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Adrenal incidentalomas (AI) are discovered after work-up unrelated to adrenal gland diseases; up to 30% of AI show subclinical endogenous cortisol excess (SH), frequently associated to hypertension, obesity, metabolic disorders and increased incidence of cardiovascular events (CVEs). We analysed 628 AI patients divided into two groups: 471 non-functional adrenal adenoma (NFA) and 157 SH. All patients underwent complete examinations, 24-h ambulatory blood pressure monitoring, biohumoral parameters and vascular damage markers, such as c-IMT and ankle brachial index. After long-term follow-up, we registered newly onset of CVEs such as myocardial infarction (MI), percutaneous stenting and surgical bypass (PTA/CABG), stroke, overall/cardiovascular mortality. Moreover, SH patients underwent to surgical (SSH) or pharmacological treatment (MSH). SH patients showed higher prevalence of metabolic syndrome, diabetes mellitus, and previous CVEs respect NFA at baseline. After follow-up MSH group showed higher recurrence of major CV events compared with NFA and SSH (RR 2.27 MSH vs NFA for MI; RR 2.30 MSH vs NFA for PTA/CABG; RR 2.41 MSH vs NFA for stroke). In SSH there was a significant reduction of the number of antihypertensive medications needed to reach target blood pressure levels (2.3 ± 1.0 to 1.5 ± 0.4 drugs). None differences were found in SH patients, distinguished in relation to cortisol plasma levels after dexamethasone suppression test (1.8–5 µg/dL, above 5 µg/dL). SH is linked to relevant cardiovascular and metabolic alterations, leading to worsen clinical outcomes. In eligible patients, adrenalectomy is valid and safe option to treat SH, reducing cardiometabolic abnormalities.

INTORDUCTION Aldosterone is known to play important role in developing cardiovascular, metabolic, renal damage in hypertensive patients. AIM Aim of study was to evaluate parameters obtained by eco-color Doppler study, as non-invasive and easly performed method in asyntomatic patients with Essential Hypertension (EH) and Primary Aldosteronism (PA), without overt organ damage. METHODS From April 2019 to March 2020 we consecutively enrolled 73 hypertensive subjects (48 males, 25 women), distinguished in two groups: 30 EH patients (mean age 49.5 ± 18.7 years) and 43 PA patients (mean age 53.1 ± 11.6 years)] [23 with aldosterone-secreting adrenal adenoma (APA), 20 with idiopathic aldosteronism (IHA)]. RESULTS PA group showed higher renal filtration rate and 24-h urinary excretion of albumin respect to EH; moreover, in PA we found higher Pulsatility Index, altered percentage of Renale Resistance Index, Atrophy Index, and reducted parietal thickness than EH. The correlation study showed that plasma aldosterone were positively correlated with pulsatility index in PA group (right r = 0.35; p < 0.05; left r = 0.36; p < 0.05). CONCLUSION parameters obtained through the intra-renal eco-color Doppler examination, easly performed and non-invasive, can be useful in the early-stage identification of subclinical microvascular alterations, especially in PA, condition characterized by increased risk of cardio-vascular remodelling and metabolic alterations.

No studies have carried out an extensive analysis of the possible association between non-syndromic pheochromocytomas and paragangliomas (PPGLs) and other malignancies. To assess the risk of additional malignancy in PPGL, we retrospectively evaluated 741 patients with PPGLs followed-up in twelve referral centers in Italy. Incidence of second malignant tumors was compared between this cohort and Italian patients with two subsequent malignancies. Among our patients, 95 (12.8%) developed a second malignant tumor, which were mainly prostate, colorectal and lung/bronchial cancers in males, breast cancer, differentiated thyroid cancer and melanoma in females. The standardized incidence ratio was 9.59 (95% CI 5.46–15.71) in males and 13.21 (95% CI 7.52–21.63) in females. At multivariable analysis, the risk of developing a second malignant tumor increased with age at diagnosis (HR 2.50, 95% CI 1.15–5.44, p = 0.021 for 50–59 vs. &lt, 50-year category, HR 3.46, 95% CI 1.67–7.15, p &lt, 0.001 for &gt, 60- vs. &lt, 50-year). In patients with available genetic evaluation, a positive genetic test was inversely associated with the risk of developing a second tumor (HR 0.25, 95% CI 0.10–0.63, p = 0.003). In conclusion, PPGLs patients have higher incidence of additional malignant tumors compared to the general population who had a first malignancy, which could have an impact on the surveillance strategy.

AIMS Sutureless valves became an alternative to standard bioprostheses, allowing surgeons to significantly reduce cross-clamping and extracorporeal circulation times, with a potential positive impact on major postoperative complications. The aim of this European multicentre study was to evaluate the safety and efficacy of sutureless valves in patients with an intermediate-risk profile undergoing aortic valve replacement (AVR). METHODS We investigated early and mid-term outcomes of 518 elderly patients with aortic stenosis at intermediate-risk profile (mean STS Score 6.1 ± 2%) undergoing AVR with sutureless aortic valve. Primary endpoints were 30-day mortality and freedom from all-cause death at follow-up. The secondary endpoint was survival freedom from MACCEs [all-cause death, stroke/transitory ischemic attack (TIA), bleeding, myocardial infarction, aortic regurgitation Grade II, endocarditis, reintervention and pacemaker implant; VARC 1--2 criteria]. RESULTS Sutureless valve implantation was successfully performed in 508 patients, with a procedural success rate of 98.1% (508/518) as per VARC criteria. Concomitant myocardial revascularization [coronary artery bypass grafting (CABG)] was performed in 74 out of 518 patients (14.3%). In-hospital mortality was 1.9% (10/518). Postoperative complications included revision for bleeding (23/518; 4.4%), prolonged intubation more than 48h (4/518; 0.7%), acute renal failure (14/518; 2.7%), stroke/TIA (11/518; 2.1%), pacemaker implantation (26/518; 5.1%) and aortic regurgitation more than Grade II (7/518; 1.4%). At 48-month follow-up, Kaplan-Meier overall survival and freedom from MACCEs in patients receiving isolated AVR were 83.7% [95% confidence interval (95% CI): 81.1-86.3] and 78.4% (95% CI: 75.5-81.4), respectively, while in patients with concomitant CABG, Kaplan-Meier overall survival and freedom from MACCEs were 82.3% (95% CI: 73.3-91.3) and 79.1% (95% CI: 69.9-88.3), respectively. CONCLUSION The use of sutureless aortic valves in elderly patients with an intermediate-risk profile provided excellent early and mid-term outcomes, providing a reliable tool in patients undergoing surgical AVR in this specific subset of population. These preliminary data need to be investigated with a TAVI control-group in further studies.

