with low flow state (defined on the basis of a stroke volume index, SVi<35 mL/m2) known to be a predictor of worse prognosis. As transcatheter aortic valve replacement (TAVR) has become widely used for patients with severe AS, issues were raised concerning its efficacy in patients with different haemodynamic classifications combining transvalvular flow state and pressure gradients. In fact, data on TAVR outcomes in patients with low gradient (LG) AS are limited and in some cases controversial. The aim of this study was to evaluate the efficacy and long-term clinical and echocardiographic outcome of TAVR in patients with different transvalvular flow-gradient patterns. Methods In this single centre study, 1078 patients (mean age 81±7 years) with severe symptomatic AS (AVA<1 cm2) undergoing TAVR were categorized according to flow-gradient patterns as follow: 867 patients (80%) with normal flow-high gradient (NF-HG: mean transaortic gradient DP mean>40 mmHg), 94 (9%) with paradoxical low flow LG (pLF-LG: DP mean<40 mmHg, ejection fraction EF > 50%, and SVi<35 mL/m2), and 117 (11%) classical LF-LG (DP mean<40 mmHg, EF < 50%, SVi<35 mL/m2). Results TAVR was feasible in all AS subtypes with similar rate of unsuccessful procedure (1.3% NF-HG, 1.1% pLF-LG, 0% LF-LG P=470). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group (Figure A). Overall, intraoperative (P=957) and 30-day mortality (P=817) did not differ significantly among the 3 groups. Longer follow-up showed that, compared to NF-HG patients, pLF-LG had similar all-cause mortality rate [HR 1.35(0.95–1.90), P=0.094] up to 5 years and LF-LG had a significant higher mortality rate [HR 1.89(1.43–2.49), P<0.001],(Figure B). Moreover, LF-LG patients had higher rehospitalization for heart failure (NF-HG: 3%, pLF-LG: 6%, LF-LG 10%, P=0.001). Conclusions We provided evidence that TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. A careful haemodynamic classifications of severe AS is of utmost importance for identifying patients who benefits the most from TAVR procedure.

Background. Transcatheter aortic valve replacement (TAVR) is an established technique to treat severe symptomatic aortic stenosis patients with a wide range of surgical risk. Currently, the common femoral artery is the first choice as the main access route for the procedure. The objective of this observational study is to report our experience on percutaneous and surgical cut-down transfemoral TAVRs comparing the two approaches. Methods. From January 2014 to January 2019, five hundred eleven consecutive patients underwent TAVR for severe symptomatic aortic stenosis. We analyzed only elective transfemoral procedures. After propensity score-matching based on age, sex, EuroSCORE II, mean aortic gradient, and left ventricular ejection fraction, we obtained two homogeneous populations: surgical cut-down (n = 119) and percutaneous (n = 225), which were labeled Group 1 and Group 2, respectively. Results. The main findings were that there were no significant procedural outcome differences between the two groups, but Group 2 patients had a shorter length of hospital stay and were more frequently discharged home. At follow-up, Group 1 patients had lower survival rates. Conclusions. An accurate preoperative assessment of the femoral access is mandatory to achieve satisfactory outcomes with transfemoral TAVRs. Nevertheless, the percutaneous approach allows shorter in-hospital stay and the need for rehabilitation, thus potentially decreasing the costs of the procedure.

