Porcelain aorta: A surgical dilemma in orthotopic heart transplantation.

BACKGROUND: Circumferential calcification of the ascending aorta, known as porcelain aorta, in a patient candidate to a heart transplant, requires technically demanding and high-risk procedural adjustments. AIMS: This case report showed successful replacement of ascending aorta due to extensive calcification at time of heart transplantation. MATERIALS AND METHODS: In the operating theatre, after median sternotomy, cardiopulmonary bypass (CPB) was achieved via the right femoral artery and vein. Due to the impossibility of replacing the ascending aorta using safe aortic cross-clamping, a moderate hypothermia was established, and circulatory arrest was realized. According to Kazui protocol for selective anterograde cerebral perfusion via anonymous trunk and left carotid artery, ascending aorta was replaced with vascular prosthesis. RESULTS: Thanks to accurate pre-surgical planning, which included hypothermic circulatory arrest, ascending aorta replacement, before orthotopic heart implantation, we were able to perform the procedure successfully and prevent neurological events. DISCUSSION: Although different reports showed the feasibility of heart transplant combined to aortic replacement for aneurysmatic pathology, few cases were described for porcelain aorta, due to technically demanding procedure and prohibitive aortic cross-clamping. To avoid vascular embolization, dissection and mural laceration, aortic cross-clamping is not recommended. We performed aortic replacement at first, to reduce allograft ischemia. CONCLUSION: The use of hypothermic circulatory arrest technique with selective cerebral perfusion for aortic replacement, followed by vascular graft clamping to favour cardiac allograft implantation, could be considered a winning combination to guarantee procedural success and to reduce perioperative complications.

Clinicopathological insights from early structural valve deterioration of a surgical and transcatheter valve-in-valve mitral bioprotheses.

INTRODUCTION: Transcatheter mitral valve replacement (TMVR) is indicated in case of degenerated bioprosthesis in high-risk patients. However, durability of these valves still represents an important issue. METHODS: Early severe structural valve deterioration of a mitral porcine surgical bioprosthesis and of a subsequent bovine TMVR, both at 4 years follow-up, is here presented. RESULTS: Gross, histopathologic, and X-ray examination revealed massive calcification of both devices and fibrous tissue overgrowth involving the TMVR stent. CONCLUSIONS: Careful clinical evaluation and strict follow-up are mandatory to identify early signs of dysfunction and to intervene in a timely manner.

Frozen Elephant Trunk to Exclude the Kommerell Diverticulum Associated with Double Aortic Arch in Adult Redo Patient.

Kommerell diverticulum can be associated to several types of vascular rings, including double aortic arch. Surgical indications for vascular rings and Kommerell diverticulum include bulging symptoms onto trachea and esophagus too. Moreover, the aneurysmal enlargement over time can eventually cause acute aortic syndromes. Management of this pathology in adulthood is challenging and many techniques have been proposed, notably hybrid solutions. Herein, we report the case of a patient, who underwent redo surgery with frozen elephant trunk technique, caused by persisting symptoms after a previous operation of vascular ring interruption.

Biomechanics of the posterior oblique ligament of the knee.

BACKGROUND: The purpose of this systematic literature review is to analyse the isolated biomechanics of the posterior oblique ligament of the knee. In the current literature, the biomechanical aspect of the posterior oblique ligament was analysed in several articles, but this was always done in association with other capsuloligamentous structures. METHODS: A systematic review of the existing literature was performed to identify all studies dealing with the biomechanics of the posterior oblique ligament. Two independent investigators performed the research using the MEDLINE, CINAHL, Scopus, Embase and Cochrane databases. FINDINGS: A total of 10 articles analysed the biomechanics of the posterior oblique ligament, confirming the importance of this ligament for the stability of the knee in different positions. The posterior oblique ligament is the main stabiliser against internal rotation in early flexion angles (0°-30°) and it is an important restraint to posterior tibial translation in the posterior cruciate ligament deficient knee. Furthermore, the posterior oblique ligament bears up to 47% of the force borne by the anterior cruciate ligament in resisting the internal rotation loads when a pivot-shift maneuver is simulated. INTERPRETATION: This review confirms that the posterior oblique ligament is an anatomically well-defined and distinct structure that plays a key role in stabilising the knee, especially in internal rotation. The posterior oblique ligament is frequently injured along with other anatomical structures. Future studies should develop clinical tests to evaluate the functionality and stability of the the posterior oblique ligament.