Background: Arterial hypertension is associated with obstructive sleep apnoea, poor quality and duration of sleep, which might contribute to hypertension-mediated organ damage. Methods: We investigated the presence of insomnia, restless legs syndrome, and obstructive sleep apnoea using validated questionnaires (Insomnia Severity Index, Restless Legs Syndrome Rating Scale, and STOP-Bang), and their relationship with hypertension-mediated organ damage, in hypertensive patients. Results: In 159 consecutive consenting hypertensive patients [age 47(11) years, median and (interquartile range), body mass index 25.5(5.9) kg/m 2 , office systolic and diastolic blood pressure 144(23)/92(12) mmHg], the STOP-Bang, but not the other scores, predicted cardiac remodelling: compared to patients with a STOP-Bang score < 3, those at high risk of obstructive sleep apnoea showed higher left ventricular mass index [49.8(11.9) vs. 43.3(11.9) g/m 2.7 , p < 0.0001], left atrium volume [25.7(2.5) vs. 25.0(2.8) ml/m 2 , p = 0.003], and aortic root diameter [33.6(3.0) vs. 33.0(3.7) mm, p < 0.0001]. They did not differ for microalbuminuria and estimated glomerular filtration rate. At multivariate analysis, after adjustment for office systolic blood pressure values, the STOP-Bang score remained a predictor of left ventricular mass index; while the Insomnia Severity Index and restless legs syndrome risk score had no predictive value. However, a significant interaction between STOP-Bang and Restless Legs Syndrome Rating Scale scores in determining left ventricular remodelling was found. Conclusions: In consecutive hypertensive stage I patients the STOP-Bang questionnaire allowed identification of a high-risk cohort featuring a more prominent cardiac damage. Hence, this inexpensive tool can be useful for risk stratification purposes in municipalities with limited access to health care resources.

Background and aim Considering the amount of novel knowledge generated in the last five years, a team of experienced hypertensionlogists was assembled to furnish updated clinical practice guidelines for the management of primary aldosteronism. Methods To identify the most relevant studies, the authors utilized a systematic literature review in international databases by applying the PICO strategy, and then they were required to make use of only those meeting predefined quality criteria. For studies of diagnostic tests, only those that fulfilled the Standards for Reporting of Diagnostic Accuracy recommendations were considered. Results Each section was jointly prepared by at least two co-authors, who provided Class of Recommendation and Level of Evidence following the American Heart Association methodology. The guidelines were sponsored by the Italian Society of Arterial Hypertension and underwent two rounds of revision, eventually reexamined by an External Committee. They were presented and thoroughly discussed in two face-to-face meetings with all co-authors and then presented on occasion of the 36th Italian Society of Arterial Hypertension meeting in order to gather further feedbacks by all members. The text amended according to these feedbacks was subjected to a further peer review. Conclusions After this process, substantial updated information was generated, which could simplify the diagnosis of primary aldosteronism and assist practicing physicians in optimizing treatment and follow-up of patients with one of the most common curable causes of arterial hypertension.

The COVID-19 infection has rapidly spread around the world and a second wave is sweeping in many countries. Different clinical and epidemiological aspects characterize the disease and their understanding is necessary to better face the management of the pandemic in progress. The Italian society of arterial hypertension with the SARS-RAS study has contributed significantly to the knowledge of the interaction between inhibition of the renin-angiotensin system and COVID-19 infection. Furthermore, the study results help to understand some of the main aspects related to mortality and morbidity deriving from the infection through a multicentre analysis throughout the national territory.

Objectives Infective endocarditis (IE) with extensive peri-annular abscesses and aortic root involvement is a life-threatening disease. Aortic root replacement with a valved conduit is the most common intervention in this setting and represents a serious challenge for the surgeon. In the present two-center study we analyzed early and midterm outcomes of a high-risk series of IE patients undergoing aortic root reconstruction with a sub-annular implantation of a totally biological valved conduit at our centers. Methods The series comprised 29 patients (18 males, mean age: 72.3 ± 10.1 years) operated at "Lancisi Cardiovascular Center" of Ancona and "Pasquinucci Heart Hospital" of Massa, Italy, between May 2016 and October 2019. All patients had undergone a previous cardiac surgery. Median Euroscore-II was 12.6%. Following aggressive debridement, a Bioconduit was implanted using a sub-annular implantation technique in all cases. Results Thirty-day mortality was 13.8% (n = 4). Multiorgan failure was cause of death in all cases. Respiratory complications occurred in eight patients (27.6%). Renal complications requiring temporary or permanent dialysis occurred in six (20.7%) and two (6.9%) patients, respectively. Mortality and morbidity were not related to the surgical approach. At 1-year follow-up three patients died and no patients underwent reoperation neither reported endocarditis of the biological conduit. Conclusion Considered the high-risk profile of the study cohort, our results suggest safety and efficacy of our approach at 1-year. Indeed, we contend that our subannular implantation of a 100% pericardial valved conduit, allowing an effective abscess exclusion and a conduit anchoring to healthy tissues, can reduce the risk of reinfection and dehiscence.

Background: A minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates a MIA. We describe our experience with the sutureless Perceval (LivaNova, Italy) aortic bioprosthesis through a right anterior mini-thoracotomy (RAMT) approach. Methods: Between March 2011 and October 2019, 1,049 patients underwent AVR with Perceval bioprosthesis. Five hundred and three patients (48%) were operated through a RAMT approach in the second intercostal space. Considering only isolated AVR (881), 98% of patients were operated with MIA, and Perceval in RAMT approach was performed in 57% of these patients. Eight patients (1.6%) had previously undergone cardiac surgery. The prosthesis sizes implanted were: S (n=91), M (n=154), L (n=218) and XL (n=40). Concomitant procedures were mitral valve surgery (n=6), tricuspid valve repair (n=1), mitral valve repair and tricuspid valve repair (n=1) and miectomy (n=2). Mean age was 78±4 years (range, 65–89 years), 317 patients were female (63%) and EuroSCORE II was 5.9%±8.4%. Results: The 30-day mortality was 0.8% (4/503). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were 81.6±30.8 and 50.3±24.5 minutes respectively for stand-alone procedures. In two patients, early moderate paravalvular leakage appeared as a result of incomplete expansion of the sutureless valve due to oversizing of the bioprosthesis, requiring reoperations at two and nine postoperative days with sutured aortic bioprosthesis implantation. Permanent pacemaker implantation within the first thirty days was necessary in 26 (5.2%) patients. At the mean follow-up of 4.6 years (range, 1 month to 8.6 years), survival was 96%, freedom from reoperation was 99.2%, and mean transvalvular pressure gradient was 11.9±4.3 mmHg. Conclusions: AVR with the Perceval bioprosthesis in a RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates a RAMT approach.