Abstract Funding Acknowledgements Type of funding sources: None. Background. Transcatheter aortic valve-in-valve (TAVI ViV) implantation is an appealing treatment option for patients with degenerated bioprostheses. However, elevated residual gradients after TAVI ViV procedure are very common. These are an unwanted effects of prosthesis-patient mismatch (PPM). Currently, the actual incidenceof PPM, its predictors and its clinical outcomes have not been completely investigated. Purpose. The aims of this study was to investigate the incidence, predictors and clinical outcome of PPM and therefore of elevated gradients after TAVI ViV. Methods. 75 patients (age 78 ± 9 years, 36 male), who underwent TAVI-ViV due to failed aortic biological valve (60 stented, 15 stentless), were enrolled. Mechanism of bioprosthetic valve failure was stenosis (34 cases, 45%), regurgitation (24 cases, 32%) or combination (17 cases, 23%). Elevated residual gradients were defined as a mean DP> 20 mmHg. PPM was identified by the indexed effective orifice area (EOAi) measured by echocardiography (moderate PPM if 0.65 < EOAi < 0.85 cm²/m²; severe PPM if EOAi < 0.6 cm²/m²). Results. ViV TAVI was feasible in all patients, 33 patients (44%) were implanted with a balloon-expandable valve and 42 (56%) with a self-expandable valve. Post-procedural post-ballooning was performed in 16 out of 42 patients (38%) receiving a self-expandable valve. Post-operative mean DP> 20 mmHg was found in 35 patients (48%). Moderate PPM was found in 24 cases (33%) and severe PPM in 15 (20%). A logistic regression analyses identified small size of surgical prosthesis (size < 23 mm) [OR: 6.061(2.127-17.267), p = 0.001] and failed stented valve [OR: 20.727(2.522-170.364), p = 0.005] as independent predictors for the occurrence PPM. Interestingly PPM did not affect early and 1 years mortality (1 years mortality 1.3 %), while mortality was higher in pts with stentless prostheses (9%) Conclusions. PPM is a frequent finding after ViV procedures. Despite elevated residual gradients, TAVI ViV resolved prosthetic dysfunction and PPM did not affect mortality. Therefore, this procedure represents a promising new option for patients with failed biological prosthetic valves.

INTRODUCTION: Type A aortic dissection (AAD) is a life-threatening disease with very high mortality. The gold standard treatment is surgical, as medical treatment has been proven to be ineffective. It is still unclear the role of preoperative neurological dysfunction in the prognosis of the patient. Therefore, the choice of performing surgery in patients with neurological symptoms is still left to the surgeon at the time of the diagnosis. The aim of this study is to make a narrative review of the current literature about the management of patients with neurological symptoms in AAD patients.EVIDENCE ACQUISITION: A bibliographical research was performed on PubMed, looking for papers containing the words: “((preoperative neurological symptoms in type a aortic dissection) OR brain injury type A aortic dissection) AND (“2010”[Date - Publication]: “3000”[Date - Publication])”. A total of 35 papers were found.EVIDENCE SYNTHESIS: A total of 6 papers were chosen to be reviewed. All of them concluded that even patients with severe neurological symptoms (up to comatose state) had a good chance to recover neurological functions after surgery if treated in the first hours from the onset of symptoms. Interestingly, a hemorrhagic stroke was rarely found.CONCLUSIONS: Preoperative neurological dysfunction have been long considered a contraindication to surgery. Nevertheless, several authors show neurological and survival good results in patients with preoperative neurological dysfunction. They also stress the importance of surgical timing finding in 5 to 10 hours the surgical time limit to improve neurological dysfunction. A preoperative neurological dysfunction could be considered a strong advice towards surgical intervention. It is time to change and consider prompt surgery not only for survival but also for cerebral protection.

Aortic valve stenosis (AS) is a pathological condition that affects about 3% of the population, representing the most common valve disease. The main clinical feature of AS is represented by the impaired leaflet motility, due to calcification, which leads to the left ventricular outflow tract obstruction during systole. The formation and accumulation of calcium nodules are driven by valve interstitial cells (VICs). Unfortunately, to date, the in vitro and in vivo studies were not sufficient to fully recapitulate all the pathological pathways involved in AS development, as well as to define a specific and effective pharmacological treatment for AS patients. Cyclophilin A (CyPA), the most important immunophilin and endogenous ligand of cyclosporine A (CsA), is strongly involved in several detrimental cardiovascular processes, such as calcification. To date, there are no data on the CyPA role in VIC-mediated calcification process of AS. Here, we aimed to identify the role of CyPA in AS by studying VIC calcification, in vitro. In this study, we found that (i) CyPA is up-regulated in stenotic valves of AS patients, (ii) pro-calcifying medium promotes CyPA secretion by VICs, (iii) in vitro treatment of VICs with exogenous CyPA strongly stimulates calcium deposition, and (iv) exogenous CyPA inhibition mediated by CsA analogue MM284 abolished in vitro calcium potential. Thus, CyPA represents a biological target that may act as a novel candidate in the detrimental AS development and its inhibition may provide a novel pharmacological approach for AS treatment.

Clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG) undergoing valve replacement are controversial. PLF-LG is a combination of a small aortic valve area (AVA < 1cm²), a preserved left ventricular (LV) ejection fraction (LVEF≥50%), and a ‘paradoxical’ low mean gradient due to the presence of low LV stroke volume (≤35 mL/m²). The low flow state is explained by the presence of a high afterload and pronounced LV concentric remodeling, with impaired LV filling. Surgical aortic valve replacement has been associated with very positive outcomes in normal-flow high-gradient (NF-HG) AS, whereas poorer outcomes has been reported in patients with PLF-LG AS. The aim of this study is to determine the clinical outcomes in patients with PLF-LG AS undergoing transcatheter aortic valve implantation (TAVI) compare to NF-HG patients. A total of 624 patients (age 81 ± 7 years) with symptomatic severe AS and preserved LVEF who underwent TAVI, was enrolled and divided in 2 groups: group NF-HG included 554 patients (89%) and group PLF-LG including 70 patients (11%). At 1-year follow-up, death and clinical events were reported. TAVI was feasible in all patients. A significant reduction in mean aortic pressure gradient was observed after TAVI both in PLF-LG (baseline, 30 ± 6 mmHg; 1-year, 12 ± 4 mmHg; p < 0.001) and in NF-HG (baseline, 55 ± 12 mmHg; 1-year, 11 ± 4 mmHg; p < 0.001) together with an increase in AVA (PLF-LG: baseline, 0.73 ± 0.16 cm², 1-year: 1.82 ± 0.43 cm², p < 0.001; NF-HG: baseline, 0.66 ± 0.18 cm², 1-year: 1.84 ± 0.38cm², p < 0.001). Perioperative mortality at 30-days was similar in group NF-HG (17/554, 3%) and in group PLF-LG (2/70, 3%). Figure shows the survival curves up to 5 years follow-up according to the two groups. PLF-LG and HG-AS had similar survival rate throughout the long-term follow-up. Similarly, rehospitalization rate was not different in the two groups (PLF-LG: 12% vs NF-HG: 7%, p = 0.127). Differently from surgical series, TAVI in PLF-LG AS is a useful procedure showing similar mortality and rehospitalization rates compared to NF-HG AS patients. Abstract 624 Figure. Survival curve

OBJECTIVES:During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, Northern Italy had to completely reorganize its hospital activity. In Lombardy, the hub-and-spoke system was introduced to guarantee emergency and urgent cardiovascular surgery, whereas most hospitals were dedicated to patients with coronavirus disease 2019 (COVID-19). The aim of this study was to analyse the results of the hub-and-spoke organization system.METHODS:Centro Cardiologico Monzino (Monzino) became one of the four hubs for cardiovascular surgery, with a total of eight spokes. SARS-CoV-2 screening became mandatory for all patients. New flow charts were designed to allow separated pathways based on infection status. A reorganization of spaces guaranteed COVID-19-free and COVID-19-dedicated areas. Patients were also classified into groups according to their pathological and clinical status: emergency, urgent and non-deferrable (ND).RESULTS:A total of 70 patients were referred to the Monzino hub-and-spoke network. We performed 41 operations, 28 (68.3%) of which were emergency/urgent and 13 of which were ND. The screening allowed the identification of COVID-19 (three patients, 7.3%) and non-COVID-19 patients (38 patients, 92.7%). The newly designed and shared protocols guaranteed that the cardiac patients would be divided into emergency, urgent and ND groups. The involvement of the telematic management heart team allowed constant updates and clinical discussions.CONCLUSIONS:The hub-and-spoke organization system efficiently safeguards access to heart and vascular surgical services for patients who require ND, urgent and emergency treatment. Further reorganization will be needed at the end of this pandemic when elective cases will again be scheduled, with a daily increase in the number of operations.

