Left Atrial Appendage Closure Device Embolization under the Anterior Leaflet of Mitral Valve: Echocardiographic Diagnosis and Management.

A 76-year-old man with history of previous coronary artery bypass grafting, permanent atrial fibrillation in novel oral anticoagulation therapy, and gastrointestinal bleedings underwent percutaneous left atrial appendage closure. The procedure was complicated by intraoperative device embolization, which caused a dynamic obstruction of the left ventricular outflow tract leading to severe hemodynamic instability. Transesophageal echocardiography showed a device in the ventricle site of the mitral anterior leaflet. The coronary angiography showed also patency of both arterial grafts in stable coronary artery disease. After failing the percutaneous retrieval with a snare, emergent surgery was planned. A moderate calcified aortic valve stenosis was also found, but in consideration of the unstable clinical conditions of the patient, we thought of performing a transcatheter aortic valve replacement (TAVR) in a second time. We have carefully planned the surgical retrieval of the device embolized paying attention of his several comorbidities. The strategy to remove the device with cardiopulmonary bypass without cross-clamping the aorta through a right mini-thoracotomy has been preferred.

Virtually Wall-Less versus Standard Thin-Wall Venous Cannula in the Minimally Invasive Mitral Valve Surgery: Single-Center Experience.

Background and Objectives: Minimally invasive cardiac surgery (MICS) has been developing since 1996. Peripheral cannulation is required to perform MICS, and good venous drainage and a bloodless field are crucial for the success of this procedure. We assessed the benefits of using a virtually wall-less cannula in comparison with the standard thin-wall cannula in clinical practice. Materials and Methods: Between January 2021 and December 2022, we evaluated 65 elective patients, who underwent isolated minimally invasive mitral valve surgery. Both the virtually wall-less and the thin-wall cannulas were placed through a surgical cut-down. Patients' characteristics at baseline were similar in the two groups, except for the body surface area (BSA), which was greater in the virtually wall-less group compared to the thin-wall one. In the standard group, the size of the cannula was chosen depending on the patient's BSA, and the choice of the Smartcannula was based on their height. Results: There were no significant differences between the two groups in terms of negative pressure applied, target flow achieved, hemolysis, the need for blood transfusion, and the post-operative increases in liver and renal enzymes. However, in all the patients, the estimated target flow was achieved, thereby showing the better hemodynamic performance of the virtually wall-less cannula, since, in this group, the patients' BSA was significantly greater compared to the thin-wall group. Ultimately, the mean cross-clamp time, as an indirect index of the effectiveness of the venous drainage, is shorter in the virtually wall-less group compared with the thin-wall group. Conclusions: The virtually wall-less cannula should be preferred in minimally invasive mitral valve surgery due to its superior performance in terms of venous drainage compared with the standard thin-wall cannula.

Replacement of Ascending Aortic Aneurysm with Anomalous Origin of the Right Coronary Artery: Multidisciplinary Imaging for the Diagnosis.

This case report presents a rare scenario involving a congenital anomaly of the right coronary artery's (RCA) origin in association with an ascending aortic aneurysm. While both anomalies are individually recognized in the literature, their coexistence and potential interplay remain understudied. The aim of this report is to emphasize the challenges and implications associated with such a combination. A 78-year-old male patient with an enlarged ascending aortic aneurysm necessitating surgical intervention was found to have an anomalous origin of the RCA during preoperative coronary angiography, confirmed by computed tomography scan. Transesophageal echocardiography further elucidated the coronary abnormality. Intraoperatively, successful aortic replacement was performed, and careful repositioning of the anomalous right coronary ostium was achieved. This case raises important considerations regarding the potential complications arising from coronary anomalies and their impact on the surgical management of ascending aortic aneurysms. The rarity of this combination limits our understanding of their association, making a multidisciplinary approach crucial for optimal patient care. Further research and comprehensive evaluation of similar cases are necessary to better understand the relationship between coronary anomalies and ascending aortic aneurysms. Such investigations will help in improving treatment strategies and outcomes for patients with these complex conditions.

The impact of pericardial approach and myocardial protection onto postoperative right ventricle function reduction.

BACKGROUND: The reduction of RV function after cardiac surgery is a well-known phenomenon. It could persist up-to one year after the operation and often leads to an incomplete recovery at follow-up echocardiographic control. The aim of the present study is to analyze the impact of different modalities of pericardial incision (lateral versus anterior) and of myocardial protection protocols (Buckberg versus Custodiol) onto postoperative RV dynamic by relating two- and three-dimensional echocardiographic parameters in patients undergoing mitral valve repair through minimally invasive or traditional surgery approach. METHODS: We have analyzed 44 consecutive patients with severe degenerative mitral regurgitation who underwent mitral reparation with different surgical approach and cardioplegia type: Group 1 (17 pts): sternotomy with Buckberg cardioplegia protocol; Group 2 (10 pts): sternotomy with Custodiol cardioplegia; Group 3 (17 pts): mini-invasive surgery with Custodiol cardioplegia. Two-dimensional transthoracic echocardiography was performed pre- and 6 months post-surgery to evaluate RV function by tricuspid annular plane systolic excursion (TAPSE). RESULTS: All patients underwent successful and uneventful. A postoperative TAPSE reduction was found in all groups. However, mini-invasive patients experienced a significant reduced variation versus traditional surgery. CONCLUSIONS: Mini-invasive mitral repair, with lateral incision of pericardium, reduces postoperative TAPSE fall, while cardioplegia protocol fails to have an impact onto longitudinal RV function. In our study, the RV seems to experience a clinically irrelevant geometrical modification too, whose entity appears to be less evident in case of lateral pericardial approach. These results could strengthen the use of minimally invasive approach also to preserve RV function.