Background and Aim: Left Ventricular Pseudoaneurysm (LVPA) is a rare but disastrous complication of myocardial infarction. Urgent surgical repair is required to avoid catastrophic rupture and it’s is necessary in order to exclude the pseudoaneurysm to preserve the LV geometry and function. Beating heart repair can be successfully performed in specific patients. Methods: A 71-years old male patient with a history of systemic hypertension, cigarette smoking, hyoercholesterolemia, peripheral arterial disease, presented with a 48-hours progressive epigastric pain. The diagnosis of anterior STEMI was made and the patient was referred for early coronary angiography, which revealed an occlusion of the left anterior descending artery and a PTCA with a stent implantation was successfully performed. Two days later, the echocardiography showed an apical free wall defect, suspicious of a small LVPA. An MRI confirmed the diagnosis and the patient was admitted to cardiac surgery department. A beating heart repair of the LVPA was performed. A 2-0 Prolene purse-string suture was done at the apex of the left ventricle between the viable myocardium and the infarcted tissues. The exclusion of the pseudoaneurysm was performed using two suture lines (U-shaped single stitches and a continuous 2-0 Prolene suture reinforced by Teflon strips) with the apposition of a bovine pericardial patch. Results: Postoperative echocardiography showed the successful exclusion of the psudoaneurysm, confirmed by a one-month-post- intervention MRI. Conclusions: Beating heart repair of post-infarction left ventricular pseudoaneurysm is a new, feasible and simple approach and provides good short and middle-term results in selected patients.
Since its introduction in 1995, minimally invasive mitral valve surgery (MIMVS) has been shown to be a valid alternative to conventional sternotomy and several studies have reported excellent clinical outcomes. While MIMVS is now a commonly performed procedure, it is still difficult to standardize. We proprose here a "road to safer surgery", and offer some tips and tricks that could be useful in its learning and performance, and may help surgeons minimize the risk of major complications. With the introduction of 3D vision with a 3D videothoracoscope for 4K stereoscopic acquisition, a medical LCD ultra-HD monitor and active 3D glasses, it is possible to obtain a very realistic view of the surgical field and the mitral valve anatomy, while significantly reducing the learning curve. We describe the procedure step-by-step, with details from the pre-operative phase to the end of the operation. The procedure is structured in consecutive stages: patient induction and positioning, thoracoscopic access and port placement, surgical field exposure, and operative technique.
A 70-year-old male patient was admitted to the emergency room in cardiac arrest. The patient was resuscitated and then referred to our cardiac surgery department, where he was diagnosed with suspected effusive constrictive pericarditis. A failed trial of TEE-guided pericardiocentesis led to the decision of surgical intervention. Sternotomy was performed and revealed pericardial thickening and very dense adhesions involving the pericardium and both pleurae, suggesting a neoplastic disease. An extensive pericardiectomy and bilateral pleural decortication were performed. After surgery, the patient improved significantly and was discharged from the intensive care unit 24 h later. Pericardial thickening, dense adhesions, the amount and color of pericardial fluid and the aspect of epicardial tissue increased our suspicion of neoplastic disease. Histological samples were sent to be analyzed immediately; a few days later, they were unexpectedly negative for any neoplastic disease but showed a group-B-hemolytic Streptococcus agalactiae infection, which causes pericarditis in extremely rare cases. Postoperatively, the patient, under intravenous antibiotic and anti-inflammatory therapy, remained asymptomatic and was discharged ten days after the surgery. At the three-month follow-up, transthoracic echocardiography showed a normal right and left ventricular function with no pericardial effusion.
Background and Aim: Surgery of thoracic aortic emergencies is challenging and carries significant high morbidity and mortality rate. In the last decade, Thoracic EndoVascular Aortic Repair (TEVAR) has shown improved early and late outcome, mostly in emergency. To assess early and long-term results after TEVAR for thoracic aortic emergencies we retrospectively reviewed our experience. Methods: From March 2001 to March 2018, out of 289 patients undergone TEVAR, we retrospectively reviewed 191 patients, 164 (85.9%) men; aged from 19 to 84 years, treated in urgent/emergent conditions: 51 patients (26.7%) for contained or free rupture of degenerative aneurysms, 118 (61.8%) for complicated acute or chronic type B aortic dissections and 22 (11.5%) for traumatic aortic injuries. Results: The overall 30 days mortality was 4.4% (8 patients). Open surgical conversion was not required.. Periprocedural complications included arterial rupture or dissection (5.7%; 11 patients) and TIA/stroke (1.6%; 3 patients). Left subclavian artery (LSA) overstenting was achieved in 79 patients (41.3%). Follow-up ranged from 2 to 204 months and included clinical examinations and serial CT-scan. There were 8 late deaths aorta-related (4.4%). A secondary endovascular procedure was required in 13 pts (7.1%). One patient (0.5%), with retrograde aortic dissection, required open surgery. No patient with LSA overstenting required a secondary revascularization or showed subclavian steal phenomenon. Conclusions: The early and mid-term technical and clinical results supports the safety and effectiveness of thoracic endovascular surgery in patients with acute aortic syndromes too. More cases and longer follow-up are required.
