A cardiac intimal sarcoma mimicking infective endocarditis.

Primary malignant cardiac tumors are rare and usually misdiagnosed because they can mimic more common intracardiac lesions, therefore, in clinical practice it is important to always consider even uncommon diseases in order to avoid delayed diagnosis and to plan the most appropriate therapeutic strategy in a timely fashion. We report a case of a 73-year-old man with clinical signs and imaging findings (echocardiography) suggesting infective bacterial endocarditis of the mitral valve. However, intraoperative evaluation raised suspicion that the mitral lesions had a different nature. Surgical removal of the mass was performed, and the final correct diagnosis was made through pathologic examination, revealing a mitral valve sarcoma thus allowing for the beginning of specific oncological treatment.

Transapical TAVI: Survival, Hemodynamics, Devices and Machine Learning. Lessons Learned After 10-Year Experience.

Aim of this single-center, retrospective study was to assess early and long-term clinical and hemodynamic results of transapical aortic valve implantation (TA-TAVI), and to identify predictors of survival at follow-up. All patients undergoing TA-TAVI for severe aortic valve stenosis at our institution were reviewed. A hybrid approach based on machine-learning techniques was employed to identify survival predictors, using a bagging-decision-tree algorithm and a Random-Forest algorithm, respectively. Two-hundred-thirty-four consecutive patients underwent TA-TAVI (March 2009-May 2019). All cause 30-day mortality was 5.1%. Device success was 95.7%. Median follow-up time was 35.2 months. Kaplan-Meier overall survival rates at 2, 5, and 8 years were 75%, 44%, and 15%, respectively. Structural-valve-deterioration occurred in 25 patients (11.3%) overall. The strongest predictors of survival at follow-up were age, body-mass-index, and ejection fraction. TA-TAVI provided valid early and long-term outcomes. These data support its choice as an optimal alternative access whenever the transfemoral route is not feasible.

Propensity-Weighted Comparison of Conventional Stented and Rapid-Deployment Aortic Bioprostheses.

Aim of this study was to compare early clinical and hemodynamic outcomes of Intuity and ME bioprostheses. A propensity score weighting approach was performed. Preoperative variables were defined according to EuroSCORE criteria and postoperative complications according to VARC-2 definitions. We evaluated 375 patients who underwent SAVR with the 2 study devices. Intuity and ME were implanted in 252 (67.2%) and in 123 (32.8%) patients, respectively. There were no differences in terms of postoperative complications, including mortality (1% in each group; OR 0.46[0.05;4.21]). The incidence of pace-maker implantation was 6% and 5% in Intuity and ME groups, respectively (OR 0.53[0.27;1.07]). Intuity showed significantly lower gradients (Median mean gradients: 9mmHg vs 14mmHg, P<0.001), larger effective orifice area index (1.13cm2/m2 vs 1cm2/m2, P=0.007) and lower incidence of patient-prosthesis mismatch (7.1% vs 22.8%, P=0.006). The RD Intuity provides similar early clinical outcomes but shows significantly better hemodynamic performance compared to the ME valve.

Total Endovascular Aortic Arch Repair: From Dream to Reality.

The gold-standard therapy for the treatment of aortic arch pathologies is conventional open surgery. Recently, total endovascular aortic arch replacement with branched stent-grafts has been introduced into clinical practice with the aim of reducing invasiveness especially in selected high-risk patients. The aim of this review is to describe the two most commonly used branched devices for endovascular arch stent-grafting: Nexus (Endospan, Herzlia, Israle) and RelayBranch (Terumo Aortic, Glasgow, United Kingdom). Nexus is a CE-certified off-the-shelf, single branch, double stent graft system. It consists of two different components: a main module for the aortic arch and the descending aorta with a side-branch for the brachiocephalic artery (BCA), and a curved module for the ascending aorta that lands into the sino-tubular junction and connects to the main module through a side-facing self-protecting sleeve. Nexus may be used in urgent-emergency cases and also in patients with only one suitable supra-aortic target vessel but, on the other hand, it makes cerebral blood flow dependent on one source vessel only. The RelayBranch Thoracic Stent-Graft System is a custom made, double branched endograft with a wide window on its superior portion to accommodate two inner tunnels for BCA and left common carotid artery connection; bilateral cervical accesses are generally used to advance guidewires for catheterization of the inner tunnels in a retrograde fashion. RelayBranch can be customized on every patient's specific anatomy and provides a double blood source for the brain, but it cannot be used in urgent-emergency conditions. Therefore, in order to optimize outcomes, the choice of the most appropriate device should be made considering pros and cons of each system and patient's anatomy by an experienced aortic team. In conclusion, total endovascular aortic arch exclusion is a promising reality in selected high-risk patients.