ObjectiveThe Society of Thoracic Surgeons score performance relative to other scores in minimally invasive cardiac surgery is not known.MethodsPatients who underwent surgery from 2003 to 2018 identified from database. Additional variables included for STS score calculation, EuroSCORE II and age, creatinine and ejection fraction score calculation.ResultsA total of 4751 patients were identified from main database. There were actual 47 (0.99%) hospitals deaths. The mean STS score predicted mortality were 2.0 ± 2.1. Discriminatory power was uniformly good (for STS Mortality: area under curve, 0.86; 95% confidence interval, 0.81 - 0.91). The mean EuroSCORE II predicted mortality were 2.9 ± 3.8. Discriminatory power was uniformly good similar to that of STS (for EuroSCORE II Mortality: area under curve, 0.9; 95% confidence interval, 0.86 - 0.93). The mean ACEF predicted mortality were 2.5 ± 2.3. Discriminatory power was uniformly good but inferior to that of STS and EuroSCORE II (for ACEF Mortality: area under curve, 0.72; 95% confidence interval, 0.65 - 0.8).Calibration pattern for STS score was the best for of mortality prediction (p < 0.01), EuroSCORE II and ACEF were constantly overestimating mortality (respectively, p < 0.01 and p < 0.01). scores.ConclusionsThe STS score has acceptable discrimination power for this sub-population. However, it is not calibrated for the the subset. EuroSCORE II is has good discrimination power, but not calibrate for the this subset of patients. ACEF score had similar performance to EuroSCORE. No algorithm seems suitable for accurate risk estimation.

ObjectiveWe sought to review our experience of new titanium knot fastener devices. We hypothesized that it might reduce the cardiop-polmonary bypass time, aortic cross-clamping time and intervention time.MaterialsWe reviewed our electronic records in order identify the patients who underwent mitral valve (MV) repair and replacement in totally endoscopic setup. Surgical approach was trough limited right periareolar or inframmamary thoracotomy with mainly femoro-femoral arterio-venous cannulation. A part of patients underwent interventions using fast knotting system (FK group, Cor-Knot Device, ISL Solutions Inc) and remaining patients served as control group (conventional hand knotting, HK). We identified the FK patients and performed propensity score matching to match 1:1 ratio from main cohort using FK versus HK.ResultsA total of 306 patients underwent mitral valve repair or replacement on via right thoracotomy, 265 (87%) patients underwent using FK, remaining. There were on average 2.6 minutes of CPB time reduction (p = 0.64), and 3.1 minutes of CXC time reduction (p = 0.47). However, when dividing into procedures based on complexity, there were on average 8.6 minutes of CPB time reduction (p = 0.18), and 6.9 minutes of CXC time reduction (p = 0.16) in simple cases; on average in complex cases 12 minutes of CPB time was augmented (p = 0.24), and 2.5 minutes of CXC time was augmented(p = 0.76).In propensity matched population the effect of CPB and CXC reduction was consistent and repeated and there were on average 0.5 minutes of CPB time reduction (p = 0.12), and 3.6 minutes of CXC time augmentation (p = 0.05). However, when dividing into procedures based on complexity, there were on average 0.2 minutes of CPB time reduction (p = 0.16), and 2.7 minutes of CXC time augmentation (p = 0.06) in simple cases; on average 5 minutes of CPB time augmentation (p = 0.34), and 14.2 minutes of CXC time augmentation (p = 0.58) in complex cases.ConclusionsTitanium fasteners are useful tool to have in minimally invasive approaches, especially in complex cases and redo interventions. Titanium are comfortable and fast in many cases then conventional knot tying, but it is also expensive the traditional knotting. The titanium fasteners do not offer significant time reduction. In matched group the pattern of time saving were identical to main cohort.

Cardiomyopathies are myocardial disorders in which heart muscle is structurally and/or functionally abnormal. Previously, structural cardiomyocyte disorders due to adrenal diseases, such as hyperaldosteronism, hypercortisolism, and hypercatecholaminism, were misunderstood, and endomyocardial biopsy (EMB) was not performed because was considered dangerous and too invasive. Recent data confirm that, if performed in experienced centers, EMB is a safe technique and gives precious information about physiopathological processes implied in clinical abnormalities in patients with different systemic disturbances. In this review, we illustrate the most important features in patients affected by primary aldosteronism (PA), Cushing’s syndrome (CS), and pheochromocytoma (PHEO). Then, we critically describe microscopic and ultrastructural aspects that have emerged from the newest EMB studies. In PA, the autonomous hypersecretion of aldosterone induces the alteration of ion and water homeostasis, intracellular vacuolization, and swelling; interstitial oedema could be a peculiar feature of myocardial toxicity. In CS, cardiomyocyte hypertrophy and myofibrillolysis could be related to higher expression of atrogin-1. Finally, in PHEO, the hypercontraction of myofilaments with the formation of contraction bands and occasional cellular necrosis has been observed. We expect to clear the role of EMB in patients with cardiomyopathies and adrenal disease, and we believe EMB is a valid tool to implement new management and therapies.

The aim of our cross-sectional study was to evaluate skin microvascular alterations in patients with hypertension secondary to primary aldosteronism (PA) and in subjects with essential hypertension (EH). Skin microcirculation was detected by nailfold videocapillaroscopy (NVC) and laser Doppler perfusion imaging (LDPI), both noninvasive techniques for the evaluation of digital capillaroscopic damage and hand skin blood perfusion. From September 2018 to April 2019, we consecutively enrolled 80 patients, of whom 42 had PA and 38 had EH. A morphological and structural study of cutaneous microcirculation was carried out through NVC, while functional evaluation of the peripheral microcirculation was carried out with LDPI. Using LDPI indices, dermal perfusion gradients were calculated in various regions of interest at the level of the back of the hand (ROI1 and ROI2). No differences between the two groups in NVC parameters were found. In contrast, LDPI showed worse skin perfusion parameters in patients with PA compared with patients with EH (ROI1: 143.9 ± 29.9 pU vs 163.3 ± 35.2 pU, p = 0.01; perfusion gradient ROI1–ROI2: 62.4 ± 28.8 pU vs 79.3 ± 33.5 pU, p = 0.019). Furthermore, the ROI1–ROI2 (proximal-distal) perfusion gradient was negatively correlated with aldosterone plasma levels (r −0.269; p = 0.017). Multivariate analysis showed that aldosterone was significantly associated with the ROI1–ROI2 perfusion gradient (b −0.220; p = 0.044). Patients with PA showed altered skin perfusion and greater microvascular dysfunction compared with the EH group. Our results are consistent with the hypothesis that aldosterone may have a pathophysiological role in microvascular remodeling in patients with PA, with predominant functional dysfunction.

