Finger ischemia in a young lady: an unusual presentation of papillary fibroelastoma with intraventricular location.

An otherwise healthy 32-year-old woman suffered from finger ischemia. An echocardiogram and computed tomography scan revealed a mobile mass in the left ventricle that was attached to the anterior papillary muscle and did not involve the valve leaflets. The tumor was resected, and histopathology confirmed it to be a papillary fibroelastoma. Our case emphasizes the significance of a comprehensive diagnostic work-up for a peripheral ischemic lesion. This resulted in the discovery of an unusual intra-ventricular origin for a commonly benign tumor.

First Case of Tricuspid Valve Surgery in a Neurofibromatosis Type 1 Patient.

The neurofibromatosis is a large class of different genetic disorders: Neurofibromatosis type 1, type 2, type 3 (or Schwannomatosys), which have different clinical characterization. Neurofibromatosis type 1 (NF1), also known as Von Recklinghausen disease, represents 95% of the total cases. It is a complex autosomal dominant disorder with multisystem involvement, frequently associated to cardiac malformation. We present the case of a 52-years-old male affected by NF-1 with severe tricuspid regurgitation and atrial septal defect (ASD). No previous report about tricuspid valve surgery in NF-1 are available in the literature. A complete perioperative assessment was performed, including dermatologist evaluation, angio-CT scan and transesophageal echocardiography. The patient underwent uneventfully tricuspid valve replacement and ASD closure, with no wound complication even at 6-months follow-up. Treating congenital malformation in patient with complex genetic disorders like NF-1 is safe and can be resolutive, permitting to reduce long-term risk of complications for the patients. Preoperative assessments are fundamental, as well as in-hospital care and expertise on congenital heart defects.

Sutureless aortic valve replacement in high risk patients neutralizes expected worse hospital outcome: A clinical and economic analysis.

BACKGROUND: Aortic valve replacement (AVR) by sutureless prostheses is changing surgeon options, although which patients benefit most, as well as their possible economic impact is still to be defined. METHODS: Perceval-S prosthesis (LivaNova) is reserved, at the documented Institution, for patients at perceived high surgical risk. This retrospective analysis of outcome and resource consumption compared Perceval with other tissue valves. To clarify the comparison, only patients respecting 'instructions-for- use' of Perceval were reviewed. INCLUSION CRITERIA: > 65 years, +/- coronary artery bypass grafting, patent foramen ovale closure or myectomy. EXCLUSION CRITERIA: bicuspid, combined valve or aortic sur- gery. Costs were calculated per patient on a daily basis including preoperative tests, operating costs (hourly basis), disposables, drugs, blood components and personnel. RESULTS: The sutureless group (SU-AVR) had a higher risk profile than the sutured group (ST-AVR). Cardiopulmonary bypass (CPB) and cross-clamp times were significantly shorter in SU-AVR (isolated AVR: cross-clamp 52.9 ± 12.6 vs. 69 ± 15.3 min, p < 0.001; CPB 79.4 ± 20.3 vs. 92.7 ± 18.2 min, p < 0.001). Hospital mortality was 0.9% in SU-AVR and nil in ST-AVR, p = 0.489; intubation 7 (IQR 5-10.7) and 7 h (IQR 5-9), p = 0.785; intensive care unit 1 (IQR 1-1) and 1 day (IQR 1-1), p = 0.258; ward stay 5.5 (IQR 4-7) and 5 days (IQR 4-6), p = 0.002; pacemaker 5.7% (6/106) and 0.9% (1/109), p = 0.063, respectively. Hospital costs (excluding the prosthesis) were $12,825 (IQR 11,733-15,334) for SU-AVR and $12,386 (IQR 11,217-14,230) in ST-AVR, p = 0.055. CONCLUSIONS: Despite higher operative risks in SU-AVR, hospital mortality, morbidity and resource consumption did not differ. Operative times were shorter with the sutureless device and this improve- ment, along with more frequent ministernotomy, may have improved many postoperative aims.

Sutureless prosthesis for failed small Mitroflow valves: the Perceval-after-Mitroflow procedure.