Clinical and Hemodynamic Outcomes of Rapid-Deployment Aortic Bioprostheses.

Aim of this retrospective, multicenter study was to evaluate early and mid-term clinical and hemodynamic results of patients who underwent surgical aortic valve replacement (SAVR) with Intuity rapid-deployment bioprostheses (RDB) (Edwards Lifesciences, Irvine, CA). We analyzed data from the Italian Registry of Intuity Valve (INTU-ITA registry) that is a national, real-world and independent from the industry registry. Preoperative variables were defined according to EuroSCORE and postoperative outcomes according to Valve Academic Research Consortium (VARC). Survival distribution was evaluated using the Kaplan-Meier approach. A Cox-Proportional Hazard Model was employed to assess the effect of the covariates on patients' survival. The registry included 1687 patients from 23 centers (June 2012-September 2019). Aortic cross clamp time for isolated SAVR was 55 minutes (IQR: 45-70 minute). Postoperative pace-maker rate was 6.3%. At discharge transaortic peak and mean gradients were: 18 mm Hg (IQR: 14-23 mm Hg) and 10 mmHg (IQR: 8-13 mm Hg), respectively. Indexed effective orifice area was 1.10 cm2/m2 (IQR: 0.91-1.31 cm2/m2) and the incidence of severe patient-prosthesis mismatch was 0.6%. Hemodynamic data for all valve sizes remained stable during follow-up. Thirty-day overall mortality was 1.8% (30 patients), and at follow-up it was 5.3% (89 patients). Kaplan-Meier overall survival was 95.5% (94.3-96.7%); 90.7% (88.3-93.1%); 86.4% (82.6-90.4%) at 1, 3, and 5 years, respectively. Serum creatinine (HR: 1.36; 95%CI: 1.04-1.81; p = 0.0397) and cross-clamp time (HR: 1.01; 95%CI: 1.002-1.017; p = 0.0077) were identified as independent predictors of mortality. According to our data from the INTU-ITA registry, SAVR with RDB provides good early clinical and hemodynamic results that are confirmed at follow-up.

Double Transapical Access During Neochord Implantation.

Mitral valve repair using transapical off-pump beating-heart neochordae implantation is a relatively new procedure with promising early and mid-term results in selected patients. Nevertheless, early failures a few days after the procedure, requiring surgical reintervention, have been described. We describe a case of intraoperative acute procedural failure treated with a second procedure through a different transapical access adjacent to the first one. The final result was excellent with trivial residual regurgitation and the subsequent hospitalization was uneventful. This case demonstrates that a second transapical mitral neochordae implantation is feasible and should be considered in case of intraoperative acute procedural failure.

Emergency Endovascular Total Arch Exclusion With an Off-the-Shelf Bimodular Device.

A patient with a history of surgery for type A acute aortic dissection was readmitted for aortic arch and descending aortic dissection with rupture at the isthmus and periaortic hematoma. Due to the high surgical risk, the aortic team chose an endovascular approach, and the patient successfully underwent emergency total arch exclusion with an off-the-shelf, bimodular, single-branch device. The main module was deployed in the aortic arch and in the brachiocephalic trunk, and the second module was deployed in the ascending aorta. Despite the good perioperative outcome with no cerebrovascular events, the patient died 20 days later because of sudden iliac rupture.

Transapical Antegrade Ascending Aorta Stent-Grafting: Going Through the Front Door.

