Role of Multimodal Imaging in Patients With Suspected Infections After the Bentall Procedure.

Purpose: This study aimed to assess the diagnostic performances of multimodal imaging [i.e., white blood cell single-photon emission computed tomography/CT (99mTc-HMPAO-WBC SPECT/CT) and 18-fluoride-fluorodeoxyglucose positron emission tomography/CT ([18F]FDG PET/CT)] in patients with suspected infection after the Bentall procedure, proposing new specific diagnostic criteria for the diagnosis. Methods: Between January 2009 and December 2019, we selected within a cardiovascular infections registry, 76 surgically treated patients (27 women and 49 men, median 66 years, and range 29-83 years). All the patients underwent molecular imaging for a suspected infection after the replacement of the aortic valve and ascending aorta according to the Bentall procedure. We analyzed 98 scans including 49 99mTc-WBC and 49 [18F]FDG PET/CT. A total of 22 patients with very early/early suspected infection (<3 months after surgery) were imaged with both the techniques. Positive imaging was classified according to the anatomical site of increased uptake: to the aortic valve (AV), to both the AV and AV tube graft (AVTG) or to the TG, to surrounding tissue, and/or to extracardiac sites (embolic events or other sites of concomitant infection). Standard clinical workup included in all the patients having echocardiography/CT, blood culture, and the Duke criteria. Pretest probability and positive/negative likelihood ratio were calculated. Sensitivity and specificity of 99mTc labeled hexamethylpropylene amine oxime-WBC SPECT/CT (99mTc-HMPAO-WBC SPECT/CT) and [18F]FDG PET/CT imaging were calculated by using microbiology (n = 35) or clinical follow-up (n = 41) as final diagnosis. 99mTc-HMPAO-WBC scintigraphy and [18F]FDG PET/CT findings were compared with 95% CIs by using the McNemar test to those of echocardiography/CT, blood culture, and the Duke criteria. Results: Sensitivity, specificity, and accuracy of 99mTc-HMPAO-WBC were 86, 92, and 88%, respectively, with a slightly higher sensitivity for tube graft infection (TGI) as compared to isolated AV and combined AVTG. Overall, sensitivity, specificity, and accuracy of [18F]FDG PET/CT were 97, 73, and 90%, respectively. In 22 patients with suspected very early and early postsurgical infections, the two imaging modalities were concordant in 17 cases [10 true positive (TP) and 7 true negative (TN)]. [18F]FDG PET/CT presented a higher sensitivity than 99mTc-HMPAO-WBC scan. 99mTc-HMPAO-WBC scan correctly classified as negative three false-positive (FP) PET/CT findings. Conclusion: Our findings supported the use of 99mTc-HMPAO-WBC SPECT/CT and [18F]FDG PET/CT in patients with suspicion infection after the Bentall procedure early in the course of the disease onset to confirm the diagnosis and provide a comprehensive assessment of disease burden through the proposed criteria.

Splenectomy and Valve Replacement in Patients With Infective Endocarditis and Splenic Abscesses.

In patients with infective endocarditis (IE), splenic involvement is a rare but well-known adverse event. The treatment of patients with IE and splenic abscesses is still challenging and controversial. We report 3 patients with IE and splenic abscesses who underwent successful valve replacement and splenectomy. Our experience confirms that in such a patient, a valve operation combined with splenectomy can be performed with excellent results during the same hospitalization. The timing of splenectomy and the type of surgical approach should be based mainly on the stability of a patient's hemodynamic condition.

Intimal Sarcoma of the Descending Aorta Mimicking Aortitis.

We describe a 74-year-old male patient with an intimal sarcoma of the descending aorta mimicking aortitis. The patient presented with lower back pain, fever, and increased C-reactive protein, erythrocyte sedimentation rate, and immunoglobulin G4 (IgG4) serum levels, together with Staphylococcus epidermidis-positive blood cultures. These findings, together with evidence of a 49-mm pseudoaneurysm of the descending thoracic aorta, caused us to suspect aortitis. However, postoperative histology and immunohistochemistry demonstrated the presence of an intimal aortic sarcoma. At the 8-month follow-up, local recurrence of the neoplasm and lung metastases were noted.

Management of Prosthetic Thrombosis During Pregnancy: Importance of a Multidisciplinary Approach.

A 40-year-old female of African origin presented in the 32nd week of her second pregnancy with thrombosis of a bileaflet mechanical prosthesis implanted in the mitral position. After an emergency cesarean section, she was successfully treated by means of a multidisciplinary approach.

A composed graft for subclavian artery reconstruction in case of redo surgery for aortic coarctation.

