Quadricuspid aortic valve repair with a modified-tricuspidization technique

INTRODUCTION: Quadricuspid aortic valve (QAV) is an extremely rare developmental abnormality with an incidence of 0.006%. QAV is an incidental finding that in some patients (23%) may determine aortic regurgitation (AR). Altogether 16% of patients indeed require surgery with AR being the most frequent indication. METHODS AND RESULTS: We describe a case report of a 46 year‐old female affected by severe aortic regurgitation due to QAV successfully treated with a  modified‐tricuspidization technique associated with cusp extension, prolapsing commissure suturing, and sub‐commissural annuloplasty. DISCUSSION: QAV repair represents an attractive perspective to overcome the drawbacks of either mechanical or biological prosthesis

Doppler Ultrasound Selection and Follow-Up of the Internal Mammary Artery as Coronary Graft

The impact of coronary artery disease (CAD) on all-cause mortality and overall disabilities is well-established. Percutaneous and/or surgical coronary revascularization procedures dramatically reduced the occurrence of adverse cardiovascular events in patients suffering from atherosclerosis. Specifically, guidelines from the European Society of Cardiology on the management of myocardial revascularization promoted coronary artery by-pass graft (CABG) intervention in patients with specific alterations in the coronary tree due to the higher beneficial effects of this procedure as compared to the percutaneous one. The left internal mammary artery (LIMA) is one of the best-performing vessels in CABG procedures due to its location and its own structural characteristics. Nevertheless, the non-invasive assessment of its patency is challenging. Doppler ultrasonography (DU) might perform as a reliable technique for the non-invasive evaluation of the patency of LIMA. Data from the literature revealed that DU may detect severe (>70%) stenosis of the LIMA graft. In this case, pulsed-wave Doppler might show peak diastolic velocity/peak systolic velocity < 0.5 and diastolic fraction < 50%. A stress test might also be adopted for the evaluation of patency of LIMA through DU. The aim of this narrative review is to evaluate the impact of DU on the evaluation of the patency of LIMA graft in patients who undergo follow-up after CABG intervention

ENDOCARDITE INFETTIVA ED EMBOLIZZAZIONE SETTICA: OTTIMIZZAZIONE DEL PERCORSO DIAGNOSTICO E TERAPEUTICO

OBIETTIVI La mortalità nei pazienti affetti da endocardite infettiva (EI) è tutt’oggi ancora elevata (20%), essendo le cause di morte non solo strettamente cardiache, ma anche dovute frequentemente allo stato settico ed all’interessamento multi-organo per i possibili fenomeni embolici associati. Quest’ultima evenienza in letteratura supera il 40%. Peraltro le attuali linee guida inoltre non forniscono raccomandazioni per uno screening sistematico di embolia settica. Inoltre la frequente embolizzazione a livello della milza, con evoluzione in infarto semplice o in ascesso splenico, mentre comporta terapia conservativa nel primo caso, prevede la splenectomia nella forma ascessuale a causa dell’alta incidenza in questi casi di rottura della milza e di setticemia diffusa. La diagnosi differenziale delle due forme rimane tuttavia ancora oggi difficile. Scopo principale dello studio è stato quello di individuare l'incidenza di embolizzazione splenica nella EI; ulteriori obiettivi sono stati quello di differenziare l'infarto dall'ascesso splenico con le più attuali tecniche diagnostiche, ed infine determinare momento e condotta ottimali della terapia chirurgica combinata. METODI Sono stati studiati 55 pazienti operati consecutivamente nel nostro centro per EI dal gennaio 2011 al marzo 2014. E’ stata eseguita in tutti i casi TAC total-body che dimostrava embolizzazione splenica in 22 pazienti; questi ultimi sono stati sottoposti ad eco-contrastografia ad alta definizione della milza. Tale esame evidenziava la presenza di ascesso in 15 pazienti nei quali è stata eseguita la splenectomia, mentre nei restanti 7, nei quali l’esame dimostrava infarto semplice, la milza non è stata rimossa. La splenectomia è stata eseguita sempre nella stessa seduta operatoria, subito dopo l'intervento cardiochirurgico. Nello studio sono stati considerati due gruppi: 1°) pazienti sottoposti a chirurgia cardiaca isolata (40 pazienti), e 2°) pazienti sottoposti ad intervento combinato cardiaco e splenectomia (15 pazienti). E' stato eseguito follow-up telefonico. RISULTATI L'esecuzione sistematica da noi adottata della TAC total-body ha documentato un'incidenza di embolia della milza (39%) sovrapponibile a quella presente in letteratura. Peraltro, l'uso sistematico della contrasto-ecografia ad alta definizione in pazienti con embolizzazione splenica ha documentato un'incidenza di ascesso splenico molto più alta nel nostro studio (27,3%), rispetto a quella riscontrata in letteratura (5%). Le caratteristiche pre-, peri- e post-operatorie sono state sovrapponibili a quelle della letteratura. Mortalità ospedaliera, degenza in terapia intensiva e degenza totale del soggiorno in ospedale non hanno mostrato differenze significative tra i due gruppi. La degenza non ha mai superato i 30 giorni. Abbiamo riscontrato tre decessi nel follow-up. CONCLUSIONI L'alta incidenza di embolizzazione in corso di EI rende obbligatoria una ricerca sistematica di questa eventualità mediante TAC total-body. In caso di embolizzazione splenica l’eco-contrastografia ad alta definizione è molto utile per la diagnosi differenziale tra infarto ed ascesso splenico e quindi per porre in tal caso indicazione alla rimozione della milza. La simultaneità delle due procedure, cardiochirurgica e splenectomia, non comporta differenze significative nella mortalità e morbilità rispetto all'intervento isolato di chirurgia cardiaca

