Ultra-rapid regrowth of urothelial cardiac metastasis after debulking surgery.

Cardiac metastases of urothelial carcinoma are a rare manifestation, and most of them are asymptomatic or autoptic findings. We report a case of a 64-year-old Caucasian man fully asymptomatic, who has been accidentally diagnosed with a right atrial mass during his routine follow up for previous urothelial cancer. Endomyocardial biopsy, and histological examination of the mass were crucial to reach a definitive diagnosis of urothelial metastasis. He underwent a debulking surgery of the mass to avoid cardiac life-threatening complications. Despite effective removal of the atrial metastasis, after 45 days the patient experienced an ultra-rapid regrowth of the mass in the same position. This case demonstrates how rapidly a urothelial cardiac metastasis can grow back, and that surgery does not avoid by itself early recurrence.

A new cannula for antegrade selective cerebral perfusion.

OBJECTIVE: Our aim was to perform antegrade selective cerebral perfusion with a different surgical technique using a new type of cannula. METHODS: This cannula has been designed to be introduced in the supra-aortic vessels directly using a standard guidewire technique (Seldinger technique). The cannula can also be inserted from the ostia of a vessel if preferred. Furthermore, this device can be introduced before the institution of hypothermic circulatory arrest and opening the aortic arch. RESULTS: We have performed operations on 5 patients so far using this cannula. No stroke or spinal cord injuries were detected. At the moment, both intraoperatively and at computed tomography scan follow-up, no significant stenosis of the cannulation sites were noted. Follow-up at 2 years found that patients are alive and free from new major neurological events. CONCLUSIONS: Transarterial introduction using the Seldinger technique of our cannula (AV Flow; MedEurope Srl, Bologna, Italy) represents an alternative to the current well-established techniques. The major advantages we describe are complete cerebral protection throughout the hypothermic circulatory arrest and easier arch vessels reimplantation or hemiarch operations.

Performing Antegrade Selective Cerebral Perfusion Using the AV Cannula: A Novel Approach.

Antegrade selective cerebral perfusion has become the preferred choice for brain protection during aortic arch surgery. To perform antegrade selective cerebral perfusion, cannulas have been introduced directly into the ostia of the supra-aortic vessels (SAV) after institution of hypothermic circulatory arrest and opening the aortic arch. We describe a different surgical technique with a new type of cannula for antegrade selective cerebral perfusion. This cannula, called AV (Andrea Venturini) cannula, has been designed to be introduced in the SAV directly using a standard guidewire technique (Seldinger's technique). The AV cannula can also be introduced from the ostia of the SAV if preferred. The AV cannula can be introduced before the institution of hypothermic circulatory arrest and before opening the aortic arch. One great advantage of this technique is that the ostia of the SAV remain free from a cannula, allowing the operator easier access and a faster anastomosis or reimplantation.

Papillary fibroelastoma, unusual cause of stroke in a young man: a case report.

BACKGROUND: Papillary fibroelastoma is the third most common primary benign tumor with an incidence of up to 0.33% in autopsy series; it accounts for approximately 75% of all cardiac valvular tumors. CASE PRESENTATION: We describe a rare case of a 28-Year-old man that while playing football, had a sudden onset of neurological deficit: aphasia, right hemiparesis and right facial numbness. Transthoracic echocardiography (TTE) showed a 10x10 mm mass attached to the anterior mitral valve leaflet. The patient was treated surgically for the prevention of further embolic complications. Histologic examination of the resected mass revealed a papillary fibroelastoma. It is the third most frequent primary cardiac tumor, after myxoma and fibroma, and the most common primary tumor of heart valves. Despite the benign nature of this tumor, it carries very high risk of embolic complications. The successful complete resection of the papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent. CONCLUSIONS: Differential diagnosis of cardiac masses requires clinical informations, laboratory tests, blood cultures and appropriate use of imaging modalities. Papillary fibroelastoma is a potential cause of embolic stroke in the young. The prompt surgical excision of papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent.

The TRIBECA study: (TRI)fecta (B)ioprosthesis (E)valuation versus (C)arpentier Magna-Ease in (A)ortic position.

OBJECTIVE: To determine whether the Trifecta bioprosthetic aortic valve produces postoperative haemodynamic results comparable with or better than those of the Magna Ease aortic valve bioprosthesis. METHODS: We retrospectively reviewed the medical records of patients who had undergone aortic valve replacement with Trifecta or Magna Ease prostheses at eight European institutions between January 2011 and May 2013, and analysed early postoperative haemodynamic performance by means of echocardiography. RESULTS: A total of 791 patients underwent aortic valve replacement (469 Magna Ease, 322 Trifecta). Haemodynamic variables were evaluated on discharge and during the follow-up (minimum 6 months, maximum 12 months). The mean gradient and the indexed effective orifice area (IEOA) were as follows: 10 mmHg [interquartile range (IQR): 8-13] and 1.10 cm(2)/m(2) (IQR: 0.95-1.27) for Trifecta; 16 mmHg (IQR: 11-22) and 0.96 cm(2)/m(2) (IQR: 0.77-1.13) for Magna Ease (P < 0.001). These significant differences were maintained across all valve sizes. Similar statistically significant differences were found when patients were matched and/or stratified for preoperative characteristics: body-surface area, ejection fraction, mean gradients and valve size. Severe prosthesis-patient mismatch (IEOA: <0.65 cm(2)/m(2)) was detected in 2 patients (0.6%) with Trifecta and 40 patients (8.5%) with Magna Ease (P < 0.001). CONCLUSIONS: The haemodynamic performance of the Trifecta bioprosthesis was superior to that of the Magna Ease valve across all conventional prosthesis sizes, with almost no incidence of severe patient-prosthesis mismatch. The long-term follow-up is needed to determine whether these significant haemodynamic differences will persist, and influence clinical outcomes.

