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Ventricular assist devices (VADs) are considered the standard of care for end-stage heart failure (HF) patients. Despite increasing confidence in the technology, evidence data, endorsement by scientific societies and guidelines, the number of implants reached a steady state and is not increasing at the expected pace. This is most likely related to complications that are still burdening the technology and consequently excluding the most needy, ill, and fragile population. In this manuscript we are reporting a single-center experience in a very fragile, elderly and end-stage HF population, with a superficial, partial support device: the CircuLite Synergy. The patients were included in the pre-CE mark clinical study and consequently the device underwent technical adjustment during the support, based on the complications recorded. At our institution were implanted 6 patients overall: 3 patients survived to discharge and 2 survived up to 5 years. Most of the complications recorded were due to patients' frailty and overall clinical conditions. The initial experience with the CircuLite Synergy device is proving that a more "superficial" device might be more tolerable in an elderly, frail population. Partial support has proven hemodynamically efficacious and efficient in relieving heart failure symptoms, improving medical therapy tolerability, and improving quality of life. Unfortunately, the technology was not made available due to financial uncertainty and poor management, but we hope that once the concept has been proved someone will collect the legacy.

Breast cancer (CM) is the most commonly diagnosed form of cancer in Italy and the most common malignancy in women (25%) with 53,000 new cases. This disease affects all age groups (1 in 40 women49 years, 1 in 20 between 50 and 69 years, 1 in 25 between 70 and 84 years). The percentage of patients diagnosed with cancer within 5 years of diagnosis is higher than for other cancers, and this conviction rate in these cancer patients has increased, leading to an ever-improving level of attention. The research aims to understand the main needs of women with breast cancer, compare them with those reported in the literature and in particular to identify which of these are still unsatisfied. Method The study is based on the use of the narrative interview conducted by the Case Manager, in the Breast Unit of Melegnano (Milan), selected with a sampling of convenience.The participants who joined the research project were 12 women with breast cancer, aged between 40 and 60, who are in the active treatment phase of the disease.As highlighted by literature, various unmet needs have emerged, afferent to well-defined areas: emotional health, continuity of care, information, adverse effects, educational strategies, economics, information and social support. The study showed that, the needs that are most unsatisfied relate to the information area and the psychological area.The interviews conducted underlined the importance of the role of the Case Care Manager as a facilitator of the disease path that patients are experiencing both in terms of the clinical and psychological aspects but also as a support in managing daily life. future research should investigate the role of the Case Vare manager in meeting these needs.

There are sex differences in vulnerability to Coronavirus disease 2019 (COVID-19). The coronavirus S protein mediates viral entry into target cells employing the host cellular serine protease TMPRSS2 for S-protein priming. The TMPRSS2 gene expression is responsive to androgen stimulation and it could partially explain sex differences. We hypothesized that men chronically exposed to 5-alpha reductase inhibitors (5ARIs) for benign prostate hyperplasia (BPH) have a lower risk of hospitalization for COVID-19.This is a population-based case-control study on consecutive patients positive for SARS-CoV-2 virus who required hospitalization for COVID-19 (cases), age-matched to beneficiaries of the Lombardy Regional Health Service (controls). Data were collected by two high-volume COVID-19 regional centers of Lombardy (Italy). The primary outcome was to compare the prevalence of patients chronically exposed to 5ARIs, who required hospitalization for COVID-19, with the one of controls.Overall, 943 males were enrolled; 45 (4.77%) were exposed to 5ARI. COVID-19 patients aged55 years under 5ARI treatment were significantly less than expected on the basis of the prevalence of 5ARI treatment among age-matched controls (5.57 vs. 8.14%; P=0.0083, 95% CI: 0.75-3.97%). This disproportion was higher for men aged65 (7.14 vs. 12.31%; P=0.0001, 95% CI: 2.83-6.97%). Eighteen 5ARIs-patients died; the mean age of men who died was higher than those who did not: 75.98±9.29 vs. 64.78±13.57 (P0.001). Cox-regression and multivariable models did not show correlation between 5ARIs exposure and protection against intensive care unit admission/death.Men exposed to 5ARIs might be less vulnerable to severe COVID-19, supporting its use in disease prophylaxis.

