[Ross procedure in a patient with mitro-aortic endocarditis]. / Intervento di Ross in paziente con endocardite infettiva mitro-aortica.

Infective endocarditis (IE) affecting the heart valves is burdened by a high risk of mortality and complications. In the aortic valve IE, when valve replacement is essential, there is evidence of good results with the use of pulmonary autographs (Ross procedure), but the application of this technique remains limited due to its poor dissemination. We present a complex case of mitro-aortic IE treated with the Ross procedure associated with removal of vegetation from the mitral valve in a 28-year-old patient undergoing hemodialytic treatment, already undergoing cardiac surgery through sternotomy in the past.

Iatrogenic Acute Aortic Dissection in the Era of Minimally Invasive Cardiac Surgery - Experience of a Center and Review of Literature.

INTRODUCTION: Iatrogenic acute aortic dissection (IAAD) type A is a rare but potentially fatal complication of cardiac surgery. METHODS: The purpose of this article is to review the literature since the first reports of IAAD in 1978, examining its clinical characteristics and describing operative details and surgical outcomes. Moreover, we reviewed the recent literature to identify current trends and risk factors for IAAD in minimally invasive cardiac surgery procedures, often related to femoral artery cannulation for retrograde perfusion. RESULTS: We found that IAAD ranges from 0.04 to 0.29% of cardiac patients in overall trials and ranged from 0.12 to 0.16% between 1978-1990, before the minimally invasive surgical era. And we concluded that since the first cases to the recent reports, the incidence of IAAD has not significantly changed. As minimally invasive procedures are on the rise, some authors think that the incidence of IAAD could increase in the future; we think that using all the precaution - such a strict monitoring of perfusion pressure throughout the intervention, avoiding extremely high jet pressures using vasodilators, repositioning of arterial cannula, or splitting perfusion in both femoral arteries -, this complication can be extremely reduced. Finally, we describe a very singular case occurring during mitral valve replacement followed by spontaneous dissection of left anterior descending artery one month later. CONCLUSION: The present article adds to the literature a more detailed clinical picture of this entity, including patients' characteristics, the mechanism, timing, and localization of the tear, and mortality details.

Cardiovascular Outcomes in Advanced Maternal Age Delivering Women. Clinical Review and Medico-Legal Issues.

Background and objecives: Adverse cardiovascular outcomes during pregnancy have increased over the past few decades, with increased numbers of women delivering later in their reproductive life. Other factors include higher rates of female obesity, diabetes, hypertension, cardiovascular diseases and assisted reproductive technology, which has extended fertility. Those at risk require extensive prenatal maternal screening, constant pregnancy supervising, monitoring during labor, delivery and puerperium and careful anesthetic evaluation during delivery. Materials and Methods: The present review reports the relevant information available on cardiovascular outcomes in advanced maternal age delivering women and related medico-legal issues. The search was performed on Pubmed, Cochrane, Semantic Scholar, Medline and Embase databases, accessed by Ovid, including among others the terms "cardiomyopathy", "ischaemic heart disease", "arrhythmias", "hypertension", "peripartum period", "diabetes", "advanced maternal age" "anesthesia", "maternal morbidity and mortality" and "litigation". Results: To the extent that underestimating risk factors for peripartum cardiomyopathy (PPCM) can adversely impact maternal and fetal outcomes, the legal implications of misdiagnosis or mismanagement can result in high compensatory damages. Substantial indemnity payments drive up costs of insurance coverage. Conclusions: Multidisciplinary approaches are necessary from obstetricians, cardiologists, anesthesiologists and perinatologists for pregnancy monitoring and delivery outcomes.

Congenital Aorto-Right Ventricular Fistula Associated with Pulmonary Hypertension in an Old Female Patient.

We report a late clinical presentation of an aorto-right ventricular fistula (RVF) extending from the right sinus of Valsalva into the RV outflow tract with significant left-to-right shunt and severe pulmonary hypertension. A three-dimensional transesophageal echocardiogram and a chest-computed tomography scans were performed to better characterize the abnormality. Aorto- RVF can be either congenital or acquired, secondary to endocarditis, Valsalva aneurysm rupture, chest trauma, or aortic dissection.

Usefulness of intravascular ultrasound in a case of angiographically unapparent myocardial bridging.

A patient with an acute coronary syndrome underwent coronary angiography, which showed only a moderate stenosis in the mid portion of the left anterior descending artery. Intravascular ultrasound was performed for a better assessment of the lesion, and surprisingly, it showed a myocardial bridge over the narrowed segment, which was unapparent at angiography. In fact, the systolic compression of the artery was very limited, and no 'step down-step up' course was recognized. Given the absence of significant atherosclerosis in the intramyocardial and adjacent segments, and considering the poor results reported for stenting of tunnelled coronary arteries, we decided to treat the patient medically. At 6-month follow-up, the patient is asymptomatic and has no inducible ischemia.In conclusion, this case shows how intravascular ultrasound can be useful in patients with an unclear angiographic diagnosis for a better patient management.