(1) Background: We aim to present our experience with resection of the inferior vena cava (IVC) without reconstruction in two patients diagnosed with renal tumors.(2) Case Report: The first case was diagnosed with right renal vein sarcoma and the second case was diagnosed with clear cell renal carcinoma; both presented signs of invasion and thrombosis of the IVC at infrarenal and cruoric levels, along with the development of collateral circulation with the help of the paravertebral plexus. In both patients, en bloc right nephrectomy was performed along with the resection of the thrombosed IVC without further reconstruction. In the case of the patient with right vein sarcoma, preservation of the left renal and caval intrahepatic vein was possible, whilst in the second case diagnosed with clear cell renal carcinoma, the associated left renal thrombosis also enforced the resection of the left renal vein.(3) Discussion: Postoperative evolution was favorable in both cases and did not exhibit major complications. Antibiotic therapy, analgesics, and anticoagulant medication were administered at therapeutic doses after surgery in both cases. The histopathological examination of the surgical specimen confirmed the diagnoses of renal vein sarcoma in the first case and clear cell renal carcinoma in the second case. Surgical treatment and adjuvant chemotherapy prolonged survival for two years for the first case and for two months, up until this moment, for the second case. The survival of clear cell renal carcinoma is currently at two months.(4) Conclusions: The resection of the inferior vena cava, without subsequent reconstruction in cases presenting diffused distal thrombosis, can represent an alternative to IVC reconstruction, which might lead to a major ulterior risk of thrombosis. In some cases, this can result in long-term survival.

•TEVAR can be used to treat TBAD; however, more distal tears might lead to suboptimal remodeling of the aorta.•The PETTICOAT technique describes use of bare metal stents to extend the proximal stent graft and hereby enhance aortic remodeling in TBAD.•The PETTICOAT technique is time-consuming and complex and often requires reinterventions.•Use of the multilayer flow modulator stents might overcome the drawbacks of the PETTICOAT technique.

Intraoperative haemostasis is of paramount importance in the practice of cardiovascular surgery. Over the past 70 years, topical haemostatic methods have advanced significantly and today we deal with various haemostatic agents with different properties and different mechanisms of action. The particularity of coagulation mechanisms after extracorporeal circulation, has encouraged the introduction of new types of topic agents to achieve haemostasis, where conventional methods prove their limits. These products have an important role in cardiac, as well as in vascular, surgery, mainly in major vascular procedures, like aortic dissections and aortic aneurysms. This article presents those agents used for topical application and the mechanism of haemostasis and offers general recommendations for their use in the operating room.

Chondrosarcomas represent approximately 20% of primary malignant bone cancers, being known as the most frequent neoplasia of the anterior thoracic wall. In our case, we present a case of a primary sternal chondrosarcoma in a 50-year-old female patient that has been polychemiotherapy and radiotherapy treated for breast cancer. Despite the initial treated malignancy of breast cancer in the personal pathologic history of the patient, it was discovered that the sternal tumor was not a metastatic disease from the breast neoplasm. After multiple investigations, the patient was successfully treated for the sternal chondrosarcoma after a radical sternal resection with a chest wall reconstruction completed with two titanium plates that were anchored on the ribs and with the placement of methyl methacrylate mesh.

The atrial septal defect is, after bicuspid aortic valve disease, the most common congenital cardiac disease present in the adult population. The most common atrial septal defects are the ostium secundum type (75–80%), followed by the ostium primum type (15%). The sinus venosus atrial septal defects (SV-ASD), defined as a communication in the posterior part of the interatrial septum, account for about 5 to 10% of atrial septal defects. Approximately 90% of SV-ASDs are associated with partial anomalous pulmonary venous drainage (PAPVD). The minimally invasive approach has gained ground in the treatment of ASDs, especially those of the ostium secundum type. The sinus venosus type is a relatively uncommon form of ASD, which, when associated with a PAPVD, is considered a complex cardiac malformation, and is usually treated in a classical manner, through median sternotomy. We describe the case of a 45-year-old woman diagnosed in adolescence with SV-ASD with PAPVD, who successfully underwent minimally invasive repair with fresh autologous pericardial patch reconstruction through an anterolateral mini-thoracotomy incision. The patient presented with shortness of breath and fatigue after heavy exertions, episodes of paroxysmal nocturnal dyspnea, palpitations during effort and at rest, and had a history of syncope dating from 17 years previously. Echocardiography revealed an SV-ASD with PAPVD in the right atrium and the intraoperative examination discovered that both right pulmonary veins were draining into the superior vena cava.

