Successful surgical employment of Impella recovery system for right ventricular failure after previous aortic valve replacement.

A 58-year-old woman underwent aortic valve replacement. On the second postoperative day the patient referred a sharply chest pain, and an emergent coronary angiography revealed total occlusion of the right coronary artery. An intra-aortic ballon pump was placed and the patient underwent emergent off-pump coronary revascularization of the right coronary artery. Five hours later, due to unstable hemodynamic the extracorporeal membrane oxygenation was implanted without improvement of the right ventricular (RV) function. Then we decided to implant the Impella Right Direct (RD). After 9 days of Impella's insertion the RV was recovered and the device was successfully explanted. After 16 days of Impella explanted the patient was discharged. This case suggest that implantation of Impella RD is clinically feasible, associated with hemodynamic improvement, and facilitate successful bridge-to-recovery in patients with post-cardiotomy RV failure due to myocardial infarction unresponsive to coronary artery bypass grafting, maximal medical therapy, contrapulsation and extracorporeal membrane oxygenation.

Papillary fibroelastoma of an anomalous mitral valve chorda.

Cardiac papillary fibroelastoma (CPF) is a rare primary cardiac tumour. This tumour constitutes about 10-15% of all primary cardiac tumours. We report here a case of CPF of an anomalous mitral valve chorda.

Postendocarditis mitral valve aneurysm.

Mitral valve aneurysm is defined as a localized, thin-walled, saccular bulge of the mitral leaflet toward the left atrium. In this study, we report a case of mitral aneurysm of the posterior leaflet (scallop P3) secondary to primary mitral endocarditis in a patient who underwent prosthetic aortic valve replacement and coronary artery bypass graft.

A rare case of anterior chest closure only with omental flap after devastating mediastinitis: case report.

We describe a case of 73-year-old patient who has been operated in emergency on triple coronary artery bypass graft (CABG), which was complicated with respiratory insufficiency and devastating mediastinitis. The anterior mediastinum was closed with an omental flap that was allowed to epithelize spontaneously. The patient was discharged after 110 days. Despite the large number of cases with mediastinitis described in the literature, the chest closure with only an omental flap without closure of subcutaneous tissue and skin is rare.

Safe wrapping of the borderline dilated ascending aorta during aortic valve replacement.

BACKGROUND: Techniques of reduction aortoplasty are widely published in the literature with conflicting results. External support seems to be an important factor in preventing recurrence but, in some cases, this technique caused erosion of the aorta because of the wrinkles the prosthesis creates in the rear side of the aorta. CASE PRESENTATION: A 73 year old patient with aortic valve stenosis and borderline dilated ascending aorta had aortic valve replacement and simple wrapping without aortoplasty. To avoid the formation of wrinkles, the dacron external support was tailored appropriately to obtain a curved, custom-made prosthesis. This custom-made prosthesis had the same diameter as the dilated aorta and, after valve replacement, fitted it properly. After 18 months neither computerized axial tomography nor ecocardiography detected wrinkles or dilatation recurrence. CONCLUSION: A safe, simple and probably new way to prepare an external wrapping is presented, which in this patient respected the shape of the aorta and prevented the formation of wrinkles in the prosthesis and possible complications such as wall erosion.

Left ventricle remodelling by double-patch sandwich technique.

BACKGROUND: The sandwich double-patch technique was adopted as an alternative method for reconstruction of the left ventricle after excision of postinfarction dysfunctional myocardium to solve technical problems due to the thick edges of the ventricular wall. METHODS: Over a 5-year period, 12 of 21 patients with postinfarction antero-apical left ventricular aneurysm had thick wall edges after wall excision. It was due to akinetic muscular thick tissue in 6 cases, while in the other 6 with classic fibrous aneurysm, thick edges remained after the cut of the border zone. The ventricular opening was sandwiched between two patches and this is a technique which is currently used for the treatment of the interventricular septum rupture. In our patients the patches are much smaller than the removed aneurysm and they were sutured simply by a single row of single stitches. However, in contrast to interventricular septum rupture where the patches loosen the tension of the tissues, in our patients the patches pull strongly and restrain the walls by fastening their edges and supporting tight stitches. In this way they could narrow the cavity and close the ventricle. RESULTS: The resected area varied from 5 x 4 to 8 x 8 cm. Excision was extended into the interventricular septum in 5 patients, thus opening the right ventricle. CABG was performed on all patients but two. Left ventricular volumes and the ejection fraction changed significantly: end-systolic volume 93.5 +/- 12.4 to 57.8 +/- 8.9 ml, p < 0.001; end-diastolic volume 157.2 +/- 16.7 to 115.3 +/- 14.9 ml, p < 0.001; ejection fraction 40.3 +/- 4.2 to 49.5 +/- 5.7%, p < 0.001. All patients did well. One patient suffered from bleeding, which was not from the wall suture, and another had a left arm paresis. The post-operative hospital stay was 5 to 30 days with a mean 10.5 +/- 7.5 days/patient. At follow-up, 9 to 60 months mean 34, all patients were symptom-free. NYHA class 2.5 +/- 0.8 changed to 1.2 +/- 0.4, p < 0.001. CONCLUSION: The double-patch sandwich technique (bi-patch closure) offers some advantages and does not result in increased morbidity and mortality. In the case of excising a left ventricular aneurysm, this technique in no way requires eversion of the edges, felt strips, buttressed and multiple sutures, all of which are needed for longitudinal linear closure. Moreover, it does not require purse string sutures, endocardial scar remnant to secure the patch or folding the excluded non-functional tissue, all of which are needed for endoventricular patch repair.

[Cardiac surgery in octogenarians: a five-year experience]. / La cardiochirurgia nell'ultraottantenne: cinque anni di esperienza.

BACKGROUND: Cardiac surgery in octogenarians is increasing in industrialized countries and therefore represents a growing population. The aim of this study was to evaluate characteristics and outcomes of octogenarian patients undergoing cardiac surgery. METHODS: We reviewed all consecutive octogenarians operated on during the last 5 years. Among 1912 patients operated on between April 2000 and December 2004, we identified 223 patients (11.6%) aged > 80 years. Median age was 82.17 +/- 2.11 years, and 52.5% were males. The mean EuroSCORE score was 9.4 +/- 1.8. Among them 43 patients (19.3%) had isolated aortic valve replacement, 127 patients (57%) had isolated coronary artery bypass graft, 40 patients (17.9%) had aortic valve replacement combined with coronary artery bypass graft, 11 patients (4.9%) had mitral valve repair, and 2 patients (0.9%) had ventricular septal rupture repair. RESULTS: The overall hospital mortality was 5.4%; cumulative actuarial survival at 4 years was 77.6%. CONCLUSIONS: We conclude that for unselected octogenarians the operative mortality is acceptable and only slightly increased than in younger age groups; the late survival rate is good.

Transatrial approach of acquired posterior ventricular septal rupture and double orifice technique in tricuspid valve repair.

We present a successful transatrial repair of ventricular septal rupture and tricuspid valve reconstruction, using the "edge-to-edge" technique, as a serious complication of a posterior myocardial infarction in an 83-year-old woman.