Background:In acute coronary syndrome (ACS) with non-ST elevation myocardial infarction, there is a subgroup of patients who are difficult to treat; these are patients with a complex left anterior descending artery (LAD) lesion or a non-LAD culprit lesion but who are not suitable for standard coronary artery bypass grafting (CABG). Staged hybrid coronary revascularization (HCR), combining primary percutaneous coronary intervention on the non-LAD culprit lesion with CABG, represents an attractive solution. Methods:We conducted a retrospective observational study to compare effectiveness and safety of HCR vs CABG alone. From December 6, 2016, to December 21, 2021, at our institution, 339 patients underwent urgent CABG with or without previous primary percutaneous coronary intervention; 65 received HCR (study group) and 274 received CABG alone (control group). Primary outcomes were major adverse cardiac and cerebrovascular events at 30 days and at long-term follow-up. Secondary outcomes were in-hospital postoperative complications. Results:Significant preoperative differences were detected in the mean EuroSCORE II: 3.4 (1.5-7.8) in HCR vs 2.5 (1.1-4.5) in CABG (P < .05). Patients in the CABG group needed more blood transfusions than patients in the HCR group (P = .004). Conversely, no other significant differences were detected for in-hospital postoperative complications. Survival analysis did not show significant differences between HCR and CABG, either to 30 days (hazard ratio, 0.51 [95% CI, 0.03-4.04]; P = .52) or to longer follow-up (maximum 5 years; hazard ratio, 0.40 [95% CI, 0.09-1.68]; P = .21). Conclusions:Our data support the safety and effectiveness of staged HCR in the scenario of ACS.

Myxoma is the most common benign primary tumor of the heart. Diagnosis of cardiac myxoma is difficult as it presents itself with varying nonspecific symptoms, and an echocardiography can easily diagnose it. Sometimes, it can cause cardiac syncope and thromboembolic events. A woman with a recent infection by severe acute respiratory syndrome coronavirus-2 was admitted to our hospital with respiratory symptoms: dyspnea and tachypnea; cardiac symptoms: atrial fibrillation; and neurological symptoms: syncope. Initially, she performed brain computed tomography (CT) and CT angiography value. Transthoracic echocardiogram and transesophageal echocardiogram showed an atrial mobile mass. Chest X-ray did not show any interstitial lesions. Therefore, urgent cardiac surgery was performed to remove the mass. The histological examination confirmed the presence of a cardiac myxoma. Our experience could show the importance of early diagnosis and prompt surgical treatment to prevent stroke.

To assess, using a patient-specific computational fluid dynamics (CFD) analysis, hemodynamic characteristics of four different arterial cannulation sites routinely used during cardiopulmonary bypass (CPB). The arterial cannula was a standard 22 Fr diameter rigid cannula with a straight tip. A 3D real aorta model was generated from CT images using segmentation and reverse engineering techniques. The 22 Fr cannula was modeled and inserted at four common cannulation sites along the aortic vessel perpendicular to it. Each cannulation site was assigned to a clinical case-scenario characterized by the location of the arterial cannulation site: case 1, in the ascending aorta, 2 cm above the ST junction; case 2, in the aortic arc between the origin of the first two epi-aortic vessels (EAV) i.e brachiocephalic trunk and left common carotid artery; case 3, in the right subclavian artery; case 4, in the right common femoral artery. The assumption of identical boundary conditions was chosen for all simulations in order to enhance the only effects of arterial cannulation site onto blood flow distribution and Shear Stress indexes over the aortic vessel and its major branches. The flow was delivered through the cannula assuming the ascending aorta below the cannulation site was cross-clamped, as during open heart surgery.

This case report describes an unusual case of a 69-year-old man who had an aortic valve replacement with the Smeloff-Cutter aortic mechanical prosthesis for aortic valve regurgitation at the age of 18 years. Echocardiography revealed a well-suited and well-functioning mechanical prosthesis. Even though the patient did not take any anticoagulant therapy or anti-platelets agent for 12 years, he was in surprisingly good health. To the best of our knowledge, this is the first time a mechanical 'ball-in-cage' valve prosthesis has lasted for such a long time without complications, although the patient has not been compliant with the anticoagulant therapy for 12 consecutive years.