Purpose To compare the predictive accuracy of five different algorithms as verified by successful ablation site using 3D electroanatomical non-contact mapping in patients with symptomatic and asymptomatic but high ventricular burden RVOT tachycardias. Methods 28 Consecutive patients admitted for radiofrequency catheter ablation for symptomatic and asymptomatic, but high ventricular burden idiopathic VPC were recruited for this study. All patients had previous failed or intolerant to beta-blocker and/or at least one class IC anti-arrhythmic agents, and they had normal left ventricular ejection fraction. All patients had documented monomorphic VPC with left bundle branch block morphology and an inferior axis. Concordance of the arrhythmia origin based on ECG algorithm and 3D mapping system site were further evaluated. Of the five algorithms, two algorithms with easy‐applicability and having a memorable design (Dixit and Joshi) and three algorithms with more complex and detailed design (Ito, Zhang, Pytkowski) were selected for comparisons. Results Assessment of the diagnostic accuracy showed that each of the five algorithms had only moderate accuracy, and the greatest accuracy was observed in the algorithm proposed by Pytkowski algorithm when assessed by a general cardiologist and Dixit algorithm when evaluated by the electrophysiologist. However, when the algorithms were compared for their accuracy, specificity, sensitivity, no significant differences were found ( p = 0.99). Conclusions The ECG based algorithms for precise localising RVOTA origin simplify the mapping process, reduce the procedural and fluoroscopic time, and improve clinical outcomes, resulting in greater clinical utility. All the five published 12-lead ECG algorithms for ROTVA differentiation were similar in terms of the diagnostic accuracy, specificity, sensitivity and LRs.

Purpose To report a single-center series of patients with type B aortic dissection treated with the Multilayer Flow Modulator (MFM). Materials and Methods Over a 36-month period, 23 patients (median age 53 years; 20 men) with complicated type B aortic dissections (2 acute, 5 subacute, and 16 chronic) were treated with the MFM. Primary endpoints of rupture or dissection-related death, overall mortality, and reintervention were evaluated using the Kaplan-Meier method; estimates for freedom from the endpoints are reported with the 95% confidence interval (CI). Secondary outcomes included technical success, adverse events, and aortic remodeling. Clinical and imaging data were collected preoperatively, directly postoperatively, and annually to 36 months for analysis using computational fluid dynamics (CFD). Results Initial technical success was 91.3%. The estimates of the endpoints at 12 months were 100% for freedom from rupture or aortic-related death, 95.7% for freedom from overall mortality, and 91.3% for freedom from reintervention. No device-related neurological or systemic complications occurred, and no additional reinterventions were needed during follow-up. A total of 144 branches overstented by the MFM remained patent. Morphologic analysis of the aortic dissection showed progressive true lumen volume increase (75.9%, p<0.001) with concomitant false lumen volume decrease (42.8%, p<0.001); the CFD analyses showed increased laminar flow. Conclusion In the current series, the MFM provided a safe and feasible treatment option for complicated acute, subacute, and chronic type B aortic dissections, with high technical success, low mortality, and active aortic remodeling. Further studies should elucidate the long-term safety of the MFM and its effectiveness in a larger patient cohort.

Recently, multilayer stents for type B aortic dissections (TBAD) have been proposed to decrease false lumen flow, increase and streamline true lumen flow, and retain branch vessel patency. We aimed to provide a protocol with standardized techniques to investigate aortic remodeling of TBAD by multilayer flow modulators (MFM) in static geometric and hemodynamic analyses. Combining existing literature and new insights, a standardized protocol was designed. Using pre- and postoperative CT scans, geometric models were constructed, lumen dimensions were calculated, computational fluid dynamics (CFD) models were composed, and velocity and pressures were calculated. Sixteen TBAD cases treated with MFM were included for analysis. For each case, aortic remodeling was analyzed using post-processing medical imaging software. After 3D models were created, geometrical anatomical measurements were performed, and meshes for finite element analysis were generated. MFM cases were compared pre- and postoperatively; true lumen volumes increased (p < 0.001), false lumen volumes decreased (p = 0.001), true lumen diameter at the plane of maximum compression (PMC) increased (p < 0.001), and false lumen index decreased (p = 0.008). True lumen flow was streamlined, and the overall fluid velocity and pressures decreased (p < 0.001 and p = 0.006, respectively). This protocol provided a standardized method to evaluate the effects of MFM treatments in TBAD on geometric analyses, PMC, and CFD outcomes.