A New and Unexpected Complication After Arch Stent Grafting for Residual Dissection.

This report describes a complication after stent grafting of the aortic arch for residual dissection after ascending aorta and aortic arch replacement for acute type A dissection. One year later, a pseudoaneurysm originating from the proximal suture line and therefore far from the stent graft landing zone developed and fistulized into the pulmonary artery. Possible causes were suture damage during stent deployment and change of system forces after stent placement leading to high tension on the suture line. Emergency surgery was performed. Aortic arch stent grafting is a new and promising technique, but its complications are still not completely known.

Treatment of complete ankylosed elbow with total arthroplasty.

We reported the case of a 38-year-old patient who in 2017 presented to our institution after post-traumatic complete ankylosis of the elbow. He complained of stiffness and pain, and the radiographs revealed complete fusion of the humeroulnar joint. The Mayo Elbow Performance Score (MEPS) on admission was 31, and the elbow was fused at 90° flexed position. The patient underwent semiconstrained total elbow arthroplasty with Bryan-Morrey approach; after a 2.1 years follow-up, active arc of movement was 120°. The MEPS was excellent with a 100 points score, the patient was able to complete all activities of daily living. We did not report any complications. Total elbow arthroplasty has shown to be a good therapeutic option that make it possible to restore adequate functional range of motion and relieve pain in young patients with post-traumatic stiffness/arthritis of the elbow.

Bilateral Cemented Custom-Made Total Hip Arthroplasty in Paget's Disease with Femoral Cortical Thickening and Canal Narrowing.

In this report, we present a case of a 57-year-old man complaining of pain in both his hips. Clinically, the patient reported lameness and reduction in the range of motion of the hips. Radiographic imaging showed a very narrow medullary femoral canal, confirmed by a computed tomography scan. In consideration of the narrowness of the femoral canal and cortex thickening, and due to the rarity of the clinical case, we opted to use a custom-made prosthesis. We performed total hip arthroplasty, initially on the right side. One year later, we repeated the procedure on the left side. One year after the last surgery, the patient reported well-being and continuous improvement in walking, with no complications. This case report highlights the features and the critical issues related to this kind of surgery in patients affected by Paget's disease of the bone and the importance of custom-made implants in challenging cases.

Clinical Contribution of Wrist and Hand Sonography: Pilot Study.

OBJECTIVES: The purpose of this study was to evaluate the clinical contribution of wrist and hand sonography. METHODS: This study was performed in a tertiary academic medical center. Institutional review board approval was obtained. Data collection was done retrospectively from January 2012 to December 2016 and prospectively from January 2017 to July 2017. The study included 112 consecutive patients (52 men and 60 women; mean age, 47 ± 16 years; range, 15-87 years). A total of 126 examinations were performed. All ultrasound examinations were done with high-resolution probes with up-to-date protocols. The clinical contribution of wrist and hand sonography was assessed (ultrasound examinations contributive/noncontributive). Descriptive statistic and nonparametric tests were used. RESULTS: In 96 of 126 (76%) examinations, sonography proved to be contributive, and in 30 of 126 (24%) examinations, sonography proved to be noncontributive. The contributive/noncontributive ratio was 3.2 (96/30). A total of 51 of 126 (40%) examinations were performed in patients with a history of previous trauma. Sonography proved to be significantly more contributive in a posttraumatic setting (chi-square, 9.2; P = .0023). CONCLUSION: Wrist and hand sonography significantly influences the diagnostic and therapeutic path, especially in a posttraumatic setting.