Although the indications for surgical management of severe functional tricuspid regurgitation (TR) are now generally accepted, controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, particularly in patients with annular dilation. Echocardiographic imaging is the gold standard to identify functional TR and distinguish it from a primitive or degenerative form. Currently, surgery remains the best approach for the interventional treatment of TR. Ring annuloplasty seems to provide better results than suture annuloplasty (De Vega technique) and rigid rings appear to be more reliable in the long term, in comparison with flexible bands. Tricuspid valve repair is more beneficial compared with replacement, except in highly selected cases of long-standing TR with multifactorial mechanism.

La dissezione aortica acuta di tipo A (DAA) è una patologia letale per la quale l’intervento chirurgico rappresenta l’unica terapia efficace. L’obiettivo primario della chirurgia è prevenire la rottura intra-pericardica dell’aorta mediante la sostituzione dell’aorta ascendente e l’escissione del tear intimale prossimale per ripristinare una perfusione efficace del vero lume distale. Nei pazienti sottoposti ad intervento per DAA esiste tuttavia un rischio non trascurabile di progressione della patologia con insorgenza di eventi aortici avversi, sviluppo di aneurismi cronici post-dissezione, e necessità di reinterventi aortici sia a livello prossimale che dell’aorta distale. Ad oggi tuttavia non esistono chiare evidenze per il corretto management del follow-up clinico e strumentale di questi pazienti. Scopo di questa rassegna è analizzare le evidenze e le controversie e valutare il ruolo dei possibili fattori prognostici chirurgici, clinici e strumentali per la gestione dei pazienti sottoposti ad intervento chirurgico per DAA.

Sebbene le indicazioni per la gestione chirurgica dell’insufficienza tricuspidale (IT) funzionale severa siano generalmente accettate, permangono dubbi sul ruolo dell’intervento in presenza di IT moderata. Tuttavia, vi è una tendenza all’intervento in questo contesto, in particolare nei pazienti con dilatazione anulare. L’imaging ecocardiografico è l’esame fondamentale per identificare l’IT di tipo funzionale e distinguerla da una forma primitiva o degenerativa. Attualmente, la chirurgia rimane l’approccio migliore per il trattamento interventistico dell’IT. La valvuloplastica con anello è da preferire alla tecnica di De Vega e gli anelli rigidi sembrano offrire i risultati a lungo termine più affidabili. La riparazione deve generalmente essere preferita alla sostituzione, tranne che in casi estremamente selezionati di IT inveterata a meccanismo multifattoriale.

Myxoma is one of the most common cardiac tumors. It is relatively straightforward to diagnose by echocardiography. Sometimes, It can causes cardiac syncope and thromboembolic events. A woman without comorbidities was admitted to our hospital with stroke symptoms: left-sided hemiplegia and dysarthria. After brain computed tomography (CT) and angio-CT value, she was initially treated with pharmacological thrombolysis. Due to persisting symptoms, cerebral angiography and thrombectomy were then performed. At the end of this procedure, the patient had a complete neurological recovery, but she developed new symptoms, such as dyspnea and orthopnea. Transthoracic echocardiogram and transesophageal echocardiogram showed an atrial mobile mass. Therefore, an urgent cardiac surgery was performed in order to remove the mass. Histological examination confirmed cardiac myxoma. Our experience could show the importance of echocardiography to early diagnosis.

Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.

A 76-year-old woman was admitted to the authors' hospital with pulmonary edema five months after the successful implantation of a Perceval sutureless aortic valve (Sorin Group Srl, Saluggia, Italy). Both echocardiography and computed tomography scanning demonstrated migration of the aortic valve into the left ventricle, causing severe aortic and mitral (secondary) insufficiency. Following heart team discussions, the sutureless valve was replaced with a standard bioprosthesis (Perimount, Magna Ease; Edwards Lifesciences, Irvine, California, USA) with spontaneous restoration of native mitral valve competence. The present case is the first of a new presentation of early Perceval sutureless aortic valve proximal migration, and highlights the importance of careful preoperative assessment and regular postoperative follow up after sutureless aortic valve implantation.

Infective endocarditis during pregnancy carries a high mortality risk, both for the mother and for the foetus and requires a multidisciplinary team in the management of complicated cases. We report our experience with a 39-year old patient, affected by an acute active mitral endocarditis due to Abiotrophia defectiva at the 14th gestational week, strongly motivated to continue the pregnancy. Our patient successfully underwent mitral valve replacement with a normothermic high-flow cardiopulmonary bypass under continuous intraoperative foetal monitoring. Caesarean section occurred at the 38th gestational week. The delivery was uneventful and both the mother and child are doing well at the 16-month follow-up.