We assessed whether additional cusp repair during valve-sparing aortic root replacement affects the echocardiographic mid-term results; a subgroup analysis among patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) was performed.Between June 2002 and May 2015, 157 consecutive patients underwent valve-sparing aortic root replacement with the David technique. Thirty patients (19%) had BAV. In 19 patients (12%), cusp motion or anatomic abnormalities contributed in determining aortic regurgitation requiring an additional cusp repair. Mean follow-up was 7 ± 3.4 years.The cumulative 1-, 5-, and 12-year survival rates were 98%, 94%, and 90%, respectively. Fourteen patients (9%) required aortic valve replacement during follow-up. In 2 patients the underlying cause was bacterial endocarditis. Freedom from aortic valve reoperation was 96% at 1 year, 92% at 5 years, and 89% at 12 years. Reoperation rate was significantly higher (p 0.001) in patients who received leaflet repair compared with patients who did not, with a freedom from reoperation at 8 years of 58% versus 94%. Among patients with BAV, those who did not require cusp repair had a freedom from reoperation at 8 years of 94%, with a significant difference compared with patients who received cusp repair (p = 0.04). Cusp repair did not affect reoperation risk in patients with tricuspid aortic valve.Adjunctive cusp repair seems to affect the mid-term reoperation risk in patients with BAV and not in patients with tricuspid aortic valve. We recommend caution in using this technique in case of asymmetric BAV requiring cusp repair.

To determine whether the hybrid approach to acute type A aortic dissection results in improved outcomes in terms of mortality, neurologic complications, need for distal aortic reintervention, and false lumen thrombosis compared with the conventional approach.Data from comparative studies of hybrid versus conventional treatment of acute type A aortic dissection were combined through meta-analysis. Pooled odd ratios were calculated using random effects models.Seven comparative studies including 967 patients were identified; of these, 503 underwent conventional proximal aortic repair and 429 extensive distal aortic repair including a stented elephant trunk technique. Between the two groups there was no significant difference in operative mortality (p = 0.96), permanent neurologic deficit (p = 0.95), and late mortality (p = 0.59). Distal aortic repair showed a higher rate of false lumen thrombosis of the thoracic aorta (odd ratio 11.16; p 0.001) and a reduced risk of distal reintervention (odd ratio 0.37; p = 0.01). In sub-group analysis, frozen elephant trunk procedure showed a lower rate of distal aortic reintervention and a higher rate of false lumen thrombosis than antegrade/retrograde stent deployment techniques (p = 0.008 and0.001, respectively).Distal aortic repair may reduce the risk of distal reintervention and increase the rate of false lumen thrombosis without significant increase in operative mortality and permanent neurologic deficit; however, no benefit with respect to late mortality was found. The frozen elephant trunk may reduce the risk of distal aortic reintervention and may increase the false lumen thrombosis of the thoracic aorta in comparison with antegrade/retrograde stent deployment procedures.

Objective To shed light on contemporary results of open total aortic arch surgery, we undertook a systematic review to identify all reports on this procedure published in the last 10 years. Methods Extensive electronic literature search was undertaken to identify all published articles from 2004 to 2014 that provided results on total aortic arch replacement. According to inclusion and exclusion criteria, 21 relevant studies were selected and meta-analyzed to assess outcomes. Results The pooled estimate for operative mortality was 5.3%. Permanent and transient neurologic deficit occurred postoperatively at a pooled rate of 3.4% and 5.2%, respectively. Pooled rate of irreversible spinal cord injury was 0.6%, whereas renal failure occurred at a pooled rate of 4.1%. Prolonged intubation occurred at pooled rate of 15.4%. Among elective patients, pooled rate of mortality and permanent neurologic deficit was 2.9% and 2.2%, respectively, with a significant difference compared with urgent/emergency surgery cases. Conclusions The main findings from this meta-analysis indicate that total aortic arch replacement can be performed with satisfactory mortality and morbidity. The pooled rates of mortality and permanent neurologic deficit among elective cases were surprisingly low, and these data have an even greater prominence when they are compared with outcomes of hybrid arch series. Under urgent/emergency surgery, early mortality and neurologic complications showed an about threefold higher rate. Moderate hypothermic circulatory arrest and early rewarming seem to provide proper renal protection, with an intermediate risk of prolonged intubation.