Central MessageRedo transapical aortic valve-in-valve is not recommended for device failure after primary transapical procedure, but it can be reliable in patients at risk for other transcatheter options or surgery.See Commentary on page 121. Redo transapical aortic valve-in-valve is not recommended for device failure after primary transapical procedure, but it can be reliable in patients at risk for other transcatheter options or surgery. See Commentary on page 121. Transapical aortic valve implantation (TA-AVI) is a minimally invasive off-pump technique to treat aortic stenosis performed through a left anterolateral mini-thoracotomy exposing the apex of left ventricle (LV). The target population consists of elderly patients with high operative risk. Redo TA valve-in-valve (VinV) for a degenerated prosthesis implanted during a primary TA- transcathether aortic valve implantation (TAVI) procedure is traditionally not recommended. The preferred approaches to this situation include a transfemoral or less common TAVI access or eventually a high-risk standard surgery. Going against this concept, we describe the case of a redo-TA aortic VinV implantation in presence of a degenerated transcatheter (TC) valve. A 73-year-old patient with a degenerated aortic SAPIEN XT prosthesis (Edwards Lifesciences, Irvine, Calif) was referred to us. Of note in his history were coronary artery bypass graft, percutaneous coronary intervention, percutaneous transluminal angioplasty of iliac arteries and thromboendarterectomy of carotid arteries and femoral vessels, and severe chronic obstructive pulmonary disease. In 2010, he underwent a TA-AVI procedure with a 23-mm Edwards SAPIEN prosthesis. A pacemaker–implantable cardioverter-defibrillator was implanted 2 years later. The patient also reported several hospital admissions for heart and lung failure. In 2017, he came to our emergency department with acute respiratory failure and pulmonary edema. A transthoracic echocardiogram (TTE) showed a degenerated aortic prosthesis leading to severe intra and paravalvular regurgitation. Computed tomography scan depicted the porcelain aorta (Figure 1), peripheral vasculopathy, patent coronary grafts (Figure 2), and marked the access site of the previous TC procedure.Figure 2The history of the patient was notable for a previous coronary artery bypass grafting procedure. Computed tomography scan was performed to assess the patency of the anastomosis. In the figure, the left internal mammary artery to anterior descending coronary artery anastomosis is shown.View Large Image Figure ViewerDownload (PPT)Figure 3Brief description of the case and its management: computed tomography scan, catheter lab images, operating room setting, and skin wound at the end of the procedure.View Large Image Figure ViewerDownload (PPT) The case management was discussed within the heart team. Concerns about patient's comorbidities (diffuse vasculopathy) and clinical history (several heart failure relapses) emerged. Therefore, it was judged more reliable to perform a VinV implantation through the previous TA access (TA redo TAVI) (Figure 3). The procedure was conducted in the hybrid room through a re-thoracotomy at fifth intercostal space. A 6-F venous introducer was used in the left femoral vein. We avoided the pigtail catheter for the aortography considering the peripheral vasculopathy and the potential of fluoroscopy alone to ensure the proper view of the prosthesis' stent, which we used as a reference. The valve implantation was then performed under fluoroscopic and transesophageal echocardiographic guidance. A 7-F catheter was advanced into the LV apex, directly across the pericardium, and secured with two 3/0 PROLENE U-stitches, forming a Greek cross. The older prosthesis was crossed through a dedicate wire, switching then to the proper introducer (a 21-F Edwards Certitude introducer sheath) to implant a 23-mm SAPIEN 3 (Edwards Lifesciences) bioprosthesis into the older one, under 180 beats-ventricular pacing. The introducer was removed and the left apical stitches