Abstract Introduction Congenital anomalies of the inferior vena cava (IVC) are a well described entity. These anomalies include complete absence, partial absence or duplication of the IVC. They are seen more frequently in those with other congenital cardiac anomalies (0.6%–2%). This congenital condition can be discovered incidentally, or due to symptoms of associated congenital heart disease, asplenia, polysplenia, congenital kidney anomalies or deep venous thrombosis. Case report We report the case of a 48 years old man scheduled for pulmonary vein isolation due to persistent atrial fibrillation resistant to antiarhythmic drugs, symptomatic for palpitations and dyspnea on exertion. Transthoracic ecgocardiography showed mild left atrium enlargement, normal systolic LV function and no significant valve disease. The transoesophageal echocardiography revealed dilation of the left atrium and absence of thrombus in the left atrium or left appendage. Multi-slice spiral thoracic computed tomography (MSCT) was also performed before the procedure and revealed absence of the inferior vena cava and significant dilation of the azygos and hemiazygos veins with subsequent drainage into the superior vena cava. Abdominal CT showed also partial situs inversus. Pulmonary vein isolation (PVI) through femoral vein approach was cancelled and the patient was scheduled for remote magnetic navigation PVI through arterial approach. Conclusions Whether the absence of the IVC is an embryonic anomaly or the result of perinatal thrombosis with regression and subsequent congenital absence of the IVC, absence of the IVC creates difficulties for catheter ablation of arrhythmias via the femoral vein approach.

Nowadays, Computational Fluid Dynamics (CFD) it's seen as the new trend in the management of aortic pathologies. Together with visualization capabilities of cardiovascular magnetic resonance (CMR) and computed tomography (CT) imaging, real time segmentation (volumetric) models further used as meshes in Computational Fluid Dynamic supply to the clinicians an innovative and extensive decision-making system. In the present paper, we identified and analysed the clinical indicators (lumens diameters, fenestrated area and blood volume) monitored by clinicians to evaluate the patient' condition before and after the intervention. In order to achieve the targeted aims, we used CT scans as input data (segmented with MIMICS software) and output 3D models (3matic), further processed to mesh model in ANSYS software. Computational results validate the improved patient' condition, meaning the blood velocity tend to have values to normal flowing conditions. As a conclusion, the linear modification of velocity can be used in further investigations as an input value of pathology treatment

Abstract Cardiac arrhythmias occur frequently in valvular patients. In valvular patients the role of echocardiography is essential, due to prognostic variations. A common indication of CT coronarography is the evaluation of the coronary arteries, with the highlighting of the light coronary plaques, but also accurately measures the dimensions of the left atrium and the anatomy of the pulmonary veins. In the last years cardiac MRI (magnetic resonance imaging) has been used in the clinic and research media to establish the gold standard measurement for the volumes of heart cavities, their function and tissue structure. All these three methods are essential for the evaluation and treatment of the cardiac patient with important arrhythmia.