Background This study describes the clinical and echocardiographic outcomes in a large single-center cohort of patients who underwent aortic valve replacement (AVR) with a sutureless Perceval (LivaNova, Milan, Italy) aortic bioprosthesis. Methods Between March 2011 and December 2015, 617 patients underwent AVR with a Perceval bioprosthesis. The mean age was 76 ± 7 years, 388 patients were female (63%), and the mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 6.2% ± 5.4%. Concomitant procedures were mitral valve surgery (n = 74), tricuspid valve repair (n = 22), coronary artery bypass grafting (n = 42), myectomy (n = 3), and ascending aorta replacement (n = 2). Results The 30-day mortality rate was 1.9% (12 of 617). A total of 475 of 516 (92%) patients who had isolated AVR underwent minimally invasive surgery with an upper ministernotomy (n = 81) or a right anterior minithoracotomy (n = 394) approach. Cardiopulmonary bypass and aortic cross-clamp times were 81.7 ± 29.1 minutes and 50.5 ± 19.8 minutes for isolated AVR and 139.7 ± 51.5 minutes and 91.5 ± 29.5 minutes for combined procedures, respectively. At mean follow-up of 16.3 months (range, 0 to 51.9 months), the survival rate was 91.3%, the rate of freedom from reoperation was 99%, and the mean transvalvular pressure gradient was 11.9 ± 5.4 mm Hg. Left ventricular ejection fraction increased from 53.6% ± 8.4% to 54.5% ± 4.8% ( p = 0.40), left ventricular mass decreased from 146.5 to 112.6 g/m 2 ( p Conclusions AVR with the Perceval bioprosthesis is associated with low mortality rates and excellent hemodynamic performance. Sutureless technology may reduce operative times, especially in combined procedures, and may make minimally invasive AVR more easily reproducible.

Adrenal gland diseases, such as primary aldosteronism and Cushing’s syndrome, are associated with higher cardiovascular risk. Excessive production of aldosterone can lead to accumulation of epicardial adipose tissue (EAT), interfering with functional state. In fact, increased mineralocorticoid signaling is critically involved in the secretion of proinflammatory cytokines by EAT with consequent profibrotic cascade activation in the myocardium. In heart failure hyperaldosteronism is strictly related to increased visceral adiposity representing an interplay between EAT and cardiac remodeling. Therefore, obese patients with heart failure are particularly sensitive to mineralocorticoid receptor antagonists. On the other hand, interaction between EAT and aldosterone is also observed in primary aldosteronism. Furthermore, previous studies suggest an active role of the fat depot surrounding the adrenal gland—paracrine secretion of adipokines from the adipose tissue surrounding the adrenal neoplasia being hormonally active. Considering the EAT characteristics of visceral adipose tissue depot, as well as periadrenal fat, correlation has been found between EAT and cardiovascular changes in adrenal diseases such as Cushing syndrome and adrenal incidentaloma. Ultrasound measured EAT could be implemented in the routine assessment of patients with endocrine-caused hypertension.

Several factors have been proposed to explain the high death rate of the coronavirus disease 2019 (COVID-19) outbreak, including hypertension and hypertension-related treatment with Renin Angiotensin System inhibitors. Also, age and multimorbidity might be confounders. No sufficient data are available to demonstrate their independent role. We designed a cross-sectional, observational, multicenter, nationwide survey in Italy to verify whether renin-angiotensin system inhibitors are related to COVID-19 severe outcomes. We analyzed information from Italian patients diagnosed with COVID-19, admitted in 26 hospitals. One thousand five hundred ninety-one charts (male, 64.1%; 66±0.4 years) were recorded. At least 1 preexisting condition was observed in 73.4% of patients, with hypertension being the most represented (54.9%). One hundred eighty-eight deaths were recorded (11.8%; mean age, 79.6±0.9 years). In nonsurvivors, older age, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, coronary artery diseases, and heart failure were more represented than in survivors. The Charlson Comorbidity Index was significantly higher in nonsurvivors compared with survivors (4.3±0.15 versus 2.6±0.05; P P =0.0001), diabetes mellitus ( P =0.004), chronic obstructive pulmonary disease ( P =0.011), and chronic kidney disease ( P =0.004) but not hypertension predicted mortality. Charlson Comorbidity Index, which cumulates age and comorbidities, predicts mortality with an exponential increase in the odds ratio by each point of score. In the COVID-19 outbreak, mortality is predicted by age and the presence of comorbidities. Our data do not support a significant interference of hypertension and antihypertensive therapy on COVID-19 lethality. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04331574.

Purpose . Starting from the description of two interesting cases, we wondered to review the literature on pelvic and bladder paragangliomas (PGLs) in order to illustrate clinical characteristics and current management, lightening the needed of a prompt diagnosis to avoid the onset of several complications. Although PGLs may arise at any site where physiologically chromaffin tissue exists, pelvic origins are not frequent (less than 2%), and the most common localization is the retroperitoneal space, whereas bladder PGLs account for less than 0.06% of all bladder neoplasms and less than 1% of all PGLs. Methods . We herein performed a brief review of the literature about pelvic PGLs in the PubMed library, conducted according to the PRISMA statement, including studies published from 1954 to 2019. We also discuss clinical presentation, morphologic appearance, and management of two cases of pelvic PGL, both of them characterized by an history of paroxysmal high blood pressure episodes uncontrolled by antihypertensive therapy associated with disabling symptoms, not clearly understood for many years. Results . Overall, we evaluated 108 case reports. The majority were females, presenting typical signs and symptoms, such as arterial hypertension (54.2%), hematuria (35.1%), and headache (33.6%). After treatment, the clinical and biochemical remission was evident in only 55% of analyzed cases. Conclusions . For their singular localization, pelvic and bladder PGLs often might be misdiagnosed. The significant delay in the proper treatment could be responsible for the relative low percentage of complete clinical and biochemical remission.

Objective Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis compared with patients with preserved LVEF. To evaluate the impact of sutureless Perceval (LivaNova, Italy) aortic bioprosthesis on LVEF and clinical outcomes in patients with baseline left ventricular (LV) dysfunction who underwent isolated aortic valve replacement (AVR). Methods Between March 2011 and August 2017, 803 patients underwent AVR with Perceval bioprosthesis implantation. Fifty-two isolated AVR had preoperative LVEF ≤45%. Mean age of these patients was 77 ± 6 years, 24 patients were female (46%), and mean EuroSCORE II was 9.4% ± 4.8%. Perceval bioprosthesis was implanted in 9 REDO operations. In 43 patients (83%), AVR was performed in minimally invasive surgery with an upper ministernotomy ( n = 13) or right anterior minithoracotomy ( n = 30). Results One patient died in hospital. Cardiopulmonary bypass and aortic cross-clamp times were 85.5 ± 26 minutes and 55.5 ± 19 minutes, respectively. At mean follow-up of 33 ± 20 months (range: 1 to 75 months), survival was 90%, freedom from reoperation was 100%, and mean transvalvular pressure gradient was 11 ± 5 mmHg. LVEF improved from 37% ± 7% preoperatively to 43% ± 8% at discharge ( P < 0.01) and further increased to 47% ± 9% at follow-up ( P = 0.06), LV mass decreased from 149.8 ± 16.9 g/m2 preoperatively to 115.3 ± 11.6 g/m2 at follow-up ( P < 0.001), and moderate paravalvular leakage occurred in 1 patient without hemolysis not requiring any treatment. Conclusions AVR with sutureless aortic bioprosthesis implantation in patients with preoperative LV dysfunction demonstrated a significant immediate and early improvement in LVEF.