carefully ligated, again during ventricular pacing. No complications occurred. The postprocedural TEE measured a maximal gradient of 38 mm Hg and a mean velocity of 3.1 m/s. The postoperative course was uneventful. The TTE confirmed the regular function and position of the valve, without any paravalvular leak. The patient was discharged on the ninth postoperative day. At 1 year, the TTE confirmed a good result, with a mean gradient across the valve of 28 mm Hg and preserved LV function (ejection fraction 70%) (Video 1). Permission was granted by the patient's respective parents to publish the proposed case report. Only 2 reports exist on the possible use of TA-AVI as an effective treatment option in a failed TC valve.1Pasic M. Unbehaun A. Dreysse S. Buz S. Drews T. Kukucka M. et al.Transapical aortic valve implantation after previous aortic valve replacement: clinical proof of the "valve-in-valve" concept.J Thorac Cardiovasc Surg. 2011; 142: 270-277Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar,2Wilbring M. Sill B. Tugtekin S.M. Alexiou K. Simonis G. Matschke K. et al.Transcatheter valve-in-valve implantation for deteriorated aortic bioprosthesis: initial clinical results and follow-up in a series of high-risk patients.Ann Thorac Surg. 2012; 93: 734-741Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Less is known about the results and the feasibility of a VinV TA approach to address a degenerated TA-TC valve.3Ferrari E. Locca D. Marcucci C. Jeanrenaud X. Urgent reoperative transapical valve-in-valve shortly after a transapical aortic valve implantation.Eur J Cardiothorac Surg. 2014; 46: 748-750Crossref PubMed Scopus (2) Google Scholar,4Kiefer P. Seeburger J. Chu M.W. Ender J. Vollroth M. Noack T. et al.Reoperative transapical aortic valve implantation for early structural valve deterioration of SAPIEN XT valve.Ann Thorac Surg. 2013; 95: 2169-2170Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In the presented case, the discussion within the heart team pointed out concerns regarding the patient's management: the diffuse, severe vasculopathy contraindicated a transfemoral TAVI, whereas respiratory problems and graft patency posed conventional surgery at an unreasonable risk. Conversely, repeating the TA access showed potential benefits. First, opting for a transpericardial approach to eliminate risks carried by adhesiolysis to reach the ventricle, the procedure was judged adequately safe. Likewise, the antegrade access, the orthogonal positioning, the defined landing zone with the previous stent, combined with porcelain aorta, severe peripheral arteriopathy, further favored the TA option over transvascular retrograde AVI, as in the case described by Kiefer and colleagues.4Kiefer P. Seeburger J. Chu M.W. Ender J. Vollroth M. Noack T. et al.Reoperative transapical aortic valve implantation for early structural valve deterioration of SAPIEN XT valve.Ann Thorac Surg. 2013; 95: 2169-2170Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In a prospective study by Kempfert and colleagues,5Kempfert J. Van Linden A. Linke A. Borger M.A. Rastan A. Mukherjee C. et al.Transapical off-pump valve-in-valve implantation in patients with degenerated aortic xenografts.Ann Thorac Surg. 2010; 89: 1934-1941Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar the technical feasibility of TA VinV implantation in patients affected by different types of degenerated aortic xenografts has been already analyzed, showing excellent outcomes. According to our single experience, we believe that it is of worth to further investigate the supposed good results of the TA approach in frail patients with a failed TC valve approaching a larger cohort by a randomized controlled trial or at least an observational study. Such studies could ease the broadening of the procedure as well as the expansion of its current indication in this setting. https://www.jtcvstechniques.org/cms/asset/f46af573-13cc-42fa-ba64-468636499e7a/mmc1.mp4Loading ... Download .mp4 (2.02 MB) Help with .mp4 files Video 1We performed a cardiac CT scan in our