[Giant coronary aneurysm incidentally detected on transthoracic echocardiography in a patient with previous Bentall procedure]. / Riscontro incidentale di aneurisma coronarico gigante tramite ecocardiogramma transtoracico in esiti di pregresso intervento di Bentall.

Coronary artery aneurysms represent a rare pathology (0.2-4.9% of patients undergoing coronary angiography) that may reach considerable size. The clinical presentation is various, manifesting as acute coronary syndrome or, conversely, remaining silent lifelong. We here report the case of an incidental finding by transthoracic echocardiography of a paracardiac mass of considerable size in a patient with vasculopathy that underwent a Bentall procedure for acute aortic dissection 18 years earlier. On thoracic computed tomography angiography, a 62 mm-sized giant aneurysm located in the proximal right coronary artery was evidenced. The optimal treatment of patients affected by coronary artery aneurysms remains debated; therefore, the therapeutic strategy should be individualized considering the etiology, clinical presentation, anatomical characteristics and concomitant presence of obstructive coronary artery disease.

Coronary microvascular dysfunction in patients undergoing transcatheter aortic valve implantation.

OBJECTIVES: This study aimed to evaluate the prognostic value of coronary microvascular dysfunction (CMD) at long term after transcatheter aortic valve implantation (TAVI) and to explore its relationship with extravalvular cardiac damage (EVCD). Moreover, we sought to test the correlation between angiography-derived index of microcirculatory resistance (IMRangio) and invasive IMR in patients with aortic stenosis (AS). METHODS: This was a retrospective analysis of the Verona Valvular Heart Disease Registry (Italy) including 250 patients (83 (80-86) years, 53% female) with severe AS who underwent TAVI between 2019 and 2021. IMRangio was calculated offline using a computational flow model applied to coronary angiography obtained during the TAVI workup. CMD was defined as IMRangio ≥30 units.The primary endpoint was the composite of cardiovascular death and rehospitalisation for heart failure (HF). Advanced EVCD was defined as pulmonary circulation impairment, severe tricuspid regurgitation or right ventricular dysfunction.The correlation between IMR and IMRangio was prospectively assessed in 31 patients undergoing TAVI. RESULTS: The primary endpoint occurred in 28 (11.2%) patients at a median follow-up of 22 (IQR 12-30) months. Patients with CMD met the primary endpoint more frequently than those without CMD (22.9% vs 2.8%, p<0.0001). Patients with CMD were more frequently characterised by advanced EVCD (33 (31.4%) vs 27 (18.6%), p=0.024). CMD was an independent predictor of adverse outcomes (adjusted HR 6.672 (2.251 to 19.778), p=0.001) and provided incremental prognostic value compared with conventional clinical and imaging variables. IMRangio demonstrated fair correlation with IMR. CONCLUSIONS: CMD is an independent predictor of cardiovascular mortality and HF after TAVI.

Outpatient tricuspid regurgitation in the community: Clinical context and outcome.

BACKGROUND AND AIMS: Epidemiology of tricuspid regurgitation (TR) is poorly known and its burden in the community is challenging to define. We aimed to evaluate the prevalence of TR in a geographically defined area and its outcome, in particular overall survival and hospitalization, considering different clinical contexts. METHODS: We retrospectively analyzed consecutive outpatients referred between 2006 and 2013 for echocardiography and clinical evaluation. Patients with at least moderate TR were included and five different clinical settings were defined: concomitant significant left-sided valvular heart disease (LVHD-TR), heart failure (HF-TR), previous open-heart valvular surgery (postop-TR), pulmonary hypertension (PHTN-TR) and isolated TR (isolated-TR). Primary endpoint was a composite outcome of all-cause mortality or first hospitalization for HF. RESULTS: Of 6797 consecutive patients with a clinical visit and echocardiograms performed in routine practice in a geographically defined community, moderate or severe TR was found in 4.8% of patients (327) . During median follow-up of 6.1 years, TR severity was a determinant of event-free survival. Analyzed for each clinical subset, eight-year event-free survival was 87 ± 7% for postop-TR subgroup, 75 ± 7% for isolated-TR, 67 ± 6% for PHTN-TR, 58 ± 6% for LHVD -TR and 52 ± 11% for HF-TR. CONCLUSION: Moderate or more TR is a notable finding in the community and has impact on event-free survival in all clinical settings, with the worst outcomes when associated with relevant left-sided valvular heart disease and HF.

Case Report: Severe Aortic Valve Regurgitation and Pseudoaneurysm in Aortic Valve-Sparing Operation: The Usefulness of Multimodality Imaging in a Complex Clinical Scenario.

Background: Failure of the native aortic valve and degenerative anatomy of ascending aorta in patients with previous Tirone-David operation may represent a clinical challenge, because sometimes the risk of reoperation is prohibitive. Case: We described the case of a patient suffering from severe aortic valve regurgitation and pseudoaneurysm of the aortic arch, 6 years after cardiac surgery operation. The aim of this clinical case was to assess if the complex anatomy of aortic pseudoaneurysm and aortic root geometry can be accurately reproduced from contrast-enhanced computed tomography scan into a three-dimensional (3D) printed model. Based on this procedural method, with the aid of transesophageal 3D ultrasound, we efficaciously treated the patient percutaneously with a combination of transcatheter occluder device plus microcoil embolization and transfemoral aortic valve implantation. The patient was free from complications and the need to redo cardiac surgery. Conclusion: To the best of our knowledge, this is the first description of two simultaneous complications and their staged treatment in a patient with previous aortic valve-sparing operation. This is a useful report in a single 3D model applying such specific technology to these two simultaneous clinical settings.