INTRODUCTION: Primary hyperparathyroidism is associated with a cluster of cardiovascular manifestations, including hypertension, leading to increased cardiovascular risk. PURPOSE: The aim of our study was to investigate the ambulatory blood pressure monitoring-derived short-term blood pressure variability in patients with primary hyperparathyroidism, in comparison with patients with essential hypertension and normotensive controls. METHODS: Twenty-five patients with primary hyperparathyroidism (7 normotensive,18 hypertensive) underwent ambulatory blood pressure monitoring at diagnosis, and fifteen out of them were re-evaluated after parathyroidectomy. Short-term-blood pressure variability was derived from ambulatory blood pressure monitoring and calculated as the following: 1) Standard Deviation of 24-h, day-time and night-time-BP; 2) the average of day-time and night-time-Standard Deviation, weighted for the duration of the day and night periods (24-h "weighted" Standard Deviation of BP); 3) average real variability, i.e., the average of the absolute differences between all consecutive BP measurements. RESULTS: Baseline data of normotensive and essential hypertension patients were matched for age, sex, BMI and 24-h ambulatory blood pressure monitoring values with normotensive and hypertensive-primary hyperparathyroidism patients, respectively. Normotensive-primary hyperparathyroidism patients showed a 24-h weighted Standard Deviation (P

A 62-year-old woman was admitted for evaluation of an incidentally discovered adrenal mass and hypertension. CT scan revealed a 7 cm mass in the right adrenal gland. After careful examination, the patient was diagnosed with subclinical hypercortisolism (SH). Adrenalectomy was performed. Histopathological examination showed an adrenocortical adenoma. Symptoms and signs of myasthenia gravis appeared 5 months later. CT of the chest showed a solid tissue mass in the mediastinum. The patient underwent a sternotomy with excision of the tumor, which histologically proved to be a type 2B thymoma. We describe a rare case of SH due to an incidentally discovered adrenocortical adenoma in a patient who manifested myasthenia gravis after surgical remission of the cortisol excess.

BACKGROUND AND AIMS The adrenal mineralocorticoid system plays a key role in cardiovascular, metabolic and renal damage. This study aimed to assess the relationship between plasma aldosterone concentration (PAC) and some surrogate markers of subclinical atherosclerosis, such as carotid intima-media thickness (cIMT), ankle-brachial index (ABI) and biochemical parameters in patients with essential hypertension. METHODS AND RESULTS From January 2014 to December 2017, we consecutively enrolled 804 essential hypertensive patients (407 men and 397 women, mean age 50 ± 14 years) without cardiovascular complications, distinguishing patients in quartiles according to PAC. Compared with the first quartile, the highest PAC quartile was associated with the highest levels of serum uric acid (SUA) (5.3 ± 1.3 vs. 5.0 ± 1.0 mg/dl; P = 0.01), triglycerides (117.5 ± 15.7 vs. 106.8 ± 10.5 mg/dl; P

Data on short-term blood pressure variability (BPV), which is a well-established cardiovascular prognostic tool, in pheochromocytoma and paraganglioma (PPGL) patients is still lack and conflicting. We retrospectively evaluated 23 PPGL patients referred to our unit from 2010 to 2019 to analyze 24 h ambulatory blood pressure monitoring (24-h ABPM)-derived markers of short-term BPV, before and after surgical treatment. PPGL diagnosis was assessed according to guidelines and confirmed by histologic examination. The 24-h ABPM-derived markers of short-term BPV included: circadian pressure rhythm, standard deviation (SD) and weighted SD (wSD) of 24-h, daytime, and night-time systolic and diastolic blood pressure (BP), average real variability (ARV) of 24-h, daytime, and night-time systolic and diastolic BP. 7 males and 16 females of 53 &plusmn, 18 years old were evaluated. After surgical resection of PPGL we found a significant decrease in 24-h systolic BP ARV (8.8 &plusmn, 1.6 vs. 7.6 &plusmn, 1.3 mmHg, p &lt, 0.001), in 24-h diastolic BP ARV (7.5 &plusmn, 1.6 vs. 6.9 &plusmn, 1.4 mmHg, p = 0.031), and in wSD of 24-h diastolic BP (9.7 &plusmn, 2.0 vs 8.8 &plusmn, 2.1 mmHg, p = 0.050) comparing to baseline measurements. Moreover, baseline 24-h urinary metanephrines significantly correlated with wSD of both 24-h systolic and diastolic BP. Our study highlights as PPGL patients, after proper treatment, show a significant decrease in some short-term BPV markers, which might represent a further cardiovascular risk factor.

Objective:Data about short-term blood pressure variability (BPV), whose changes represent a well-established cardiovascular risk factor, in pheochromocytoma and paraganglioma (PPGL) patients is lack and still conflicting. The aim of this study is to analyse 24-h ambulatory blood pressure monitoring

Objective Left ventricular (LV) hypertrophy in aortic stenosis (AS) constitutes a risk factor for cardiac morbidity and mortality. The aim of this study was to investigate the degree of LV mass regression after aortic valve replacement (AVR) with two alternative sutureless self-expanding strategies: Perceval S (Sorin Group, Saluggia, Italy) (P) and 3f Enable (Medtronic, ATS Medical, Minneapolis, MN USA) (e) aortic bioprostheses. Methods Between March 2010 and December 2011, 129 patients with symptomatic AS underwent AVR with the Perceval S or 3f Enable bioprostheses in two cardiac surgery departments (Massa, Italy; Nuremberg, Germany). We analyzed 45 patients in group P and 19 in group E undergoing isolated AVR with a 6-month follow-up. The LV mass was calculated using the Devereux formula and was indexed to body surface area. Results Baseline patient characteristics showed no significant differences between the two groups. There were no in-hospital deaths. Two patients in group P died at follow-up versus zero in group E ( P = 0.49). Mean LV mass index decreased from 146.6 (78) g/m2 at baseline to 123.3 (63) g/m2 at follow-up ( P < 0.001) in group P and from 146.1 (47.6) g/m2 to 118.1 (39.8) g/m2 ( P = 0.003) in group E, with no significant difference between the two groups ( P = 0.315). This effect was accompanied by significant clinical improvement. Conclusions: In isolated AS, AVR with sutureless bioprostheses is associated with a significant regression in LV mass at 6-month follow-up. No significant differences were present between the two alternative sutureless strategies. However, regression needs an evaluation with long-term echocardiographic examinations.