The Prognostic Impact of Estimated Creatinine Clearance by Bioelectrical Impedance Analysis in Heart Failure: Comparison of Different eGFR Formulas

The estimation of glomerular filtration rate (eGFR) provides prognostic information in patients with heart failure (HF). Bioelectrical impedance analysis may calculate eGFR (Donadio formula). The aim of this study was to evaluate the impact of the Donadio formula in predicting all-cause mortality in patients with HF as compared to Cockroft-Gault, MDRD-4 (Modification of Diet in renal Disease Study), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. Four-hundred thirty-six subjects with HF (52% men; mean age 75 ± 11 years; 42% acute HF) were enrolled. Ninety-two patients (21%) died during the follow-up (median 463 days, IQR 287–669). The area under the receiver operator characteristic curve for eGFR, as estimated by Cockroft-Gault formula (AUC = 0.75), was significantly higher than those derived from Donadio (AUC = 0.72), MDRD-4 (AUC = 0.68), and CKD-EPI (AUC = 0.71) formulas. At multivariate analysis, all eGFR formulas were independent predictors of death; 1 mL/min/1.73 m2 increase in eGFR—as measured by Cockroft-Gault, Donadio, MDRD-4, and CKD-EPI formulas—provided a 2.6%, 1.5%, 1.2%, and 1.6% increase, respectively, in mortality rate. Conclusions. eGFR, as calculated with the Donadio formula, was an independent predictor of mortality in patients with HF as well as the measurements derived from MDRD4 and CKD-EPI formulas, but less accurate than Cockroft-Gault

Acute kidney injury in high-risk cardiac surgery patients: roles of inflammation and coagulation

Acute kidney injury (AKI) is a common complication following cardiac surgery. Cardiopulmonary bypass elicits coagulation and inflammation activation and oxidative stress, all involved in AKI but never simultaneously assessed. We aimed to evaluate relations between oxidative stress, inflammatory and coagulation systems activation and postoperative renal function in patients with normal preoperative renal function

The Impairment in Kidney Function in the Oral Anticoagulation Era. A Pathophysiological Insight

The need for anticoagulation in patients with atrial fibrillation (AF) is fundamental to prevent thromboembolic events. Direct oral anticoagulants (DOACs) recently demonstrated to be superior, or at least equal, to Warfarin in reducing the risk for stroke/systemic embolism and preventing major bleeding and intracranial hemorrhages. The AF population often suffers from chronic kidney disease (CKD). Indeed, the relationship between AF and renal function is bidirectional: AF can trigger kidney failure, while kidney impairment can promote alterations able to enhance AF. Therefore, there are concerns regarding prescriptions of anticoagulants to patients with AF and CKD. The worsening in kidney function can be effectively due to anticoagulants administration. Warfarin has been recognized to promote acute kidney injury in case of excessive anticoagulation levels. Nevertheless, further mechanisms can induce the chronic worsening of renal function, thus leading to terminal kidney failure as observed in post-hoc analysis from registration trials and dedicated observational studies. By contrast, DOACs seem to protect kidneys from injuries more efficiently than Warfarin, although they still continue to play a role in promoting some kidney lesions. However, the exact mechanisms remain unknown. This narrative review aimed to discuss the influence of oral anticoagulants on renal impairment as well as to overview potential pathophysiological mechanisms related to this clinical complication