patient to demonstrate the presence of porcelain aorta, severe peripheral vasculopathy, the patency of the grafts, and finally to identify properly the site of the sheath introduction across the left ventricular apex. The heart team discussion confirmed the indication for a redo transapical valve in valve aortic implantation. In the video, we show our hybrid operating room and transthoracic preprocedural echocardiogram to identify the left ventricular apex and then make a short and precise incision at the fifth intercostal space. Because it was a redo case, we directly crossed the pericardium without opening it with a 7-F catheter, followed by a 21-F sheath. Two 3/o polipropylene U stitches, forming a Greek cross, were passed through both pericardium and myocardium of the left ventricle. In the bottom, on the left side, a short video of the VinV procedure carried under fluoroscopic guide is shown: the valve opening was performed very quickly during a rapid ventricular pacing. In the bottom, on the right side, you can see the same opening procedure under transesophageal echocardiographic guide. We then show the transesophageal echocardiographic check a few minutes after valve implantation, which showed the absence of paravalvular leaks and a maximal gradient of 38 mm Hg across the prosthesis, with a velocity of 3.1 m/s. The postoperative course was uneventful, and the patient was discharged on the ninth postoperative day. Video available at: https://www.jtcvs.org/article/S2666-2507(20)30625-8/fulltext.

Abstract Background Controversial data exist on clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG) undergoing valve replacement. This entity is a combination of a small aortic valve area (AVA<1cm2), a preserved left ventricular ejection fraction (LVEF≥50%), and a “paradoxical” low mean gradient due to the presence of low LV stroke volume (≤35 mL/m2). The low flow state is explained by the presence of a high afterload and pronounced LV concentric remodeling, with impaired LV filling. Currently, poorer outcomes have been reported after surgical aortic valve replacement in patients with PLF-LG AS compared with the normal-flow high-gradient (NF-HG) AS. Purpose The aim of this study was to determine the clinical outcomes in patients with PLF-LG AS undergoing transcatheter aortic valve implantation (TAVI) compare to NF-HG patients. Methods A total of 609 patients (age 81±6 years) with symptomatic severe AS and preserved LVEF who underwent TAVI, was enrolled and divided in two groups: group A included patients with NF-HG (542 patients) and group B including those with PLF-LG (66 patients). At 1-year follow-up, death and clinical events were reported. Results TAVI was feasible in all patients. A significant reduction in mean aortic pressure gradient was observed after TAVI both in PLF-LG (baseline, 30±5 mmHg; 1-year, 11±4 mmHg; p<0.001) and in NF-HG (baseline, 53±11 mmHg; 1-year, 12±4 mmHg; p<0.001) together with an increase in AVA (PLF-LG: baseline, 0.74±0.16 cm2, 1-year: 1.83±0.41 cm2, p<0.001; NF-HG: baseline, 0.65±0.16 cm2, 1-year: 1.84±0.35cm2, p<0.001). Perioperative mortality at 30-days was similar in group A (17/542, 3%) and in group B (2/66, 3%). Figure shows the survival curves up to 5 years follow-up according to the two groups. PLF-LG and HG-AS had similar survival rate throughout the long-term follow-up. Similarly, rehospitalization rate was not different in the two groups (PLF-LG: 12% vs NF-HG: 7%, p=0.121). Kaplan-Meier analysis Conclusions Differently from surgical series, TAVI patients with PLF-LG AS had showed similar mortality and rehospitalization rates compared to NF-HG.

Introduction: Severe coronary calcification hampers visual coronary computed tomography angiography (CCTA) assessment due to the blooming artefact and have been associated with discrepancy between non-invasive and invasive luminal evaluation. Moreover, the presence of severe calcification, which are easily detectable with CCTA, could influence treatment decision and planning in patients with multivessel coronary artery disease.