Introduction. Cushing’s syndrome (CS) is a clinical condition characterized by excessive cortisol production, associated with metabolic complications, such as diabetes mellitus, dyslipidemia, metabolic syndrome, hypertension, and cardiovascular diseases. Nowadays, the occurrence of autoimmune diseases in CS have not been completely evaluated in the previous studies. Objective. The aim of this study was to evaluate the occurrence of autoimmune diseases in CS patients after successfully treated. Materials and Methods. From January 2001 to December 2017, in our Secondary Hypertension Unit, we evaluated 147 CS patients (91 with ACTH-independent disease, 54 with ACTH-dependent disease, and 2 patients with ectopic ACTH production. Results. 109 CS patients (74.1%) were surgically treated (67 ACTH-independent CS patients (61.5%) undergone adrenalectomy and 42 ACTH-dependent CS (38.5%) undergone transsphenoidal surgery) and evaluated after 6, 12, and 24 months after clinical and biochemical remission of disease. In 9 (8.3%) of overall treated CS patients (8.3%), during follow-up, we observed the onset of some manifestations of autoimmune diseases. In particular, one patient had a systemic lupus erythematosus, one patient had rheumatoid arthritis, 4 patients reported autoimmune thyroiditis (Basedow-Graves’ disease and Hashimoto’s thyroiditis), one patient had clinical features of psoriasis, one patient showed myasthenia gravis, and one patient had giant cell arteritis. Conclusions. Our results demonstrate that patients successfully treated for CS could develop autoimmune diseases. Therefore, after treatment, CS patients need to be strictly monitored in order to evaluate the possible onset of autoimmune diseases.

Introduction: Autosomal dominant polycystic kidney disease (ADPKD) is associated with early organ damage such as left ventricular hypertrophy and higher cardiovascular risk when compared to essential hypertension (EH). Epicardial adipose tissue (EAT) is a new cardiovascular risk factor, but its role and correlation with left ventricular mass (LVM) in ADPKD is unknown. Aims: we sought to investigate whether EAT is higher and related to LVM indexed by body surface area (LVMi) in hypertensive patients with ADPKD compared to those with EH. Methods: We performed ultrasound measurement of EAT thickness, LVM, LVMi, and left atrium size (left atrial volume indexed for body surface, LAVI) in 41 consecutive hypertensive patients with ADPKD, compared to 89 EH patients. Results: EAT was significantly higher in the ADPKD group in comparison to EH subjects (9.2 ± 2.9 mm vs. 7.8 ± 1.6 mm, p < 0.001), and significantly correlated with LVM, LVMi, and LAVI in the ADPKD group (r = 0.56, p = 0.005; r = 0.424, p = 0.022; and r = 0.48, p = < 0.001, respectively). Comparing EAT against body mass index, systolic blood pressure, and age, we found that EAT was the strongest predictor of LVMi (β = 0.42, p = 0.007). Conclusion: Our data showed that EAT was higher in ADPKD patients than in EH subjects and independently correlated with LVMi. EAT measurement can be a useful marker for the cardiovascular risk stratification in ADPKD.

Introduction Pheochromocytoma (PHEO) is a rare catecholamine-producing tumour arising from chromaffin cells in the sympatho-adrenal system, and can present as asymptomatic adrenal incidentaloma (AI). Patient We describe the case of a 61-year-old woman with a right adrenal mass incidentally discovered, who was biochemically characterized with subclinical hypercortisolism (SH). The patient was scheduled for adrenalectomy because of increasing seizure of the right adrenal gland with a haemorrhagic and focal pseudocystic appearance macroscopically, incidental histological and immunohistochemical PHEO, and micronodular cortico-adrenal hyperplasia. Discussion This report describes a rare case of incidental non-functioning PHEO coexisting with corticomedullary hyperplasia and SH. LEARNING POINTS Rare presentation of coexisting common (adrenal incidentaloma and subclinical Cushing’s syndrome) and uncommon (pheochromocytoma) endocrinological conditions.

Objective The aim of our study was to evaluate the early outcomes and 1-year survival of patients undergoing minimally invasive aortic valve replacement with the Perceval S sutureless valve for severe aortic stenosis. Methods From March 2010 to March 2013, 281 high-risk patients underwent minimally invasive aortic valve replacement with the Perceval S sutureless valve through either right anterior minithoracotomy (n = 164) or upper ministernotomy (n = 117) at 2 cardiac centers. Results The overall in-hospital mortality was 0.7% (2 patients). The overall median cardiopulmonary bypass and crossclamp time was 81 minutes (interquartile range, 68-98) and 48 minutes (interquartile range, 37-60), respectively. Postoperative stroke occurred in 5 patients (1.8%). The incidence of paravalvular leak greater than 1 of 4 and atrioventricular block requiring pacemaker implantation was 1.8% (5 patients) and 4.2% (12 patients), respectively. No migration occurred, and the mean postoperative gradient was 13 ± 4 mm Hg. At a median follow-up of 8 months (interquartile range, 4-14), the overall survival was 90%. Conclusions Minimally invasive aortic valve replacement with the Perceval S sutureless valve in high-risk patients is a safe and reproducible procedure associated with excellent hemodynamic results, postoperative outcomes, and 1-year survival.

OBJECTIVE Primary aldosteronism, an important form of secondary hypertension, is associated with significant increase of cardiovascular risk (ischaemic heart, cerebrovascular events, arrhythmias) (relative risk 4.6). The specific treatment of primary aldosteronism significantly reduces cardiovascular risk. In addition to high blood pressure values and direct action of aldosterone, new mechanisms such as increased oxidative stress are involved in the development of organ damage, metabolic, endothelial and coagulation complications. METHODS The aim of the study was to evaluate parameters of oxidative stress in 38 patients (21 men, 17 women, mean age 53.3 ± 4.7 years) with primary aldosteronism [11 aldosterone-producing adenoma (APA) (4 men, 7 women, mean age 50.2 ± 4.5 years) and 27 idiopathic adrenal hyperplasia (IHA) (17 men, 10 women, mean age 54.5 ± 5.3 years)] at diagnosis and after specific treatment (surgical or pharmacological), with respect to 50 patients with essential hypertension (26 men, 24 women, mean age 49 ± 7.4 years) and 50 healthy individuals (28 men, 22 women, mean age 48.7 ± 4.4 years). RESULTS Patients with primary aldosteronism showed significant increase of NADPH oxidase (Nox2-dp) plasma levels and urinary isoprostanes (34.9 ± 4.3 μg/dl and 216.3 ± 15.7 ng/mg, respectively; P

Cystic adrenal neoplasms are uncommon and may be incidentally discovered during radiologic procedure not directly performed for the evaluation of adrenal disease. Cystic pheochromocytomas are uncommon neoplasms that originate from the adrenal medulla, clinically differing from the more frequent solid pheochromocytomas. Here, we report a case of 72 year-old woman affected by asymptomatic pseudocystic pheochromocytoma (70x50mm), incidentally discovered, with a false negative 123I-monoiodobenzylguanidine (123I-MIBG) scintigraphy. Histopathological examination led to diagnosis of pseudocystic pheochromocytoma with typical architecture. The screening for germline mutation of succinate dehydrogenase complex subunits (SDHB, SDHC), Von Hipple-Lindau syndrome (VHL) and multiple endocrine neoplasia type 2 (RET) genes were negative, finding only some polymorphisms for RET and SDHB. We emphasize the relevance of an accurate pre-operative diagnosis, especially in rare diseases, and the requirement of experience and multidisciplinary management in these rare pathologies.