OBJECTIVE: Ascending aorta stent-grafting (AASG) is a new option that has shown initial promising results. In selected cases, when neither conventional surgery nor transfemoral retrograde approach are feasible, antegrade transapical (TA) access can be performed. The aim of this single-center retrospective study was to evaluate outcomes of patients undergoing AASG through a TA approach. METHODS: We analyzed all patients undergoing AASG through a TA approach at our institution. Three different devices were used, including Relay Stent-Graft System (Terumo Aortic, UK), Gore Conformable Thoracic Aortic Graft (W. L. Gore & Associates, Inc., USA), and Valiant Thoracic Stent Graft (Medtronic, Ireland). All patients underwent clinical and computed tomographic angiogram (CTA) evaluation before hospital discharge. RESULTS: From May 2010 to December 2019, 3 consecutive patients underwent AASG at our institution. Mean age was 69 years. Three different types of endografts were used in 1 patient each. All patients stayed in the intensive care unit for 24 hr and mean hospital stay was 12 days. We did not observe any major adverse event. One patient died of pneumonia 2 months after the procedure and the other 2 patients are alive and in good clinical conditions at a mean follow-up of 56 months. Predischarge CTA showed good anatomic results with no endoleaks in all cases. CONCLUSIONS: This initial experience shows that AASG is feasible and provides encouraging clinical and anatomic results in selected high-risk patients.

Monitoring Patients Reported Outcomes after Valve Replacement Using Wearable Devices: Insights on Feasibility and Capability Study: Feasibility Results.

Wearable devices (WDs) can objectively assess patient-reported outcomes (PROMs) in clinical trials. In this study, the feasibility and acceptability of using commercial WDs in elderly patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) will be explored. This is a prospective observational study. Participants were trained to use a WD and a smartphone to collect data on their physical activity, rest heart rate and number of hours of sleep. Validated questionnaires were also used to evaluate these outcomes. A technology acceptance questionnaire was used at the end of the follow up. In our participants an overall good compliance in wearing the device (75.1% vs. 79.8%, SAVR vs. TAVR) was assessed. Half of the patients were willing to continue using the device. Perceived ease of use is one of the domains that scored higher in the technology acceptance questionnaire. In this study we observed that the use of a WD is accepted in our frail population for an extended period. Even though commercial WDs are not tailored for clinical research, they can produce useful information on patient behavior, especially when coordinated with intervention tailored to the single patient.

Valve-shaped thrombus underneath an aortic bioprosthesis.

We describe massive thrombus formation completely occluding an aortic bioprosthesis in a patient with venoarterial extracorporeal membrane oxygenation and apical venting. The thrombus was surgically removed and the patient recovered with no complications. Timely identification and immediate surgical removal of thrombi may allow patient recovery with no severe complications.

Minimally Invasive vs Conventional Aortic Valve Replacement With Rapid-Deployment Bioprostheses.

BACKGROUND: The aim of this multicenter retrospective study was to compare early and midterm clinical and hemodynamic results of aortic valve replacement with rapid-deployment bioprostheses performed through conventional full-sternotomy vs mini-sternotomy. METHODS: Data from the Italian multicenter registry of aortic valve replacement with rapid-deployment bioprostheses (INTU-ITA registry) were analyzed. Patients were divided into 2 groups: full sternotomy (FS) and ministernotomy (MS). Primary endpoint was the comparison of early and midterm mortality. Secondary endpoints were: comparison of intraoperative variables, complications, and hemodynamic performance. A propensity score weighting approach was used for data analysis. RESULTS: A total of 1057 patients were analyzed: 435 (41.2%) and 622 (58.8%) in group FS and MS, respectively. Thirty-day mortality was 1.6% and 0.6% in FS and MS groups, respectively (P = .074). cardiopulmonary bypass time was 78.5 minutes and 83 minutes in FS and MS groups, respectively (P = .414). In the overall cohort, the incidence of intraoperative complications and of device success was 3.8% (40 patients) and 95.9% (1014 patients), respectively, with no significant differences between groups. Survival at 1, 3, and 5 years was 94.1%, 98.1%, 88.5% and 91.8%, 85.2%, and 84.8% in FS and MS groups, respectively (P = .412). The 2 groups showed similar postoperative gradients (median mean gradient, FS: 10.0 mm Hg, MS: 11.0 mm Hg; P = .170) and also similar incidence of patient-prosthesis mismatch (FS: 7%, MS: 6.4%, P = .647). CONCLUSIONS: According to our data, rapid-deployment bioprostheses allow the performance of minimally invasive aortic valve replacement with similar surgical times and similar clinical and hemodynamic outcomes to conventional surgery and should be considered the first choice in these procedures.