Because of its favourable haemodynamic characteristics and easy implantability, Mitroflow aortic valve bioprosthesis has been the valve of choice for many surgeons in patients with small aortic annulus. Disappointingly, early structural valve deterioration and high transvalvular gradients have been reported mostly in older patients with small prostheses. Reimplanting a new stented prosthesis sutured in a narrow and damaged annulus is technically challenging and demanding mainly in high-risk patients. Valve-in-valve transcatheter aortic valve implantation has been proposed as a viable option; however, it presents significant limitations because of residual high transprosthetic pressure gradients and risk of coronary occlusion. We report a series of 8 patients, with medium-term follow-up, who underwent successful Perceval-S surgical sutureless aortic implant after the removal of a degenerated small Mitroflow valve. No early mortality occurred, but 1 patient died 4 months postoperatively due to gastrointestinal disease. No major complications occurred. Early and mid-term postoperative pressure gradients were low (mean gradients 13.1 ± 3.3 mmHg and 10.2 ± 3.8 mmHg, respectively). In operable patients with a degenerated Mitroflow valve, these favourable clinical and haemodynamic results suggest that the sutureless solution is a simple, valid and safer alternative to conventional redo valve replacement or to valve-in-valve transcatheter aortic valve implantation.

Time series analysis of physiologic left ventricular reconstruction in ischemic cardiomyopathy.

OBJECTIVE: The history of left ventricular reconstruction has demonstrated that the full spectrum of recoverable physiologic parameters is essential for a good functional result. We report the long-term outcome of a new surgical technique that arranges myocardial fibers in a near-normal disposition, also recovering left ventricular twisting. METHODS: Between May 2006 and October 2013, 29 consecutive patients with previous anterior myocardial infarction and heart failure symptoms underwent physiologic left ventricular reconstruction surgery and coronary revascularization. Patients were examined by means of standard echocardiography and 2-dimensional speckle tracking at 8 time steps until 7 years after surgery. Ten geometric and functional parameters were evaluated at each step and analyzed by the linear mixed model test. RESULTS: Hospital mortality was 0%. The mean percentage of indexed end-diastolic and end-systolic volume reduction was 45.7% and 50.9%, respectively. Ejection fraction and all of the volumes were significantly different in the postoperative period with a steady correction during time. Diastolic parameters were not worsened by surgical reconstruction. Ejection fraction and deceleration time showed a significant improvement during time. Left ventricular torsion increased immediately after the surgical correction from 2.8 ± 4.4 degrees to 8.7 ± 3.9 degrees (P = .02) and was still present 4 years after surgery. CONCLUSIONS: Surgical conduction of ventricular reconstruction should be standardized to achieve the full spectrum of recoverable physiologic parameters. The renewal of ventricular torsion should be pursued as an adjunctive element of ventricular efficiency, mainly in ventricles that work at a critical level in the Frank-Starling relationship and pressure-volume loop.

Perceval sutureless valve in freestyle root: new surgical valve-in-valve therapy.

Aortic root replacement with biological conduit (homograft, autograft, or xenograft) is a valuable tool, but biological valves are often prone to degeneration. Reoperations usually require root removal and repetition of the Bentall procedure to maintain the same orifice area. A less radical option is to limit replacement to the valve. In cases of calcified or very small roots, standard valve implantation cannot be performed, and bailout with a sutureless valve may be a particularly useful option. Here we have described a case of leaflet rupture in a calcified small Freestyle root (Medtronic Inc, Minneapolis, MN) in which we performed a valve-in-valve (V-in-V) procedure with a Perceval-S prosthesis (Sorin Group, Saluggia, Italy).

Medium-term results of systematic off-pump coronary surgery performed by trainee surgeons.

OBJECTIVE: Our unit has used off-pump coronary artery bypass (OPCAB) surgery since 1998, and has consequently developed teaching methods for surgical trainees. This study aimed to compare the medium-term results of OPCAB performed by experts or supervised trainees. METHODS: We retrospectively analysed the data relating to 1333 OPCAB operations performed between January 1998 and January 2006 (mean patient age: 65.3 + or - 13; M/F ratio: 2.9), and compared the medium-term outcomes of the 977 (73.3%) carried out by three expert surgeons (group A) with the remaining 356 (26.7%) carried out by four supervised trainees (group B). RESULTS: There were no preoperative differences in patient age, gender, angina class, operative priority, extent of coronary artery disease, the presence of a recent myocardial infarction or left main stenosis or European System for Cardiac Operative Risk Evaluation (EuroSCORE) between the two groups. Thirty-day mortality was 1% in group A and 0.6% in group B (p=0.43), and 4-year actuarial survival, respectively, 97.4 + or - 1.1% and 94.3 + or - 4.1% (p=0.41); the freedom from new re-vascularisation rates in the two groups were, respectively, 96 + or - 0.7% and 95.3 + or - 1.4% (p=0.3). CONCLUSIONS: The results of this study reflect our unit's long experience of OPCAB surgery and that its successful re-engineering towards the systematic use of OPCAB was feasible. They also show that, in this context, teaching OPCAB surgery is safe in a non-selected cohort of patients, and that the medium-term outcomes of the patients operated on by trainee or expert surgeons are similar.