Objective:Adrenal incidentalomas (AIs) are often discovered after an imaging-work up that is unrelated to specific adrenal gland disease. Up to 30% of AIs show endogenous cortisol excess, without signs or symptoms of clinically evident Cushing's syndrome. According to literature, subclinical hyperco

Atherosclerosis of the internal mammary artery (IMA) is generally regarded as a rare (but existent) pathological entity with only a few cases reported in the most recent literature. The only study which to our knowledge has investigated the ultrastructural features of IMA atherosclerosis, demonstrate the presence of endothelial cells loss, defects of internal elastic lamina with no evidence of lipid accumulation. In the present study, we describe two cases of IMA atherosclerosis in which ultrastructural analysis revealed the presence of a typical atherosclerotic plaque morphology with infiltration of inflammatory cells, formation of intraplaque lipid pools, and accumulation of lipid-laden foam cells throughout the thickened intima, never described in this rare lesion before. Microscopically, the lesions were also characterized by intimal thickening, invagination of endothelial cells, migration of smooth muscle cells with splitting, fenestration and/or fragmentation of the elastic sheets. Our observations add new data to the scarce and contradictory literature and to this largely understudied vascular disorder.

Sutureless aortic valve prostheses have the potential of shortening surgical time. However, whether shorter operative times may also result in improved patient outcomes remains to be established.One hundred patients underwent minimally invasive isolated aortic valve replacement. Of these, 50 patients received a Perceval (Sorin Group, Saluggia, Italy) bioprosthesis (group P) and 50 patients received a non-Perceval valve (group NP).The group P patients were older (77.5 ± 5.3 versus 71.7 ± 10 years, p = 0.001) and at higher risk (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE] 9.9 ± 6.5 versus 4.3 ± 1, p = 0.001) than group NP patients. One implant failure occurred in group P (p = 0.5), and conversion to full sternotomy was necessary in 1 patient from each group. Aortic cross-clamp and cardiopulmonary bypass times were 39.4% and 34% shorter in group P (both p0.001). Within 30 days, a total of 5 patients died (2 in group P and 3 in group NP, p = 0.5). No significant differences were observed between groups in postoperative arrhythmias and need for pacemaker implantation (p = 0.3 and p = 0.5, respectively). Despite the higher surgical risk, group P patients less frequently required blood transfusion (1.1 ± 1.1 units versus 2.3 ± 2.8 units, p = 0.007), and had a shorter intensive care unit stay (1.9 ± 0.7 versus 2.8 ± 1.9 days, p = 0.002) and a shorter intubation time (9.2 ± 3.6 hours versus 15 ± 13.8 hours, p = 0.01). Group NP patients had a mean prosthesis size significantly smaller than for group P (23 ± 2 mm versus 23.9 ± 1.1 mm, p = 0.01). The Perceval valve provided comparable hemodynamic performance to that of non-Perceval valves (mean gradient 8.4 ± 6 mm Hg versus 10 ± 4.9 mm Hg, p = 0.24).Sutureless implantation of the Perceval valve is associated with shorter cross-clamp and cardiopulmonary bypass times, resulting in improved clinical outcome. In addition, it compares favorably with conventional valves in terms of mortality and outcome variables.

Objective Important comorbid conditions in patients referred for aortic valve replacement (AVR) require less invasive strategies. We describe our initial experience with the Perceval S (Sorin Group, Saluggia, Italy) and 3f Enable (Medtronic, Minneapolis, MN USA) sutureless aortic bioprostheses. Methods We compared intraoperative data, postoperative clinical outcomes, and echocardiographic results from patients receiving a Perceval S ( P group; n = 97) or a 3f Enable (E group; n = 32) prosthesis in two cardiac surgery departments (Nuremberg, Germany, and Massa, Italy). Results Baseline patient characteristics were similar in both groups, except for mean ± SD body surface area ( P group = 2.01 ± 2.9 m2, E group = 1.83 ± 3.8 m2; P < 0.001). Sixty-five patients (67%) in the P group and 19 patients (59.5%) in the E group ( P = 0.22) underwent minimally invasive AVR with either ministernotomy or right anterior minithoracotomy approach. Concomitant procedures were performed in 37 patients (38%) in the P group and 9 patients (28%) in the E group ( P = 0.56). In-hospital mortality was 2%. The mean ± SD prosthesis diameter was 23.5 ± 1.4 mm ( P group) compared with 22.1 ± 2 mm (E group) ( P < 0.001). In isolated AVR, aortic cross-clamp time was 36 ± 12.7 minutes in the P group and 66 ± 18 minutes in the E group ( P < 0.001). At a mean ± SD follow-up of 8.3 ± 4.5 months, survival was 97% (one death in the P group). In five patients ( P group = 1, E group = 4), a moderate paravalvular leak was present ( P = 0.013). The mean ± SD transvalvular gradient was 9.1 ± 3.3 mm Hg with the Perceval S and 11.2 ± 5.2 mm Hg with the 3f Enable ( P = 0.017). Conclusions Aortic valve replacement with sutureless aortic bioprosthesis is feasible, also with a minimally invasive approach. The Perceval S showed lower operative times and moderate paravalvular leaks and lower mean transvalvular gradients than did the 3f Enable, related to the larger diameter of the Perceval S implanted. Both prostheses showed an excellent hemodynamic performance. This new technology needs long-term follow-up.

Background and Aim of the Study To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. Methods Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA)

Ambulatory blood pressure monitoring (ABPM) is a helpful tool to comprehensively identify and diagnose arterial hypertension. Moreover, it allows to better identify alterations in the circadian BP profile, as the nocturnal "nondipping" status, characterized by a lack of the physiological 10% night BP reduction and associated with a greater risk of target organ damage. However, ABPM has some limitations such as restricted availability, discomfort, particularly at night, cost implications, and reproducibility.Aim of the study was evaluate if the "nondipping" phenomenon may be related to low degree of tolerance to ABPM. Additionally, to determine whether self-reported events of sleep disorders and nighttime urinations may affect the "nondipping" status.From January 2013 to December 2015, we consecutively evaluated 1046 patients with arterial hypertension, performing ABPM, considering a tolerance index calculated on the basis of the patients' responses to a questionnaire.Thirty-eight out of 1046 patients showed complete lack of tolerance to the instrument during the day, whilst 126 during the night. There were no statistically significant differences in daytime and nighttime values of tolerance to the instrument between "dippers" and "nondippers," between "extreme-dippers" and the remaining patients or between "reverse-dippers" and the remaining patients. There were no statistically significant differences in the number of nocturnal awakenings between the groups. However, we found that the number of awakenings followed by urination was higher in "nondipping" patients and in "reverse-dipping" patients compared to the other groups.We found that the poor tolerance to the instrument does not seem to influence the BP "dipping" phenomenon among hypertensive individuals. Moreover, we think that in the evaluation of the ABPM data, factors, such as nocturnal urination and sleep disorders, need to be carefully taken into account, since may lead to a higher incidence of "nondipping" pattern.