Background The International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification represents the gold standard for the histological evaluation of Systemic Lupus Erythematosus (SLE) nephritis. A repeat biopsy (RB) might be an important tool to provide information on long-term renal outcomes and optimal therapy. Aims of this study were to evaluate the use of the ISN/RPS classification and the role of RB in routine clinical practice. Methods A total number of 142 patients with SLE nephritis and with adequate reference and RB samples were included in this multicentre retrospective study. A meticulous histological examination was centrally performed on first and RB and compared with clinical variables and follow-up data. Results Morphological features of the ISN/RPS classification: at first and RB, significant differences were observed between segmental classes (III, IV-S) and Class IV-G in mesangial proliferation, wire loops and tuft necrosis. Clinical features and ISN/RPS classification: the correlation between serum creatinine, proteinuria, blood pressure levels and histological classes at first and RB demonstrated more severe renal disease in Class IV-G, both at first and RB. Agreement between ISN/RPS classification at first and RB: 40.8% of patients changed the histological class. Fifty per cent of Class II (mild mesangial form) were reclassified as Class IV-G at RB, whereas 18.9% of Class IV-G were reclassified as Class II. The transition among segmental (III/IV-S) and mesangial forms (II/IV-G) was extremely rare. The comparison between the clinical parameters at the final follow-up and the ISN/RPS classification confirmed that the trend of serum creatinine and proteinuria between the different classes was better described at the RB (higher in Class IV-G) than on the first biopsy. Conclusions The histopathological data suggest that morphological differences between segmental and global forms do exist, possibly due to different pathogenetic mechanisms. An RB strategy could provide additional information on long-term renal outcomes. A strategy of protocol biopsies could be useful in perspective future trials to better understand the therapeutic response and the natural history of this disease.

The Synergy system, a miniature partial circulatory support device, is implanted by an off-pump, minimally invasive surgical approach. The system has been optimized to improve performance in an EU clinical trial for chronic ambulatory heart failure. This therefore offers the possibility of treating elderly chronic heart failure patients who might not usually be considered for long-term circulatory support.From June 2007 to December 2012, 63 patients were implanted with the Synergy system (12 patients ≥70 years) using four different releases of the device. Briefly, the system draws blood through the inflow cannula from the left atrium into the micro-pump (placed in a right subclavicular pocket) and pumps it through an outflow graft to the right subclavian artery. In this paper, we present an intermediate analysis of the clinical trial as performed on April 30, 2013, leading to the placing of the CE mark.Mean duration of support is ongoing at 230 days (range 23-1387). Follow-up showed improved hemodynamic response, with additional improvements in 6-min walk distance (299 ± 144 to 420 ± 119 m) and Minnesota Living with Heart Failure Questionnaire (69.5 ± 20.4 to 49.2 ± 24.3). Older patients had longer mean durations of support (337 vs 188 days). On average, elderly and younger patients showed similar improvements in hemodynamics and 6-min walk distance (107 ± 120 vs 130 ± 121 m). Major adverse cardiac events included bleeding (n=4) with one bleeding related to renal failure resulting in death.Clinical use of the Synergy device was associated with a significant functional improvement. Very low adverse event rates were reported with the latest device release. Older patients had smaller body sizes and worse renal function than younger patients. Both groups experienced similar hemodynamic benefits and functional improvements. The risk of bleeding and renal dysfunction appears to be increased in the elderly, though still within acceptable ranges compared to other full support devices. Minimally invasive long-term circulatory support devices, like Synergy, offer a new treatment option that might be available even for the elderly chronic heart failure population.