A novel approach to ventricular rupture: clinical needs and surgical technique.

Cardiac rupture is a life-threatening event that often occurs after myocardial infarction and is often associated with significant death. Pericardiocentesis provides hemodynamic short-term improvement; however, patients with cardiac rupture require an emergency operation. This report describes a new procedure used to repair left ventricle free wall rupture after myocardial infarction. The technique described repairs the rupture off-pump and without the need for suturing. Midterm results demonstrate the feasibility and durability of this procedure.

Diagnosing left ventricular aneurysm from pseudo-aneurysm: a case report and a review in literature.

Rupture of the free wall of the left ventricle (LV) is a catastrophic complication occurring in 4% of patients after myocardial infarction (MI) and in 23% of those who die of MI. Rarely the rupture is contained by an adherent pericardium creating a pseudo-aneurysm. This clinical finding calls for emergency surgery. If no ruptures are detectable and myocardium wall integrity is confirmed, we are in the presence of a true aneurysm, which can be treated by means of elective surgery. Differentiation between these two pathologies remains difficult. We report the case of a patient with a true aneurysm, initially diagnosed as pseudo-aneurysm at our institution; we have reviewed the literature on this difficult diagnosis and outlined characteristic findings of each clinical entity.

Unexpected limited chronic dissection of the ascending aorta.

We report a rare case of a limited chronic dissection of the ascending aorta that was accidentally discovered at operation performed for severe aortic stenosis and moderate to severe dilatation of the ascending aorta. Preoperative investigations such as transoesophageal echocardiography and cardiac catheterization missed the diagnosis of dissection. Intraoperative findings included a 3.5 cm eccentric bulge of the ascending aorta and a 5 mm circular shaped intimal tear comunicating with a limited hematoma or small dissection of the media layer. (The rarety of the report is that the chronic dissection is limited to a small area (approximatively 3.5 x 2.5 cm) of the ascending aorta).

Mitral valve annuloplasty and myocardial revascularization in the treatment of ischemic dilated cardiomyopathy.

The aim of this study was to examine perioperative mortality and morbidity and midterm results in patients undergoing coronary bypass graft and mitral valve annuloplasty with advanced dilated cardiomyopathy. Sixty-one patients with ischemic dilated cardiomyopathy underwent coronary artery bypass grafting and mitral valve annuloplasty between January 1998 and December 2003. Patients eligible for revascularization that presented a mild or more severe mitral valve regurgitation at echocardiography (effective regurgitant orifice > 0.2 cm(2)) were considered for annuloplasty with a Cosgrove ring. New York Heart Association class (NYHA) III/IV was present in 40 patients (66%) and Canadian Cardiovascular Society class III-IV in 19 (31%). A previous acute myocardial infarction was reported in 48 patients (79%). The mean number of graft anastomoses was 2.5 +/- 0.7 and the left internal mammary artery was used in 49 patients (80%). In-hospital mortality was 4.9% (3 patients), due to unsuccessful weaning from cardiopulmonary bypass, multiple organ failure, and stroke, respectively. Left ventricle ejection fraction improved from 28.9% +/- 5.2% preoperatively to 35.4% +/- 8.1% at follow-up (P = 0.0001) and a significant reduction in NYHA III/IV was detected: from 40 patients preoperatively (66%) to 14 (31%) at follow-up (P = 0.031). Midterm cardiac-related mortality rate was 3.4%. In our experience combined coronary artery bypass grafting and ring annuloplasty for ischemic dilated cardiomyopathy can be performed with acceptable risks for in-hospital mortality and morbidity. Midterm results show a good survival rate and a durable functional improvement in this subset of patients.

Acute coronary syndromes without persistent st-segment elevation: advances in surgical revascularization.

Coronary artery bypass grafting (CABG) still plays a fundamental role in the management of acute coronary syndromes. The aim of this study is to report the experience of our center in the treatment of patients with acute coronary sindromes without persistent ST elevation urgently operated on with CABG, and to discuss surgical problems related. Two-hundred and six patients were urgently operated on for CABG for acute coronary syndromes without persistent ST-segment elevation from January 2001 to February 2003. The majority of them had three vessel coronary disease (72%) and left main stem disease occurred in 20% of the patients. Mean LVEF (left ventricular ejection fraction) was 54 +/- 12% whereas 9% of the patients had a LVEF < 40%. Twenty-one patients (10%) received glycoprotein IIb/IIIa receptor inhibitors and 35 (17%) received intravenous heparin therapy before surgery. Mean interval time between the onset of symptoms and surgery was 16 +/- 10 days (range 4-50). In-hospital mortality was 2% (4 patients). Perioperative AMI (acute myocardial infarction) occurred in 4% (8 patients) and a transient low cardiac output syndrome in 27 patients (13%). Bleeding requiring surgery occurred in 1% of the patients. Transient respiratory insufficiency was present in 12 patients (6%) and acute renal failure in 8 patients (4%). Mean I.C.U. time was 2.4 days (1-17). Urgent CABG for acute coronary syndromes shows a low risk for in-hospital mortality and morbidity. In acute patients arterial grafts are not detrimental for the outcome, but are recommended in the absence of contraindications to improve long-term results. In spite of recent developments in cardioplegic cardiac arrest, optimal myocardial protection against perioperative myocardial infarction still remains a challenge.