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Left ventricular assist device (LVAD) obstruction can be a dramatic and life-threatening complication in patients with advanced heart failure (HF). Despite surgical redo is often required in these patients, it is associated with a high risk of periprocedural negative outcome. We report the case of a 68-year-old male with a thrombotic stenosis of the LVAD proximal outflow-graft. Following Heart Team debate, a percutaneous intervention was planned during veno-arterial Extra Corporeal Membrane Oxygenation (ECMO) assistance. To achieve the needed catheter support, we used the “distal balloon anchoring technique” through the outflow-graft and managed to implant a covered stent, rapidly restoring the flow through the LVAD. The patient was discharged without further complications. Our case shows that, in selected cases, percutaneous treatment of LVAD obstructions can be feasible, especially using advanced techniques derived from the experiences in coronary interventions and under ECMO assistance. More cases and prospective studies are mostly needed to explore long-term patency of the LVADs and clinical outcomes in these high-risk patients.

Objectives: To examine the surgical treatment and mortality rate of valvular infective endocarditis complicated by an abscess in patients at a major tertiary care center. Background: Infective endocarditis (IE) involving a heart valve is fatal if left untreated. The appearance of a comorbid abscess impacts the choice of treatment and surgical technique and, in some instances, may present unique technical challenges. Methods: Departmental data from all patients who underwent surgery for IE at a single major tertiary care center from July 2007 to January 2016 were retrospectively screened for the presence of an intracardiac abscess. Patients with at least one confirmed abscess were examined further with respect to the surgical procedures completed and 30-day mortality rate. Results: Over the almost nine years of data collection, we identified 14 patients (9 males, 5 females) with at least one confirmed cardiac abscess. Patients ranged in age from 28 to 77 years old (mean 57.8 ± 14 years). Various surgical procedures were performed, including aortic or/and mitral valve replacement, mitral or/and tricuspid valve repair, and a freestyle prosthetic valve implant in the pulmonary position. In two patients, surgery was extended to include the ascending aorta; while two patients underwent coronary artery bypass grafting. A patch technique was adopted whenever necessary. Overall, 12 patients survived, while one died from septic shock and another from pneumonia. Conclusions: An abscess is a serious complication of valvular infective endocarditis that can appreciably increase the complexity of surgical intervention. In our experience, however, this seemed not to directly affect the 30-day mortality-rate, with both deaths ascribed to disseminated infection.

Objectives The purpose of this study was to clarify the molecular mechanisms linking human mitochondrial deoxyribonucleic acid (mtDNA) dysfunction to cardiac remodeling. Background Defects of the mitochondrial genome cause a heterogeneous group of clinical disorders, including mitochondrial cardiomyopathies (MIC). The molecular events linking mtDNA defects to cardiac remodeling are unknown. Energy derangements and increase of mitochondrial-derived reactive oxygen species (ROS) could both play a role in the development of cardiac dysfunction in MIC. In addition, mitochondrial proliferation could interfere with sarcomere alignment and contraction. Methods We performed a detailed morphologic and molecular analysis on failing hearts from 3 patients with MIC, failing human hearts due to ischemic heart disease (IHD) or dilated cardiomyopathies (DCM), and nonfailing hearts. Results The MIC hearts showed marked mitochondrial proliferation with myofibril displacement. Consistent with morphologic features, increase in mtDNA content per cell and induction of genes involved in mitochondrial biogenesis, fatty acid metabolism, and glucose transport were observed. Down-regulation of these genes characterized DCM and IHD hearts. A pronounced increase in mitochondrial-derived ROS was observed in MIC hearts compared with failing hearts due to other causes. This was paralleled by up-regulation of genes encoding for uncoupling proteins and antioxidant enzymes. However, there was not a significant increase in antioxidant enzyme activity. Conclusions Our results suggest that besides energy deficiency, mitochondrial biogenesis per se is a maladaptive response in MIC and, possibly, in other metabolic cardiomyopathies.

Primary cardiac lymphomas (PCLs), involving solely heart and/or pericardium at presentation, are rare events. They are frequently recognized at autopsy and generally carry a poor prognosis due either to a delay in the diagnosis or to infiltration of heart structures. We report here on two patients with large B-cell PCL. One is a 52-year-old man who presented with multiple cardiac tumors infiltrating mainly the right atrium and the inter-atrial septum. Diagnosis was established by ultrasound-assisted transesophageal biopsy of the intra-atrial multilobated tumor mass. He was treated with Rituximab-implemented high-dose sequential (R-HDS) chemotherapy followed by autologous peripheral blood stem cell transplantation, attaining complete response. He had no evidence of disease 24 months from onset. The second patient was a 70-year-old woman who presented with pericardial tamponade and low-output cardiac failure. Despite prompt pericadiocentesis and chemotherapy with cyclophosphamide and vincristine, she died 2 weeks later. Postmortem examination revealed large B-cell lymphoma proliferation confined to the heart. Whether primitive heart localizations represent an independent prognostic factor, and what specific measures should be adopted in patients with this rare presentation is the subject of the present report and review of the literature.