Abdominal aortic aneurysms (AAA) are common and potentially life-threatening aortic dilatations, due to the effect of hemodynamic changes on the aortic wall. Previous research has shown a potential pathophysiological role for increased macroscopic aneurysmal wall stiffness; however, not investigating micromechanical stiffness. We aimed to compile a new protocol to examine micromechanical live aortic stiffness (elastic moduli), correlated to histological findings with quantitative immunofluorescence (QIF). Live AAA biopsies (n = 7) and non-dilated aortas (controls: n = 3) were sectioned. Local elastic moduli of aortic intima, media and adventitia were analysed in the direction towards the lumen and vice versa with nanoindentation. Smooth muscle cells (SMC), collagen and fibroblasts were examined using QIF. Nanoindentation of AAA vs. controls demonstrated a 4-fold decrease in elastic moduli (p = 0.022) for layers combined and a 26-fold decrease (p = 0.017) for media-to-intima direction. QIF of AAA vs. controls revealed a 4-, 3- and 6-fold decrease of SMC, collagen and fibroblasts, respectively (p = 0.036). Correlations were found between bidirectional intima and media measurements (rho = 0.661, p = 0.038) and all QIF analyses (rho = 0.857-0.905, p = 0.002-0.007). We present a novel protocol to analyse microscopic elastic moduli in live aortic tissues using nanoindentation. Hence, our preliminary findings of decreased elastic moduli and altered wall composition warrant further microscopic stiffness investigation to potentially clarify AAA pathophysiology and to explore potential treatment by wall strengthening. Statement of Significance Although extensive research on the pathophysiology of dilated abdominal aortas (aneurysms) has been performed, the exact underlying pathways are still largely unclear. Previously, the macroscopic stiffness of the pathologic and healthy aortic wall has been studied. This study however, for the first time, studied the microscopic stiffness changes in live tissue of dilated and non-dilated abdominal aortas. This new protocol provides a device to analyse the alterations on cellular level within their microenvironment, whereas previous studies studied the aorta as a whole. Outcomes of these measurements might help to better understand the underlying origin of the incidence and progression of aneurysms and other aortic diseases. (C) 2019 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Intravenous drug use is associated with infective endocarditis.Besides, it does appear that left-sided infective endocarditis is a feature of general population, whereas right-sided infective endocarditis is common in intravenous drug users.The most common etiology of right-sided infective endocarditis in intravenous drug users is Staphylococcus aureus in about 75% followed by streptococci, Gramnegative bacilli and fungi.In case of intravenous drug users with infective endocarditis, optimal treatment strategies lack a general consensus.Additionally, the best indication and timing of surgery are debatable.To overcome these problems, the early and complete surgical debridement of infected tissue together with microbial therapy assures a good prognosis in the long term.

The aim of the paper was to describe the advantages and disadvantages of the surgical adhesives most useful in major cardiovascular surgery.

Background: The aim was to expand our understanding of the dynamic evolution of the aorta throughout the dissection time course. We investigated how the disease process can be modulated to equalize lumen pressure, enhance perfusion, and stabilize the aorta along its entire length using the kinetic elephant trunk (kET) technique. Methods: We performed the kET on 9 patients with chronic symptomatic aortic dissection (CSAD) as a primary or secondary intervention, regardless of the chronicity of the dissection. Endovascular scissoring of the intraluminal septum is performed in the infradiaphragmatic dissected aorta to equalize pressure between true and false lumens and allow all branched vessels to be supplied from one lumen. The Streamliner Multilayer Flow Modulator (SMFM), an uncovered cobalt-alloy aortic device, is deployed from the aortic sinus, covering the supra-aortic branches, distally into the distal aorta (primary intervention). In the case of a previous ascending aorta Dacron graft, the SMFM is deployed (secondary intervention) at the level of the Dacron graft so that it is overlapped with the graft and landed in the distal aorta. Results: In the initial study period, all-cause and aortic-related survival were 100%, respectively; all great vessels and visceral branches were patent; and freedom of stroke, end-organ ischemia, paraplegia, and renal failure were 100%. Conclusions: The kET is a treatment process for managing CSAD. Its simplicity, consistency, and reproducibility in high-risk patients with low morbidity and mortality add to the armamentarium of the cardiovascular specialist. Further assessment of the medium-and long-term outcomes is needed to fully establish the benefits of kET.