Minimally Invasive Implantation of Continuous Flow Left Ventricular Assist Devices: The Evolution of Surgical Techniques in a Single-Center Experience.

In this work we aimed to evaluate the evolution of our surgical experience with the implantation of a continuous flow left ventricular assist device (LVAD), from the original full sternotomy approach to less invasive surgical strategies including mini-sternotomy and/or mini-thoracotomies. We reviewed all consecutive patients implanted with a continuous flow LVAD at our Institute. To exclude the possible bias related to the device used, out of 91 collected LVADs implants, we selected only those patients (n = 42) who received, between 2012 and 2015, the HeartWare HVAD. The analysis focused on the surgical approach used for the LVAD implant. Most of the patients (95%) were affected by dilated or ischemic cardiomyopathy, with an INTERMACS class I-II in the majority of cases (77%). The LVAD implant was performed through a full sternotomy in 10 patients (24%); the remaining 32 cases (76%) were managed with minimally invasive procedures. These were left mini-thoracotomy with upper mini-sternotomy (20 patients, 62%), right and left mini-thoracotomy (7 patients, 22%), and a recently developed left mini-thoracotomy with outflow graft anastomosis to the left axillary artery (5 patients, 16%). The most common adverse event on device was right heart failure (26%). Eighteen patients (43%) were transplanted. Overall estimated 24 months survival (on device or after transplant) was 68 ± 7%. The causal analysis, adjusted by propensity score weighting baseline data and sample size, showed that left mini-thoracotomy with outflow anastomosis to the left axillary artery resulted in a significantly reduced rate of post implant right heart failure (P < 0.01), and mechanical ventilation time (P = 0.049). To conclude, in our series, by applying mini-invasive implant techniques in the majority of cases, mid-term survival of continuous flow LVADs in severely compromised patients was satisfactory. In the adjusted analysis, the left anterior mini-thoracotomy with outflow anastomosis to the left axillary artery showed the most favorable results.

Coronary Artery Bypass Grafting in Elderly Patients: Insights from a Comparative Analysis of Total Arterial and Conventional Revascularization.

The benefits of total arterial (TAR) versus conventional (CR) revascularization are controversial in the higher-risk cohort of elderly patients. Taking for granted its benefit on long-term survival, we evaluated the effect of TAR on safety (death, myocardial infarction, and stroke) of patients undergoing CABG. Between 2000 and 2009, 487 patients >75 years underwent isolated CABG at our institution (150 TAR and 337 CR). Patients with arterial free-grafts were excluded. After propensity matching, the outcomes of 131 TAR and 127 CR patients were compared. TAR patients had lower incidence of post-operative myocardial infarction (p = 0.025) and stroke (p = 0.005). They also experienced shorter intensive care unit (p = 0.046) and ward stay (p = 0.028), lower output of TnI (p = 0.035), and less wound complications (leg included) (p = 0.0001), while mortality was comparable (p = 0.57). In our cohort of elderly patients with multivessel disease, TAR was associated with lower rates of myocardial infarction, stroke, and shorter hospital stay.

Evaluation of prosthetic valve thrombosis by 64-row multi-detector computed tomography. .

BACKGROUND AND AIM OF THE STUDY: Multi-detector computed tomography (MDCT), combined with retrospective electrocardiographic gating, permits cardiac imaging with high accuracy. Recent advances in MDCT have seemed to respond adequately to the need for a non-invasive and reliable assessment of the coronary artery lumen. METHODS: Two patients with prosthetic aortic valves (one bioprosthetic, one mechanical) presented at the authors' institution with dyspnea and syncopal episodes. MDCT was performed to evaluate thrombus characteristics and exclude coronary artery disease (CAD). RESULTS: Based on the MDCT coronary artery assessment, neither patient underwent preoperative invasive coronary angiography, abolishing the risk of any iatrogenic thrombus fragmentation and subsequent embolization. One patient underwent surgical treatment without complications, while medical therapy was successful in the other case. CONCLUSION: MDCT can be used for the accurate imaging of thrombi on prosthetic aortic valves, and to correctly assess possible CAD.