Objective: To explore the hypothesis that intermittent ischaemic arrest (IIA) provides better myocardial preservation but generates a larger number of cerebral microemboli (ME) and consequently a higher incidence of post-operative cerebral dysfunction compared with the single clamp technique (SCT). Methods: Ninety-one patients with stable angina undergoing elective CABG with no clinical evidence of aortic or cerebro-vascular or neurological disease were prospectively randomized to: IIA (n = 43) or SCT with intermittent anterograde cold blood cardioplegia (n = 48). Myocardial preservation was assessed by measuring serum CK-MB, Troponin-T (TnT) and Troponin-I (TnI) and from pre- and post-operative ECGs and left ventricular (LV) function by echocardiography. Intra-operative cerebral ME were counted by transcranial Doppler of the right middle cerebral artery. All patients completed the Luria Nebraska Neuropsychological Battery (LNNB) tests for motor, visual, reading, memory and intellectual processes the day before surgery and at 1 week and 6 months post-operatively. Serum levels of the neuro-specific protein S-100 were measured. Results: The two groups were comparable for age, sex, extent of coronary disease, previous myocardial infarction, diabetes, hypertension and number of arterial and venous grafts. The median number of ME detected per patient was 34 (range 4-208) and was similar in both groups. Protein S-100 levels remained normal and similar in both groups at all times except in one patient with SCT who had an operative stroke. LNNB scores were similarly depressed at 1 week and recovered in all cases at 6 months. There was no correlation between the number of ME and LNNB scores. Median peak TnI levels were 0.64 μg/l with IIA vs. 0.87 μg/l with SCT (P = NS) and TnT 0.8 μg/l vs. 1.08 μg/l (P < 0.03). SCT was however associated with longer mean ischaemic (67.6 + 16.1 vs. 34.5 + 16.5 min, P < 0.001) and mean bypass time (88.5 + 18.2 vs. 74.6 + 26.3min, P < 0.004) than IIA. Four patients with SCT and none with IIA had ECG changes suggestive of MI (P = 0.04). Conclusion: During elective CABG in patients with no clinical evidence of aortic or cerebro-vascular disease the incidence of peri-operative ME and post-operative neuropsychological disturbances are comparable with both techniques of myocardial preservation. Biochemical analysis suggests that IIA provides more effective myocardial preservation.

Anomalous origin of the left main coronary artery from the pulmonary artery is rarely associated with other conditions. We report the case of an infant born with tetralogy of Fallot and aortopulmonary window who at the time of surgical repair was found to have an anomalous left main coronary artery originating from the right pulmonary artery.

Background: Pulmonary autografts offer many theoretical advantages. However, the operation is complex, may interfere with right ventricular and pulmonary outflow function, and requires a longer operative time than does the homograft operation. The effects of these potential disadvantages are unknown. Methods: To clarify these issues we randomized 70 patients undergoing aortic valve replacement to an aortic homograft group (group A = 37 patients; 53%; 34 male, 3 female) or a pulmonary autograft group (group B = 33 patients; 47%; 28 male, 5 female). Ages varied from 12 to 65 years (mean 39 ± 15 years) for group A and from 3 to 54 years (mean 29 ± 15 years) for group B (p = not significant). Eleven patients in group A (30%) and eight in group B (24%) had previous aortic valve surgery. All patients were operated on by the same surgeon. The mean cardiopulmonary bypass time was 113 ± 29 minutes (range 66 to 175 minutes) for group A and 151 ± 31 minutes (range 115 to 226 minutes) for group B (p < 0.002). Mean aortic crossclamp time was 85 ± 19 minutes (range 45 to 140 minutes) for group A and 109 ± 20 minutes (range 74 to 164 minutes) for group B (p = 0.02). In 32 patients (86.5%) the aortic homograft was implanted as a root with coronary reimplantation. All pulmonary autografts were implanted as a root. Results: No early or late deaths had occurred in this series at a mean follow-up time of 16 months (range 3 to 21 months). Two patients (one in each group) required reexploration for bleeding. No statistically significant differences were observed between the two groups with regard to ventilatory support (group A, mean 10 ± 8.5 hours; group B, mean 29 ± 85 hours), total blood loss (group A, mean 471 ± 347 ml; group B, mean 543 ± 404 ml), intensive care unit stay (group A, mean 1.2 ± 0.6 days; group B, mean 2 ± 3.7 days), and hospital stay (group A, mean 9.5 = 3.2 days; group B, mean 12 ± 6 days). Postoperatively, all patients are in New York Heart Association class I (93%) or II (7%) (p = not significant). Ejection fraction for the two groups did not change significantly over the follow-up period. Left ventricular mass and diastolic diameter showed progressive regression, with no apparent difference between the two treatment groups to date. Echocardiographic evalu- ation of aortic valve function at 6 months showed good valve function in all patients with no evidence of aortic regurgitation in 80% of both groups. In group B the right ventricular outflow gradient was below 15 mm Hg over the follow-up period. Holter monitoring, available only in 44 patients (63%), showed most of the arrhythmias to be grade 0 to 1 of the modified Lown grading system. Conclusion: Although the pulmonary autograft requires a significantly longer operating time, this does not seem to affect early and medium-term outcome when compared with results obtained with aortic homografts. Continued patient evaluation is warranted, particularly with regard to evidence of valve degeneration and right ventricular function and arrhythmias in the long term. (J Thorac Cardiovasc Surg 1997;113:894-900)