Pseudoaneurysm fistulized into pulmonary artery 13 years after aortic surgery.

Pseudoaneurysm formation some years after aortic root or ascending aorta surgery, complicated by fistula formation through a branch of the pulmonary artery, is a rare condition described only in case reports. We describe a case of this rare complication in a 58-year-old man, which occurred 13 years after aortic surgery and was characterized by a huge pseudoaneurysm of 70 mm that fistulized into the right pulmonary artery, causing a life-threatening situation.

Aortic valve replacement in familial hypercholesterolemia: not an ordinary procedure.

Familial hypercholesterolemia is an inherited disorder with incidences of approximately 1:500 and 1:1,000,000 in heterozygous and homozygous form respectively. Affected patients usually show early coronary artery disease and severe aortic root calcification, despite optimization of therapy. We report a case of a 64-year-old woman affected by heterozygous familial hypercholesterolemia which presented dyspnea and anginal symptoms due to a severely calcified aortic root causing valve stenosis and narrowed sinotubular junction. Aortic valve replacement and aortic root enlargement were performed using the Manougian procedure. Even for experiences surgeons, this surgery could prove challenging for this group of patients due to aggressive degenerative tissue calcification of the aortic root, which often presents an extremely calcified aortic valve with a small annulus associated to a narrowed sinotubular junction.

Myocardial infarction and rupture after bronchial artery embolization.

Bronchial artery embolization is a well-known treatment for hemoptysis. Adverse events of this procedure include multiple systemic embolism and infarction. Myocardial infarction has been recently reported during bronchial artery embolization, owing to the presence of a coronary-to-bronchial artery fistula. We report the management of an ischemic left ventricular free wall rupture caused by bronchial artery embolization in a patient with massive hemoptysis, bronchiectasis, and undetected coronary-to-bronchial artery anomalous connection.

[Evolution of coronary artery bypass graft techniques]. / Evoluzione delle tecniche di bypass coronarico.

The results of coronary surgical revascularization are constantly improving despite the worsening of patient's risk profiles. Nowadays this procedure represents the gold standard for patients with multivessel disease or critical left main stenosis, according to European and American guidelines. Recent data show that these guidelines are poorly implemented in the "real world". Different reasons can explain this phenomenon, among these, the invasiveness and morbidity of surgical procedures, which determine low acceptance rates by the patients. In recent years, several procedures have been developed in order to improve surgical therapy; the most promising include complete arterial revascularization, the "no-touch aorta technique", mini-invasive techniques, improvement of biocompatibility of extracorporeal circulation, and hybrid revascularization. Although these procedures still need statistical evidence, some data support their use in specific patient subsets. If these trends will be confirmed, it will be possible to choose the best surgical strategy for each individual patient. At present, there are no data suggesting the best choice between on-pump and off-pump techniques; there are indications to use arterial conduits in young patients, whereas the no-touch aorta technique, which seems to reduce cerebrovascular complications, requires further statistical confirmation; the mini-invasive and hybrid approaches need additional data to confirm their effectiveness. This accounts for the great variability among centers regarding the strategies of myocardial revascularization, often restricted to few techniques. In our opinion, nowadays, every heart surgery unit should offer all of these modern techniques. In order to decide for the best treatment between medical, surgical and percutaneous therapies, the creation of a Heart Team has been demonstrated to be effective. All components of the Heart Team should be familiar not only with the use of anatomical and clinical risk scores, but they should also know the main aspects of each therapeutic option along with their availability. This condition is fundamental in order to discuss and set up the best surgical option for each patient, and consequently improve quality of treatment and clinical outcome. In order to suggest the best therapy to the patient, the Heart Team should take into consideration the guideline recommendations and available operative setting within the cardiac unit.