Hybrid three-stage repair of mega aorta with Lupiae technique: Tips and tricks

Mega aorta syndrome (MAS) poses a complex clinical challenge: the involvement of the ascending aorta, aortic arch, descending thoracic and abdominal aorta with extension below the origin of renal arteries requires almost total replacement of the aorta. The modality of treatment remains still controversial. Different aortic debranching techniques have been developed to re-route the origin of epiaortic and visceral vessels and achieve an optimal landing zone for implantation of subsequent endovascular grafts. We illustrate the Lupiae technique as a further evolution of the aortic debranching and hybrid repair of a mega aorta. It was developed with the purpose to exclude a very long segment of diseased aorta by implanting two or more endoprostheses between two surgically-generated landing zones. We describe a series of 27 patients treated by this hybrid three-stage mega-aorta repair; the tips and tricks discussed here facilitate a safe and effective procedure, enable treatment of frail patients and help to avoid life-threatening complications

Respiratory failure and bioelectrical phase angle are independent predictors for long-term survival in acute heart failure

Background. The assessment of long-term mortality in acute decompensated heart failure (ADHF) is challenging. Respiratory failure and congestion play a fundamental role in risk stratification of ADHF patients. The aim of this study was to investigate the impact of arterial blood gases (ABG) and congestion on long-term mortality in patients with ADHF. Methods and results. We enrolled 252 patients with ADHF. Brain natriuretic peptide (BNP), blood urea nitrogen (BUN), phase angle as assessed by means of bioimpedance vector analysis, and ABG analysis were collected at admission. The endpoint was all-cause mortality. At a median follow-up of 447&nbsp;d (interquartile range [IQR]: 248–667), 72 patients died 1–840&nbsp;d (median 106, IQR: 29–233) after discharge. Respiratory failure types I and II were observed in 78 (19%) and 53 (20%) patients, respectively. The ROC analyses revealed that the cut-off points for predicting death were: BNP &gt; 441 pg/mL, BUN &gt; 1.67 mmol/L, partial pressure in oxygen (PaO2) ≤69.7 mmHg, and phase angle ≤4.9°. Taken together, these four variables proved to be good predictors for long-term mortality in ADHF (area under the curve [AUC] 0.78, 95% CI 0.72–0.78), thus explaining 60% of all deaths. A multiparametric score based on these variables was determined: each single-unit increase promoted a 2.2-fold augmentation of the risk for death (hazard ratio [HR] 2.2, 95% CI 1.8–2.8, p&lt;&nbsp;.0001). Conclusions. A multiparametric approach based on measurements of BNP, BUN, PaO2, and phase angle is a reliable approach for long-term prediction of mortality risk in patients with ADHF

Sex Differences in the Evaluation of Congestion Markers in Patients with Acute Heart Failure

The impact of sex on the assessment of congestion in acute heart failure (AHF) is still a matter of debate. The objective of this analysis was to evaluate sex differences in the evaluation of congestion at admission in patients hospitalized for AHF. We consecutively enrolled 494 AHF patients (252 female). Clinical congestion assessment, B-type natriuretic peptide levels analysis, blood urea nitrogen to creatinine ratio (BUN/Cr), plasma volume status estimate (by means of Duarte or Kaplam-Hakim PVS), and hydration status evaluation through bioimpedance analysis were performed. There was no difference in medications between men and women. Women were older (79 &plusmn; 9 yrs vs. 77 &plusmn; 10 yrs, p = 0.005), and had higher left ventricular ejection fraction (45 &plusmn; 11% vs. 38 &plusmn; 11%, p &lt; 0.001), and lower creatinine clearance (42 &plusmn; 25 mL/min vs. 47 &plusmn; 26 mL/min, p = 0.04). The prevalence of peripheral oedema, orthopnoea, and jugular venous distention were not significantly different between women and men. BUN/Cr (27 &plusmn; 9 vs. 23 &plusmn; 13, p = 0.04) and plasma volume were higher in women than men (Duarte PVS: 6.0 &plusmn; 1.5 dL/g vs. 5.1 &plusmn; 1.5 dL/g, p &lt; 0.001; Kaplam&ndash;Hakim PVS: 7.9 &plusmn; 13% vs. &minus;7.3 &plusmn; 12%, p &lt; 0.001). At multivariate logistic regression analysis, female sex was independently associated with BUN/Cr and PVS. Female sex was independently associated with subclinical biomarkers of congestion such as BUN/Cr and PVS in patients with AHF. A sex-guided approach to the correct evaluation of patients with AHF might become the cornerstone for the correct management of these patients