Giant congenital aortic aneurysm with cleft sternum in a neonate: pathological and surgical considerations for optimal management.

We report a rare case of a neonate with congenital giant aortic aneurysm associated to cleft sternum, who underwent surgical repair. The patient died on postoperative Day 5 from cardiac arrest. Autopsy revealed a circumferential subendocardial myocardial infarction and misdiagnosed coronary ostial anomalies. A critical analysis of this unfortunate case may help optimal surgical planning in similar patients in the future.

High-resolution sonography of the palmar cutaneous branch of the median nerve.

OBJECTIVE: The aim of this study was to describe the potential value of high-resolution sonography for evaluation of the palmar cutaneous branch of the median nerve (MN). SUBJECTS AND METHODS: The volar wrists of 12 healthy volunteers and 22 consecutive patients with sensory deficit in the palmar triangle and thenar eminence suggesting neuropathy of the palmar cutaneous branch of the MN were examined with high-frequency sonography. Nine patients underwent carpal tunnel release, five had a history of penetrating trauma, six had symptoms suggesting concurrent carpal tunnel syndrome, one received surgery for palmaris tendon transfer, and one underwent resection of a ventral carpal ganglion cyst. Correlative 1.5-T MRI was performed in six patients. RESULTS: In 83% of the healthy volunteers, 17-5-MHz sonography was able to identify the palmar cutaneous branch of the MN from its origin down to slightly distal to the wrist crease. In the patient group, sonography allowed detection of nerve abnormalities in 55% of the cases. Focal hypoechoic swelling of the nerve at the fascial crossing was observed in patients who had either concurrent carpal tunnel syndrome (four cases) or previous carpal tunnel release (three cases). Sonography performed after a penetrating trauma revealed nerve encasement by scar tissue (two cases) or complete transection of the nerve ending in a terminal neuroma (one case). Nerve transection secondary to resection of a ventral carpal ganglion cyst (one case) or to carpal tunnel release (one case) was also observed. CONCLUSION: Sonography can identify the palmar cutaneous branch of the MN and characterize its abnormalities, providing unique information about this small nerve branch.

Wrist and hand ultrasound.

With adequate equipment, training, and expertise, ultrasound (US) should be regarded as the first-line imaging modality for the assessment of a wide range of pathological conditions affecting the soft tissues around the wrist and hand. With high-resolution transducers, US allows detection of foreign bodies and a reliable identification of a variety of traumatic lesions affecting tendons, retinacula and annular pulleys, ligaments, vessels, and nerves. In addition, inflammatory arthropathies, infectious disorders, overuse tendinopathies, and degenerative conditions can be diagnosed with this technique. In the wrist, US is able to identify the entrapment of the median, ulnar, and radial nerves. In patients with localized soft tissue swelling, US is able to assess the presence of a space-occupying lesion and to characterize its nature in many cases.

Reconstruction of the right atrium with pulmonary artery homograft after resection of right atrial lipomatosis.

We present a case of large right atrial mass due to lipomatous hypertrophy of the interatrial septum and left lower lobe adenocarcinoma. Combined resections of the right atrial mass with reconstruction of the superior atriocaval junction and right atrial free wall defects with pulmonary artery homograft and wedge excision of the lung tumor were performed through median sternotomy.

Neonatal intrapericardial teratoma: a challenge for the pediatric surgeon.

Congenital intrapericardial teratoma can present in the fetal and neonatal period, but prenatal diagnosis is difficult. Its clinical course, similar to that of an anterior mediastinal mass, may be fatal if the tumor is not promptly excised. We report the case of a fetus with a large anterior mediastinal mass associated with hydramnios, pleural effusion, and ascites. Perinatal surgical removal is the only lifesaving therapy; any conservative approach in these neonates should be avoided even if critically symptomatic.