We report the case of a 66-year-old woman admitted to the intensive care unit (ICU) for ongoing dyspnea and hemoptoe. She was operated upon in 1979 for aortic coarctation by the interposition of a 14 mm Dacron prosthesis from the left subclavian artery to descending aorta. Clinical evaluation performed over the years was normal with no signs of cardiac failure or prosthesis malfunctioning. The computed tomography scans (CT) showed a progressive increase of the descending aorta diameters and the onset of a pseudo-aneurysm of 50 mm in diameter. Patient was re-operated through a median sternotomy enlarged by a left thoracotomy and intra-operative findings revealed the pseudo-aneurysm originating from a dehiscence of the proximal suture. In order to allow a safe reconstruction of the dilated subclavian artery, a T-shaped composed graft was confectioned and then sutured to the descending aorta and the subclavian artery, respectively. Post-operative course was uneventful and three months CT scan showed a normal position of the composed graft.

Influence of Cardiovascular Risk Factors on Aortic Wall Motion After Repair of Type A Aortic Dissection: An Electrocardiography-Gated Computed Tomography Study.

BACKGROUND: We aimed to evaluate size changes of the thoracic aorta during the cardiac cycle with dynamic computed tomographic angiography (CTA) at specific anatomic landmarks in patients who previously underwent ascending aorta repair because of type A dissection, and to correlate aortic wall motion with several cardiovascular risk factors. METHODS: From December 2008 to December 2010, 18 patients (14 men and 4 women, mean age 64 ± 12 years) with previous aortic repair underwent electrocardiography-gated CTA follow-up. Aortic systolic and diastolic diameter and cross-sectional area were measured at 4 levels: 1 cm proximal (level A) and 1 (B), 3 (C), and 10 cm (D) distal to the origin of the left subclavian artery. RESULTS were assessed according to age and presence of diabetes, hypertension, and smoking. RESULTS: This morpho-functional evaluation of aortic wall motion demonstrated a significant influence (P < 0.05) of hypertension at level A and D and diabetes at level D. Smoking had a borderline significance at level C and D. No significant correlation with age was evident, with results not significantly different in patients ≤ 55 and > 55 years. CONCLUSIONS: Smoking, diabetes, and hypertension play a role in impairing aortic size variations. These variations might predict wall structural alterations due to cardiovascular risk factors before they become morphologically evident. This might influence timing of surveillance following repair of acute dissection, allowing it to be specifically tailored for any single subject.

Endovascular stenting for type B dissection involving a right-sided aortic arch.

Endovascular stent-graft repair is emerging as the treatment of choice for complicated type B aortic dissection. In this report we describe a patient who presented with type B aortic dissection involving a right-sided aortic arch (RAA), a rare congenital vascular anomaly. The initial aggressive medical treatment proved unsuccessful due to false aneurysm expansion. Given the greater complexity of conventional surgical repair and the limited experience with this rare malformation, endovascular repair was preferred and successfully performed. We report the first case of endovascular repair of type B dissection involving RAA, confirming that endovascular treatment is technically feasible also when the dissection involves this unusual vascular malformation.

Delayed papillary muscle rupture following repair of post-infarction ventricular septal defect.

Ventricular septal defect (VSD) and papillary muscle rupture are severe complications of myocardial infarction which are usually observed individually although their simultaneous occurrence has been observed in pathological studies. An 82-year-old female underwent repair of a post-infarction VSD and 13 days later required mitral valve replacement due to delayed papillary muscle rupture. Mechanical complications of myocardial infarction can occur in the same patient even in delayed fashion and a two-stage correction may be successfully accomplished.

Emergency coronary artery bypass grafting in patients with acute myocardial infarction treated with glycoprotein IIb/IIIa receptor inhibitors.

Glycoprotein (GP) IIb/IIIa receptor inhibitors before primary angioplasty in patients with ST-elevation acute myocardial infarction (STEMI) are recommended by current guidelines. Thus, an increasing number of patients receive these drugs before coronary angiography, particularly if a between-hospital transfer is needed. However, when coronary anatomy is unsuitable for angioplasty, emergency coronary artery bypass grafting (CABG) under GP IIb/IIIa inhibitor treatment may be needed, with a potential increase in bleeding risk. Abciximab has a long duration of action, because of its high-affinity binding to GP IIb/IIIa receptors. Initial retrospective studies reported a higher incidence of major bleeding during emergency CABG after abciximab administration, leading to the recommendation of delaying surgery >12 h. However, data from the prospective trials on abciximab do not confirm the increase in bleeding risk, and current evidence shows that emergency surgery can be performed safely soon after abciximab cessation. Monitoring of activated clotting time during surgery and platelet transfusion in case of postoperative relevant bleeding are the only measures needed. No data are available on emergency surgery in patients with STEMI treated with eptifibatide or tirofiban. However, their short-lasting effects and the results of trials on non-ST-elevation acute coronary syndromes suggest that they could even reduce postoperative bleeding by preventing platelet consumption during cardiopulmonary bypass. In conclusion, the early administration of GP IIb/IIIa inhibitors, in particular of abciximab, in patients with STEMI in whom primary angioplasty is planned should not be discouraged because of the potential bleeding risk in case of emergency CABG.