This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1–20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p

Objective Aortic valve replacement in minimally invasive approach has shown to improve clinical outcomes even with a prolonged cardiopulmonary bypass and aortic cross-clamp (ACC) time. Sutureless aortic valve implantation may ideally shorten operative time. We describe our initial experience with the sutureless 3f Enable (Medtronic, Inc, ATS Medical, Minneapolis, MN USA) aortic bioprosthesis implanted in minimally invasive approach in high-risk patients. Methods Between May 2010 and May 2011, thirteen patients with severe aortic stenosis underwent aortic valve replacement with the 3f Enable bioprosthesis through an upper V-type ministernotomy interrupted at the second intercostal space. The mean ± SD age was 77 ± 3.9 years (range, 72–83 years), 10 patients were women, and the mean ± SD logistic EuroSCORE was 15% ± 13.5%. Echocardiography was performed preoperatively, at postoperative day 1, at discharge, and at follow-up. Clinical data, adverse events, and patient outcomes were recorded retrospectively. The median follow-up time was 4 months (interquartile range, 2–10 months). Results Most of the implanted valves were 21 mm in diameter (19–25 mm). The CPB and ACC times were 100.2 ± 25.3 and 66.4 ± 18.6 minutes. At short-term follow-up, the mean ± SD pressure gradient was 14 ± 4.9 mm Hg; one patient showed trivial paravalvular leakage. No patients died during hospital stay or at follow-up. Conclusions The 3f Enable sutureless bioprosthesis implanted in minimally invasive approach through an upper V-type ministernotomy is a feasible, safe, and reproducible procedure. Hemodynamic and clinical data are promising. This innovative approach might be considered as an alternative in high-risk patients. Reduction of CPB and ACC time is possible with increasing of experience and sutureless evolution of actual technology.

This study was designed to evaluate the results of unilateral laparoscopic adrenalectomy in patients with subclinical hypercortisolism (SH) due to adrenal incidentaloma (AI) concerning the main cardiometabolic disorders. We have studied between January 2000 to December 2015, 645 patients with AI (283 males and 362 females; mean age 61.9 ± 10 years) and we found 70 patients with SH (27 males and 43 females; mean age 61.9 ± 8.4 years). Twenty-six (37%) SH patients (6 males and 20 females; mean age 58.7 ± 7.1 years) underwent unilateral laparoscopic adrenalectomy, whereas 44 SH patients (21 males and 23 females; mean age 63.9 ± 9.9 years) performed a conservative treatment. All SH patients were evaluated at diagnosis and after follow-up (mean 12 months; range 9–15 months). In only SH patients undergoing unilateral adrenalectomy we found a statistical significant reduction of the arterial hypertension and metabolic syndrome (p

Primary aldosteronism (PA) is one of the most frequent forms of secondary hypertension, associated with atherosclerosis and higher risk of cardiovascular events. Platelets play a key role in the atherosclerotic process. The aim of the study was to evaluate the platelet activation by measuring serum levels of soluble CD40L (sCD40L) and P-selectin (sP-selectin) in consecutive PA patients [subgroup: aldosterone-secreting adrenal adenoma (APA) and bilateral adrenal hyperplasia (IHA)], matched with essential hypertensive (EH) patients. The subgroup of APA patients was revaluated 6-months after unilateral adrenalectomy. In all PA group, we measured higher serum levels of both sP-selectin (14.29±9.33 pg/ml) and sCD40L (9.53±4.2 ng/ml) compared to EH patients (9.39±5.3 pg/ml and 3.54±0.94 ng/ml, respectively; p0.001). After removal of APA, PA patients showed significant reduction of blood pressure (BP) values, plasma aldosterone (PAC) levels and ARR-ratio, associated with a significant reduction of sP-selectin (16.74±8.9 pg/ml vs. 8.1±3.8 pg/ml; p0.01) and sCD40L (8.6±1 ng/ml vs. 5.24±0.94 ng/ml; p0.001). In PA patients, we found a significant correlation between sP-selectin and sCD40L with PAC (r=0.52, p0.01; r=0.50, p0.01, respectively); this correlation was stronger in APA patients (r=0.54; p0.01 r=0.63; p0.01, respectively). Our results showed that PA is related to platelet activation, expressed as higher plasma values of sCD40L and sP-selectin values. Surgical treatment and consequent normalization of aldosterone secretion was associated with significant reduction of sCD40L and sP-selectin values in APA patients.

Objective There is an increase of old patients needing aortic valve surgery. Especially in this age group, a lot of new less-invasive strategies are proposed. Our goal was to study whether a sutureless aortic valve, which is implanted surgically after removal of the native valve, could be an alternative for a subgroup of patients. Methods The Sorin Perceval S is a biologic pericardial aortic valve assembled in a metal super elastic alloy stent and implanted in the aortic root without the need of suturing. As part of a premarketing multicenter study (Cavalier trial), 34 patients were screened for Perceval S implantation. All patients underwent cardiopulmonary bypass and mini-invasive approach (partial upper sternotomy). Results Fourteen patients were excluded due to standardized criteria. Twenty patients received a 21-mm valve (2 patients), 23-mm valve (6 patients), or 25-mm valve (12 patients). X-clamp time was 20.6 ± 7.6 minutes, and implantation time was 8.6 ± 3.1 minutes. Intra- and postoperative echocardiography showed no paravalvular leakage, low gradients (max 16.3 ± 5, mean 9.8 ± 4.2), and two patients with an intraprosthesis reflux (one patient with 1/4+, one patient with 2/4+). All patients were discharged without major in-hospital complications (intensive care unit stay 1.4 ± 0.5 days, hospital stay 7 ± 0.7 days). Conclusions The sutureless Perceval S aortic valve is hemodynamically excellent and a safe prosthesis in selected patients. Due to a simple and fast implantation technique, this valve could guarantee a shorter operation time in combination with a mini-invasive approach.

Rationale: Catecholamine-producing tumors are rare, occurring in less than 0.2% of patients with hypertension, but can have relevant cardiovascular morbidity and mortality. Patient concerns: A 37-year-old woman presented with a history of dyspnea, chest pain, palpitations, and paroxysmal hypertension. Electrocardiogram, echocardiogram, and cardiac magnetic resonance showed severe LVH with a prevalent involvement of the anterior portion of interventricular septum. Endomyocardial biopsy found severe hypertrophy with disarray of cardiomyocytes and ultrastructural evidence of contraction and necrosis of myocytes. Hormone investigations revealed high values of 24-hours urinary metanephrines. Abdominal computed tomography (CT) showed an enlarged left adrenal gland with a strong uptake of 123I—metaiodobenzylguanidine at scintigraphy scan. Interventions: Thus, the adrenal tumor was surgically removed. Outcomes: At follow-up examination, the patient's metanephrines levels were normalized and the transthoracic echocardiogram showed a reduction of LVH. Diagnosis and lessons: We report a rare case of catecholamine–induced cardiomyopathy due to an adrenal adenoma mixed with nodules enriched in epinephrine-types secreting granules.