Thoracic endovascular aortic repair (TEVAR) is effectively executed in patients with arch or descending aortic diseases. Peripheral access sites are preferably used as standard gates for TEVAR. Feasibility of a peripheral approach might need an intraoperative evaluation and alternative routes should have been carefully assessed. In this article, we report 2 successful cases of direct transaortic TEVAR, where stent grafts were directly introduced into the native ascending aorta without external conduits. A satisfactory result and the absence of aortic-related complications were observed at 2 and 5 years' follow-up, respectively.

We describe a case of Direct Flow (Direct Flow Medical Inc, Santa Rosa, CA) transcatheter aortic valve implantation in a patient with a mechanical valve in a mitral position.

Transcatheter aortic valve implantation (TAVI) is used to treat elderly patients with severe aortic stenosis who are considered extremely high-risk surgical candidates. The safety and effectiveness of TAVI have been demonstrated in numerous studies. The self-expanding CoreValve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) was the first transcatheter aortic valve to be granted the Conformite Europeene (CE) mark in May 2007 for retrograde transfemoral implantation. However, TAVI patients are also often affected by severe iliofemoral arteriopathy. In these patients, the retrograde transfemoral approach carries a high risk of vascular injury, making this approach unusable. Alternative arterial access sites, such as the subclavian artery, the ascending aorta, and the carotid artery, have been used for retrograde implantation of the CoreValve bioprosthesis. In the present report, we present the procedural considerations, risks, and benefits of the different types of arterial access used to implant the CoreValve bioprosthesis.

Direct aortic trans-catheter aortic valve implantation is an alternative approach to treat high risk for surgery patients affected by severe aortic stenosis and concomitant peripheral vascular disease. We describe a case of direct aortic CoreValve implantation made via a right anterior thoracotomy in a 78-year-old male affected by severe aortic stenosis and severe peripheral vasculopathy, who previously underwent coronary artery bypass grafting, with patent bilateral mammary artery grafts and chronic aortic arch dissection.

Transcatheter aortic valve implantation (TAVI) is used to treat elderly patients with severe aortic stenosis who are considered extremely high-risk surgical candidates. The safety and effectiveness of TAVI have been demonstrated in numerous studies. The self-expanding CoreValve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) was the first transcatheter aortic valve to be granted the Conformité Européene (CE) mark in May 2007 for retrograde transfemoral implantation. However, TAVI patients are also often affected by severe iliofemoral arteriopathy. In these patients, the retrograde transfemoral approach carries a high risk of vascular injury, making this approach unusable. Alternative arterial access sites, such as the subclavian artery, the ascending aorta, and the carotid artery, have been used for retrograde implantation of the CoreValve bioprosthesis. In the present report, we present the procedural considerations, risks, and benefits of the different types of arterial access used to implant the CoreValve bioprosthesis.

A 73-year old man underwent trans-septal anterograde implantation of a 26-mm Sapien-XT valve (Edwards Lifesciences, CA, USA) to treat a degenerated 27-mm Carpentier-Edwards bioprosthesis. During the follow-up, the patient experienced severe haemolysis with moderate-to-severe inter-valvular leak, and fluoroscopy revealed possible incomplete apposition of the Sapien-XT (Fig. 1). Reoperation was preferred and a mechanical 25 mm prosthesis implanted.

Redo cardiac surgery represents a clinical challenge due to a higher rate of perioperative morbidity and mortality. Mitral valve (MV) re operations can particularly be demanding in patients with patent coronary grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, leaks or thrombosis). In this article we describe our technique to manage complex mitral reoperations using a minimally invasive approach, moderate hypothermia and avoiding aortic cross-clamping. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of less invasive access and continuous myocardial perfusion. The advantage of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, reducing the risk of cardiac structures or patent graft injury. Moderate hypothermia and continuous blood perfusion can guarantee adequate myocardial protection particularly in the case of patent grafts, decreasing the dangers of an incomplete or imperfect aortic clamping at mild hypothermia and potential lesions due to demanding clamp placing. Complex MV reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space with an unclamped aorta.