Minimally invasive coronary artery bypass (MIDCAB) allows revascularization of the left anterior descending coronary (LAD) artery through a less traumatic surgical approach. However, the procedure is technically challenging and concern still exists, mainly based on graft patency. The purpose of this study is to critically evaluate short and long-term benefits of this surgical treatment.Between June 1997 and July 2012, 306 patients underwent MIDCAB on LAD. The mean age was 62 ± 10 years (range, 32-87 years) and 264 patients (86.3%) were men. Mean ejection fraction was 54%. Eighty-nine procedures (29.1%) were performed using a hybrid approach by means of MIDCAB and postoperative (60 patients, 67.4%) or preoperative (29 patients, 32.6%) percutaneous interventions on non-LAD vessels. A EuroScore more than 6 was found in 43 (14%) patients. The average follow-up time was 9.5 ± 3.2 years and was 89% complete.Six patients (1.9%) required intraoperative conversion to sternotomy, whereas cardiopulmonary bypass institution after the sternotomy was necessary in one. Postoperative acute myocardial infarction occurring nine patients (2.9%), low output syndrome in four (1.3%). Postoperative mortality was 1.6% (n = 5), and perioperative stroke rate 0.6% (n = 2). Five and 10-year survival were 94.1 and 86.9%, respectively. Freedom from death due to cardiac events and major cardiac and cerebral events at 10 years was, respectively, 97.1 and 92.1%.The results confirm the favorable short and long-term results of the MIDCAB procedure. MIDCAB, in experienced centers, can represent an alternative treatment option for LAD disease.

The authors report a clinical case of alveolar adenoma presenting as a solitary pulmonary nodule which was positive to PET and deeply located in the lung. Few cases of alveolar adenomas have been reported in literature; these lesions are considered pulmonary neoplasms with benign behaviour, usually presenting as a peripheral or subpleural coin lesion; the PET activities of such neoplasms were unknown. The present clinical case was singular for the deep location of the nodule and its tight adhesion to left inferior pulmonary vein requiring a lobectomy. In addition, alveolar adenoma PET behaviour has been reported as light positivity.

Objectives Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and mid-term results. The success of this operation primarily depends on preserving the highly sophisticated dynamic function of the aortic valve by recreating an anatomical three-dimensional configuration similar to the normal aortic root, thus minimizing the mechanical stress and strain on the cusps. Over the years several techniques have been proposed to reproduce the sinuses of Valsalva. We reviewed our experience with aortic valve reimplantation by means of a modified Dacron graft that incorporates sinuses of Valsalva, in a series of 100 consecutive patients. Methods During a 60-month period, 100 patients with aortic root aneurysm underwent aortic valve reimplantation using the Gelweave Valsalva prosthesis. There were 74 males and the mean age was 60+/-12 years (range 28-83 years). Five patients had the Marfan's syndrome, 15 had a bicuspid aortic valve. Cusp repair was performed in five patients. The mean follow-up time was 28.6 months (range 1-60). Transesophageal echocardiogram was performed at the end of each procedure to assess the aortic valve in terms of competence, dynamic motion and level of coaptation within the graft. Results There was one hospital death and two late deaths. Overall survival at 60 months was 91.7+/-5.1%. Five patients developed severe aortic incompetence (AI) during follow-up requiring aortic valve replacement (AVR). The 60 months freedom from re-operation due to AI was 90.9+/-4.4%. One patient had moderate AI at latest echocardiographic study. The 60 months freedom from AI>2+ was 91.6+/-7.9%. Cox regression identified cusp's repair as independent risk factor (P=0.001) for late reimplantation failure (AVR or AI>2+). There were no episodes of endocarditis and the majority of the patients (88%) were in New York Heart Association functional class I. Conclusions The aortic valve reimplantation with the Gelweave Valsalva prosthesis provided satisfactory mid-term results. An accurate assessment of the level of coaptation of the aortic cusps in respect to the lower rim of the Dacron graft by means of intraoperative transesophageal echocardiogram at the end of each procedure is mandatory in order to avoid early reimplantation failure. Cusp's repair may play an important role in the development of late AI. However, long-term results are needed in order to define the durability of this technique.