We present the results of up to 36-month follow-up after complete coverage of supra-aortic trunks with new-generation multilayer stents for complex aortic diseases. A total of 29 patients with complex aortic diseases underwent thoracic endovascular aortic repair with multilayer flow modulator (MFM) stents (type A and B aortic dissection and thoracoabdominal aneurysms). All patients had the aortic arch entirely covered with the MFM stent. The primary objective was to assess whether total coverage of all cerebral vessels may lead to a neurologic event in the first 30 days after intervention. The secondary objectives were to assess the long-term patency of the covered cerebral vessels and the advent of any major neurologic event at a mean follow-up of 18 months. In this prospective study, 29 patients with complex aortic disease underwent endovascular repair with an MFM stent. Computational flow dynamics analysis was performed at each follow-up. All patients underwent endovascular treatment with a new-generation multilayer aortic stent. The patients' disease was classified as type B aortic dissection (n = 16), residual type B aortic dissection after type A surgical correction (n = 4), and thoracoabdominal aneurysm (n = 9). At 1-month follow-up, no neurologic events had been noted. Procedural success has been 100%, without any branch occlusions (brachiocephalic artery, left common carotid artery, left subclavian artery) during the follow-up. No patients were lost to follow-up, with the longest follow-up of 36 months and an average follow-up of 18 months. There has been no supra-aortic artery occlusion or progression of the dissection in the 29 patients analyzed. One patient presented with a transient ischemic attack that proved to be due to a spontaneous dissection of a minor cerebral vessel during a hypertensive crisis. Morphologic computational flow dynamics analysis confirmed lamination of flow in all supra-aortic arteries and dissection remodeling with a reduction in false lumen and diameter. MFM stents are a safe option in the treatment of complex aortic diseases. Total coverage of all supra-aortic trunks does not lead to any neurologic complication.

Rationale: Streptococcus viridans, a heterogeneous group of alpha-hemolytic streptococci, is part of the normal flora of the mouth, usually responsible for dental caries (Streptococcus mutans, Streptococcus sanguinis), and pericoronitis, as well as for subacute infective endocarditis. They are responsible for 40-60% of the endocarditis cases occurring on the normal valves, especially in male patients and over 45 years of age. A change in the bacterial flora of the oral cavity is taking part after orthodontic fixed appliances are introduced into the oral cavity, change that is associated with an increased concentration of the acidogenic bacteria. Bacteraemia is the consequence of oral cavity infections, the association of infective endocarditis with fixed orthodontic appliance, as it has been described by us for the first time, caused by Abiotrophia defectiva. Patient concerns: We present the case of a female Caucasian patient, aged 22 years, who developed infective endocarditis with Streptococcus viridans associated with fixed orthodontic appliance, located on the mitral valve, without previous cardiac pathology, and the therapeutic difficulties associated with allergic reactions (to vancomycin, and spironolactone). Diagnoses: Repetitive haemocultures were positive with Streptococcus viridans, while transthoracic echography revealed a severe mitral failure through anteromedial segment of the anterior mitral valve leaf prolapse with eccentric jet to the posterior wall. Interventions: During hospitalization, the decision to undergo surgical intervention was taken after obtaining negative haemocultures. The patient underwent surgically intervention, and a mitral valve plasty with insertion of neochords was performed. Outcomes: Intraoperative and subsequently post-discharge transesophageal echography, highlighted normofunctional mitral plasty with a remaining regurgitation grade I-II of IV, with good openness, minor tricuspid regurgitation, and mild pulmonary hypertension. Lessons: Endocarditis with oral streptococci associated with fixed orthodontic appliance seems to be not so unlikely even in young or without previous cardiac pathology patients, requiring attention in identifying possible pre-existing cardiac conditions like mitral valve prolapse with clinical and echographic monitoring of such cases. Educating and motivating the patient to observe the oral hygiene represent key steps for an optimal oral health during orthodontic treatment. Mechanical tooth cleaning helps maintaining a good oral hygiene during fixed orthodontics and decreasing the oral health risks.

PURPOSE:To report Multilayer Flow Modulator (MFM) implantation from the sinotubular junction to the distal infrarenal aorta in the treatment of type B aortic dissection (TBAD) and demonstrate aortic remodeling using computational fluid dynamics (CFD) analysis over the course of 3-year follow-up.CASE REPORT:A hypertensive patient with complicated TBAD required thoracic endovascular aortic repair due to severe thoracic pain associated with rapid progression of the false lumen aneurysm toward the distal aortic arch. Under general anesthesia, 2 aortic multilayer stents were placed over a 0.035-inch stiff guidewire in the compressed true lumen. The aorta was covered with 2 MFM stents between the sinotubular junction and the distal infrarenal aorta. Serial computed tomography scans showed progressive remodeling of the entire dissected aortic wall, with an excellent result at 24 months. Morphological and CFD vascular analysis confirmed the aortic remodeling, with a false lumen index drop from a preoperative 4.04 to 0.01 at 36 months.CONCLUSION:Endovascular aortic repair with multilayer stents is a promising treatment for complicated TBAD due to the unique ability of these devices to stabilize the entire aortic wall without compromising the flow in the major aortic side branches.