A 70-year-old patient affected by a severe Sars-Cov-2 infection, was admitted in emergency to our department during the second Coronavirus disease 2019 outbreak with suspected descending thoracic aortic ruptured aneurysm.After 36 hours of hospitalization in a specific Covid-unit, following a new onset of chest pain, surgery became mandatory, despite the patient was affected by an active Coronavirus disease 2019 infection.While the indications and the choice of surgical technique for Coronavirus disease 2019 patients are defined by the guidelines, to date, the choice of the anesthetic approach to surgically treat Covid-positive patients still represents a challenge.
In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy.From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA2DS2-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months.Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%.In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.
Abstract Introduction Since the beginning of the actual pandemia, several patients with positive anamnesis for Covid 19, are undergoing a cardiac operation. Aim of the study is to analize if the Covid 19 past infection may impact on cardiac surgery outcome. Method All the patients with a history of Covid 19 positivity, who underwent a cardiac operation at the Clinica Mediterranea in Naples from the 1st of february 2021 to the 31st dicember 2021, have been included in the study. For those patients we evaluated the basal respiratory condition, with a chest Xray or CT scan, a pneumology consult and a spirometry if required. Postoperative outcome has been evaluated analizing ventilation time, intensive care and postoperative lenght of stay, acute renal failure, acute espiratory failure, postoperative complications and death. Results Thirtheen patients on 358 had a positive anamnesis for Covid19, but a negative swab at the admission. The mean time from the infection has been 5.1 +/– months, 5 patients have had poor or no symptoms, while the remnants moderate or sever ones with evidence of interstitial pneumonia, one patient had developed extrapulmonary complications (valvular thrombosis).
Background and Aim: Traumatic aortic rupture (TAR) leads to immediate death in 75 to 90% of cases. Conventional surgery for TAR still carries high risk of serious complications and mortality. Thoracic endovascular aortic repair (TEVAR) has emerged as a valid alternative compared with open surgery Methods: From March 2001 to March 2018, out of 289 patients undergone TEVAR, 26 patients (9.0%) were treated for a TAR after road accident. To assess the risk it was evaluated the Injury Severity Score (ISS) in patients with multiple injuries and the American Society of Anesthesiologist classification (ASA class) to describe the perioperative physical status. 15 patients (57.7%) showed an unstable clinical picture (ISS ≥ 40). Four patients (15.4 %) had a delayed TEVAR, the remaining 22 (84.6 %) required an urgent or emergency treatment within 12 and 48 hours. Results: There were no operative death or surgical conversion. Any neurological complication, including paraplegia, was observed. One patients died after 48 hours for intracranial associated lesions. One vascular complication occurred requiring a rescue prosthetic ileofemoral bypass. Eleven patients (42.3%) required prolonged mechanical ventilation and two (7.7%) undergone CRRT. At follow-up (6–204 months), only one patient showed a late Type I endoleak, requiring a secondary TEVAR. Conclusions: TEVAR is a safe procedure in TAR patients, especially in unstable/emergent conditions. Moreover, TEVAR allows for prompt treatment of associated lesions in complex multitrauma patients. Most frequently the associated lesions especially of intracranial or intraabdominal organs became prognostically predictive of postoperative outcome.
Background: Reports of minimal invasive aortic arch surgery are scarce. We reviewed our experience with minimal access aortic arch surgery performed through an upper mini-sternotomy, with emphasis on details of operative technique and early and mid-term outcomes. Methods: The medical records of 123 adult patients (mean age 66 ± 12 years), who underwent primary elective minimal access aortic arch surgery in two aortic referral centers, were reviewed. The most common indication was degenerative aortic arch aneurysm in 92 (75%) patients. Standard operative and organ protection techniques used in all patients were upper mini-sternotomy, uninterrupted antegrade cerebral perfusion, and moderate systemic hypothermia (27.4 ± 1°C). Results: Sixty-eight (55%) patients received partial aortic arch replacement; the remaining 55 (45%) patients received total arch replacement, further extended with either a frozen elephant trunk in 43 (35%) patients or a conventional elephant trunk procedure in nine (7%) patients. No conversion to full sternotomy was required. New permanent renal failure occurred in one (0.8%) patient, stroke in two (1.6%), and spinal cord injury in four (3.3%) patients. Early mortality was observed in four (3.3%) patients. At five years, survival was 80 ± 6% and freedom from reoperation was 96 ± 3%. Conclusion: Minimal invasive aortic arch repair through an upper mini-sternotomy can be safely performed, with early and mid-term outcomes well comparable to series performed through a standard median sternotomy.