To investigate the changes of electrocardiographic and echocardiographic indexes of left ventricular hypertrophy (LVH) during antihypertensive therapy, 100 hypertensive patients, mean age 46 years, were studied in pretreatment condition and during 12 months of antihypertensive therapy. In pretreatment condition, 83 patients showed LVH by echocardiography (echo; left ventricular mass index greater than 130 g/m2) and 30 patients had LVH by electrocardiography (ECG) (Sokolow index greater than 35 mm). In comparison to echo index of LVH, Sokolow index showed a sensibility of 34% and a specificity of 88%. Both LV mass echo index and ECG index significantly decreased after 3 months but in different way. LV mass index mainly decreased after 12 months, whereas Sokolow index particularly decreased after 6 months, with no further changes in the subsequent months. After 12 months of therapy, the LV mass echo index normalized in 19% of the patients (16/83) and Sokolow index normalized in 57% (17/30). ECG sensibility and specificity, in comparison to LV mass echo, was 20% and 100%, respectively. Thus, ECG appears less sensitive than echo in the detection of LVH. During antihypertensive therapy ECG index of LVH normalized more precociously and to a greater extent than the echo index. However, the normalization of LVH by ECG does not necessarily mean that a complete anatomic regression of LVH has occurred.

Clinical symptoms of cardiac myxomas are often very confusing. We observed a 46-year-old woman with a left atrial myxoma simulating systemic disease with pleural-pericardial effusion. We think that like other systemic symptoms effusion (which to our knowledge has not been previously described in literature) can be attributed to the result of tumor secretion or necrosis. In fact, soon after surgical removal of the tumor, all pathological signs disappeared.

Aortic valve-sparing operation has been progressively widely performed for the treatment of aortic root aneurysm. Nowadays, this procedure has been proposed even in presence of a bicuspid aortic valve, severe aortic regurgitation or in primary aortic dissection repair. We present our ten-year experience focusing on mid-term echocardiographic follow-up.Between June 2002 and February 2012, 139 patients (mean age of 61±12 years) underwent aortic valve-sparing operation with valve reimplantation. Twenty-seven patients (19%) had bicuspid aortic valve; in eighteen cases (13%) cusp motion or anatomical abnormalities concurred in determining aortic regurgitation and needed an adjunct cusp repair. A Gelweave Valsalva™ graft was implanted in all the patients.The mortality pre-discharge was 0.7% (1 patient). The cumulative 1-year, 5-years and 8-years survival rates were 99%, 93% and 87% respectively. Postoperative aortic regurgitation more than mild degree (2+/4+) was the only significant risk factors for redo aortic valve surgery Freedom from reoperation due to aortic valve regurgitation was 96% at 1 year, 90% at 5 years and 86% at 8 years. When comparing freedom from reoperation in patients with bicuspid vs tricuspid aortic valve, no differences were found (P=0.31) and the rate of aortic valve reoperation was significantly higher (P0.001) in patients who received leaflet's repair.The durability of valve reimplantation was found to be excellent in patients with tricuspid aortic valve and normal or nearly normal cusps. Cusp prolapse and complication after cusp repair turned out to be the main causes for early failure.

Aortic false aneurysm is a rare complication after cardiac surgery. In recent years, improved results have been reported in regard to the surgical management of these high-risk lesions. We retrospectively examined 28 consecutive cases (in 27 patients) of postsurgical aortic false aneurysm diagnosed at our institution from May 1999 through December 2011. Twenty-four patients underwent reoperation. Cardiopulmonary bypass was instituted before sternotomy in 15 patients (63%). Isolated repair of the aortic false aneurysm was performed in 15 patients. Four patients (including one who had already undergone repeat false-aneurysm repair) declined surgery in favor of clinical monitoring. Eleven patients were asymptomatic at the time of diagnosis. In the other 16, the main cause was infection in 7, and previous operation for acute aortic dissection in 9. The in-hospital mortality rate was 16.6% (4 patients, 3 of whom had infective false aneurysms). Relevant postoperative sequelae were noted in 7 patients (29%). The cumulative 1-year and 5-year survival rates were 83% and 62%, respectively. The 4 patients who did not undergo reoperation were alive at a median interval of 23 months (range, 9-37 mo). Two underwent imaging evaluations; in one, computed tomography revealed an 8-mm increase of the false aneurysm's maximal diameter at 34 months. Aortic false aneurysm can develop silently. Surgical procedures should be proposed even to asymptomatic patients because of the unpredictable evolution of the condition. Radical aortic-graft replacement should be chosen rather than simple repair, because recurrent false aneurysm is possible.