Left atrial fibrosis: an essential hallmark in chronic mitral regurgitation

Abstract Chronic mitral regurgitation (MR) is the second valvular heart disease for incidence, which worsening severity gradually affects all cardiac chambers and leads to poor outcome if untreated. The recent development of minimally invasive surgical techniques and percutaneous intervention has reduced the operative risk, allowing a more confident referral of these patients for intervention. Therefore, there is a growing need of reliable markers to select the best therapeutic strategies and to identify the optimal timing for intervention. Myocardial fibrosis (MF) gradually occurs as a result of left atrial and ventricular (LA and LV) remodeling due to MR pressure and volume overload. It has been identified as an index of clinical outcome and arrhythmic risk in patients with MR. Particularly, the assessment of LA fibrosis not only allows to define different MR etiology, but also was associated with prognosis and atrial fibrillation (AF) burden. Nowadays, noninvasive estimation of MF is possible through the use of advanced imaging modalities, particularly cardiac magnetic resonance and speckle tracking echocardiography. This review discusses the role of LA fibrosis as a diagnostic and prognostic marker in patients with MR and its quantification by noninvasive multimodality cardiac imaging

Surgical Risk Factors for Ischemic Stroke Following Coronary Artery Bypass Grafting. A Multi-Factor Multimodel Analysis

Background: Ischemic stroke after coronary artery bypass (CABG) has been often linked to aortic manipulation during surgery. Objectives: The objective of the study was to estimate the rate of postoperative ischemic stroke within 30 days from CABG by surgical risk factors alone or in combination. Methods: The multinomial propensity score for multiple treatments was used to create six models with a total of 16,255 consecutive patients undergoing isolated CABG. For each model, a different classification variable was used to stratify patients. Results: Balance achieved in all models was substantial, enabling unbiased estimation of the treatment estimand. Both off-pump techniques with (0.009; 95% CI 0.006–0.011) or without proximal anastomoses (0.005; 0.005–0.003), and surgery performed on the beating heart using cardiopulmonary bypass with (0.009; 0.006–0.011) or without proximal anastomoses (0.024; 0.021–0.029) showed a mean stroke estimate significantly lower than the other techniques. Off-pump surgery and on-pump surgery without an aortic cross-clamp yielded nearly equal incidences of stroke (0.012; 0.008–0.015 and 0.018; 0.012–0.023, respectively). Using an aortic cross-clamp significantly increased the stroke estimate (0.075; 0.061–0.088), whereas using a side-biting clamp did not (0.039; 0.033–0.044). The number of aortic touches (0.029; 0.026–0.031) and the number of proximal anastomoses (0.044; 0.035–0.047) did not significantly increase the incidence of stroke. Conclusions: Aortic cross-clamping was found to be the primary cause of post-CABG ischemic stroke. Instead, additional aortic manipulation from a side-biting clamp, on-pump surgery, multiple aortic touches, number of proximal anastomoses, and aortic cannulation were found not to increase the estimate of stroke significantly. Further research on this topic is warranted

A multidisciplinary approach for the emergency care of patients with left ventricular assist devices: A practical guide

The use of a left ventricular assist device (LVAD) as a bridge-to-transplantation or destination therapy to support cardiac function in patients with end-stage heart failure (HF) is increasing in all developed countries. However, the expertise needed to implant and manage patients referred for LVAD treatment is limited to a few reference centers, which are often located far from the patient's home. Although patients undergoing LVAD implantation should be permanently referred to the LVAD center for the management and follow-up of the device also after implantation, they would refer to the local healthcare service for routine assistance and urgent health issues related to the device or generic devices. Therefore, every clinician, from a bigger to a smaller center, should be prepared to manage LVAD carriers and the possible risks associated with LVAD management. Particularly, emergency treatment of patients with LVAD differs slightly from conventional emergency protocols and requires specific knowledge and a multidisciplinary approach to avoid ineffective treatment or dangerous consequences. This review aims to provide a standard protocol for managing emergency and urgency in patients with LVAD, elucidating the role of each healthcare professional and emphasizing the importance of collaboration between the emergency department, in-hospital ward, and LVAD reference center, as well as algorithms designed to ensure timely, adequate, and effective treatment to patients with LVAD. Copyright © 2022 Cameli, Pastore, Mandoli, Landra, Lisi, Cavigli, D'Ascenzi, Focardi, Carrucola, Dokollari, Bisleri, Tsioulpas, Bernazzali, Maccherini and Valente

Surgical Outcomes of Three Repair Techniques for Partial Anomalous Pulmonary Venous Connection in Adult Patients

Objectives: To investigate primary and secondary surgical outcomes following transcaval repair (TCR), modified Warden repair, and transatrial repair techniques for partial anomalous pulmonary venous connections (PAPVCs) and sinus venosus atrial septal defects (ASDs). Methods: This is an observational cohort clinical study. Patients who underwent TCR, modified Warden repair, and transatrial surgical repair for PAPVC and ASD between January 2003 and October 2019 at our institution were included in the study. Patients had one of the surgical procedures based on the anatomy of the defect. Results: Ten patients, seven (70%) males and three (30%) females, were included in the analysis. Seven patients underwent TCR, two patients the modified Warden technique, and one patient underwent transatrial surgical repair. Mean age was 57 years ± 14.7. Mean EuroScore II was 3.4 ± 3.5. The baseline left ventricle ejection fraction was 45 ± 6.5%. No patient had previous stroke, pacemaker (PM) implantation, or myocardial infarction. Total cardiopulmonary bypass and cross-clamping time were 123 ± 72.5 and 100 ± 48.5 min, respectively. Mean mechanical ventilation, mean intensive care unit, and mean hospital length of stay for the transcaval, modified Warden, and transatrial groups were 4.6 ± 10.7, 5.7 ± 8.8, and 10.5 ± 9.2 days, respectively. Superior caval or pulmonary venous obstruction, sinus node dysfunction, and PM implantation were not present at follow-up. The patient who underwent transatrial repair had died at 5.5-year follow-up due to myocardial infarction. Total survival rate at 6 years was 90%. Conclusions: The findings from this study elicit that all three techniques have low postoperative morbidity and are feasible and reliable procedures

A Challenging Diagnosis of Unroofed Coronary Sinus, Myxoma and Left Atrial Aneurysm

An unroofed coronary sinus is a malformation that leads to a shunt between the coronary sinus and the left atrium. In our case, the shunt led to the formation of a gigantic left atrial aneurysm compressing the left atrium on transesophageal echocardiography. During surgery, a myxoma was incidentally discovered

A Challenging Diagnosis of Unroofed Coronary Sinus, Myxoma and Left Atrial Aneurysm

An unroofed coronary sinus is a malformation that leads to a shunt between the coronary sinus and the left atrium. In our case, the shunt led to the formation of a gigantic left atrial aneurysm compressing the left atrium on transesophageal echocardiography. During surgery, a myxoma was incidentally discovered