'Let's twist again': surgically induced renewal of left ventricular torsion in ischemic cardiomyopathy.

OBJECTIVES: To test the potential of the heart to be surgically restored at a near-normal global condition, granted that its physiological characteristics are respected (working volumes, chamber geometry, fiber orientation, opposite rotation of apex and base, global torsion and strain). METHODS: From May 2007 to December 2008, 12 consecutive patients with ischemic cardiomyopathy were included in this study. All patients underwent modified surgical anterior ventricular restoration combined with complete coronary revascularization and, when indicated, mitral anuloplasty. The modified restoration aims to re-approach residual myocardium, redirecting fiber orientation displaced by infarct scar toward a more physiological gross disposition. Patients were studied preoperatively and postoperatively with a complete echocardiographical assessment, including speckle-tracking analysis. RESULTS: Standard parameters significantly improved after the operation (end diastolic volume, P < 0.001; end systolic volume, P < 0.001; ejection fraction, P = 0.004), and so did peak systolic apical rotation, peak systolic left ventricular torsion and two-chamber and four-chamber longitudinal strain (P = 0.004, 0.003, 0.05 and 0.01, respectively). Pearson's correlation between apical rotation and longitudinal strain (two-chamber and four-chamber) was -0.877 (P < 0.001) and -0.720 (P = 0.008), respectively, and between torsion and longitudinal strain was -0.845 (P = 0.001) and -0.785 (P = 0.002), respectively. CONCLUSION: This study reveals an unexpected potential of the myocardium to be restored at a near-normal global condition, with regard to all of its physiological characteristics. The concept of fiber-based surgical treatment, supported by an imaging-guided preoperative study, could widen the potential of repairing a failing heart.

A new no-touch aorta technique for arterial-source, off-pump coronary surgery.

The possibility of avoiding the manipulation of the ascending aorta plays a key role in the neuroprotective effect of off-pump coronary revascularization, reducing the overall invasiveness. We have devised a new surgical plan using the proximal stump of the right internal thoracic artery as an intrathoracic, arterial source of flow for the saphenous vein, avoiding direct aorta manipulation. The saphenous vein can be as long as required, and its proximal anastomosis guarantees a better match of the two conduits and undergoes a lower peak pressure.

Patch size, shape and orientation affect geometrical outcomes of surgical anterior ventricular restoration.

OBJECTIVES: To verify whether the use of a small, oval-shaped patch limits the trend toward re-dilatation compared to endoventricular circular patch plasty and leads to different geometrical and functional results in surgical anterior restoration. METHODS: Thirty-seven patients with ischemic cardiomyopathy after anterior myocardial infarction end-systolic volume index of > or =45 ml/m2, ejection fraction of < or =35%, and no combined mitral procedures, underwent surgical anterior ventricular restoration between January 2000 and April 2003: 18 patients (group 1) were operated on using the endoventricular circular patch plasty technique (mean patch area 9.6 cm2) and 19 patients (group 2) received a small, obliquely oriented, oval-shaped patch (mean patch area 6.2 cm2). Ten geometrical parameters were studied preoperatively and at least 6 and 12 months after surgery. Data were analyzed using repeated-measures ANOVA, chi2, paired and unpaired Student's t-test, and binary logistic regression. RESULTS: Group 1 showed a worsening over time in systolic and diastolic longitudinal length, end-diastolic volume (P < 0.001), end-diastolic volume index (P = 0.006), end-systolic volume (P = 0.005), and end-systolic volume index (P = 0.03). Group 2 showed an improvement in percentage of akinesia and wall motion score index (P < 0.001) and a worsening only in end-systolic diameter (P = 0.03) and end-diastolic volume (P = 0.04). At 12-month follow-up, ANOVA revealed that the oval patch positively influenced end-diastolic volume (P = 0.03), end-systolic volume (P = 0.03), and end-systolic volume index (P = 0.05), and group 2 had a significantly higher number of patients with an end-systolic volume index of <45 ml/m2 (P = 0.01). CONCLUSION: The use of a small, narrow, obliquely oriented, oval patch may help to prevent adverse ventricular remodeling over time.