Using Wearable Devices to Monitor Physical Activity in Patients Undergoing Aortic Valve Replacement: Protocol for a Prospective Observational Study.

BACKGROUND: In last few decades, several tools have been developed to measure physical function objectively; however, their use has not been well established in clinical practice. OBJECTIVE: This study aims to describe the preoperative physical function and to assess and compare 6-month postoperative changes in the physical function of patients undergoing treatment for aortic stenosis with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). The study also aims to evaluate the feasibility of wearable devices in assessing physical function in such patients. METHODS: This is a prospective observational study. The enrollment will be conducted 1 month before patients' SAVR/TAVR. Patients will be provided with the wearable device at baseline (activity tracker device, Garmin vívoactive 3). They will be trained in the use of the device, and they will be requested to wear it on the wrist of their preferred hand until 12 months after SAVR/TAVR. After baseline assessment, they will undergo 4 follow-up assessments at 1, 3, 6, and 12 months after SAVR/TAVR. At baseline and each follow-up, they will undergo a set of standard and validated tests to assess physical function, health-related quality of life, and sleep quality. RESULTS: The ethics committee of Vicenza in Veneto Region in Italy approved the study (Protocol No. 943; January 4, 2019). As of October 2020, the enrollment of participants is ongoing. CONCLUSIONS: The use of the wearable devices for real-time monitoring of physical activity of patients undergoing aortic valve replacement is a promising opportunity for improving the clinical management and consequently, the health outcomes of such patients. TRIAL REGISTRATION: Clinicaltrials.gov NCT03843320; https://tinyurl.com/yyareu5y. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20072.

Conduction disorders after aortic valve replacement with rapid-deployment bioprostheses: early occurrence and one-year evolution.

BACKGROUND: Rapid-deployment bioprostheses represent one of the newest aortic valve substitutes introduced into clinical practice. The aim of this retrospective single-center study was to evaluate the occurrence of conduction disorders (CDs) after rapid-deployment aortic valve implantation at discharge and at 1-year follow-up, and to identify risk factors for CDs and permanent pacemaker implantation (PPI). METHODS: All patients who reached 1-year follow-up after isolated or combined aortic valve replacement (AVR) with rapid-deployment bioprostheses (Intuity Elite, Edwards Lifesciences, Irvine, CA) at our institution were included in this study. Standard 12-lead electrocardiograms (ECGs) were recorded before the procedure (within 24 hours), after the procedure as soon as the patient was moved to the intensive care unit (ICU), every day during in-hospital stay and at 1-year follow-up. The primary endpoint was the incidence of postoperative CDs at discharge and at 1-year follow up. Patients were divided in two groups: those who developed the primary endpoint (Group CD) and those who didn't (Group Non-CD). RESULTS: A total of 98 consecutive patients were included in the study. At discharge, the primary endpoint occurred in 40 patients (40.8%). In particular, new CDs and PPI occurred in 33 (33.7%) and in 7 (7.1%) patients, respectively. Valve size was the only independent predictor of primary endpoint at discharge. At 1-year, 30 patients (31.3%) presented with CDs or pacemaker-induced rhythm. In particular, in 25 patients of Group CD (64.1%), 1-year follow-up ECG revealed the persistence of the same CD as at discharge or pacemaker-induced rhythm, while 14 patients (35.9%) showed recovery of their CD. Age and prosthesis size were identified as independent predictors of CDs/pacemaker-induced rhythm at 1-year follow-up. CONCLUSIONS: According to our data, nearly 40% of patients develop a new CD after rapid-deployment aortic valve implantation. Of these, one third recover after one year. Bioprosthesis size and age were identified as independent risk factors for occurrence of CD after surgery.

One-stage off pump combined transapical aortic valve replacement and ascending aorta endografting.

An 84-year-old patient was referred for severe symptomatic aortic valve stenosis and focal chronic dissection of the ascending aorta. After multidisciplinary discussion, the patient was scheduled for combined transapical transcatheter aortic valve replacement and ascending aorta stent-grafting. The procedure was performed with a balloon aortic valvuloplasty followed by a custom-made stent graft implantation into the ascending aorta and then by balloon-expandable transapical transcatheter aortic valve replacement. The patient had an uneventful hospital stay. In conclusion, in selected high-risk patients, transapical combined ascending aorta stent-grafting and transcatheter aortic valve replacement are feasible and safe.

Long-term outcomes of sutureless and rapid-deployment aortic valve replacement: a systematic review and meta-analysis.

BACKGROUND: Sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has become a prominent area of research as the medical community evaluate its place amongst other aortic valve interventions. The main advantages of SURD-AVR established to date are the reduced cross-clamp and cardiopulmonary bypass (CPB) times, as well as facilitating minimally invasive surgery in high-risk surgical patients. This current systematic review and meta-analysis, to our knowledge, is the first focusing on long-term outcomes regarding safety, efficacy and durability of SURD-AVR from available current literature. METHODS: A literature search via six electronic databases was performed from their inception to November 2019. Inclusion criteria for this systematic review included survival and postoperative echocardiographic outcomes greater than five years in patients who underwent SURD-AVR with either Perceval or Intuity valves. Studies were identified and data extracted by two independent reviewers. Long-term survival outcomes were aggregated using digitized Kaplan-Meier curves where available. RESULTS: After applying predefined inclusion and exclusion criteria, four studies were identified for review. All four studies were observational and in total reported data for 1,998 patients. Almost half (42.4%) of patients underwent SURD-AVR via full sternotomy, with almost one third (30.1%) also undergoing concomitant cardiac procedures. Aggregate overall survival rates at 1-, 2-, 3-, and 5-year follow-up were 94.9%, 91.2%, 89.0%, and 84.2%, respectively. Incidence of strokes (4.8%), severe paravalvular leaks (PVLs) (1.5%) and permanent pacemaker (PPM) insertion (8.2%) at up to 5-year follow-up were acceptable. At 5-year follow-up hemodynamic outcomes were also acceptable for mean pressure gradient (MPG) (range, 8.8-13.6 mmHg), peak pressure gradient (PPG) (range, 18.9-21.1 mmHg) and effective orifice area (EOA) (range, 1.5-1.8 cm2). CONCLUSIONS: Evaluation of the evidence reporting long-term outcomes of SURD-AVR suggests that it is a safe procedure for AVR with low rates of complications. Long-term outcomes presented in this review show that not only does SURD-AVR have acceptable survival rates, but also good hemodynamic performance at 5-year follow-up.

The biological age of the heart is consistently younger than chronological age.

Chronological age represents the main factor in donor selection criteria for organ transplantation, however aging is very heterogeneous. Defining the biological aging of individual organs may contribute to supporting this process. In this study we examined the biological age of the heart [right (RA)/left atrium (LA)] and peripheral blood leucocytes in the same subject, and compared these to assess whether blood mirrors cardiac biological aging. Biological aging was studied in 35 donors (0.4-72 years) by exploring mitotic and non-mitotic pathways, using telomere length (TL) and age-dependent methylation changes in certain CpG loci (DNAmAge). Heart non-mitotic DNAmAge was strongly younger than that of both blood (- 10 years, p < 0.0001) and chronological age (- 12 years, p < 0.0001). Instead, heart and blood mitotic age (TL) were similar, and there was no difference in DNAmAge and TL between RA and LA. DNAmAge negatively correlated with TL in heart and blood (p ≤ 0.01). Finally, blood and heart TL (p < 0.01) and DNAmAge (p < 0.0001) were correlated. Therefore, blood can be a proxy indicator of heart biological age. While future investigation on post-transplant graft performance in relation to biological aging is still needed, our study could contribute to opening up novel basic and clinical research platforms in the field of organ transplantation.

Bailout Implantation of a New Single-Branch Stent Graft for the Aortic Arch.

In this paper we describe a case of a rapidly growing pseudoaneurysm of the aortic arch occurring after surgery for acute type A aortic dissection that was successfully treated with an off-the-shelf, single-branch, dual-module aortic arch endovascular stent graft. The main module, which has a side-branch for the innominate artery, was implanted in the aortic arch and in the descending thoracic aorta. The second module was deployed in the ascending aorta and connected to the main module through a proprietary interlocking system. Final angiography showed complete exclusion of the pseudoaneurysm and good patency of the supraaortic vessels.