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L’Insufficienza tricuspidalica (IT) di tipo funzionale, secondaria a patologia delle sezioni sinistre del cuore, è la più frequente forma di patologia della valvola tricuspide nei paesi occidentali, mentre la forma organica, più spesso isolata, risulta meno frequente. Sebbene diversi studi abbiano recentemente dimostrato evidenze in favore di un approccio chirurgico più aggressivo nella correzione dell’insufficienza tricuspidale funzionale, solo una piccola parte di questi pazienti viene trattata; ancor più raro è il ricorso alla chirurgia in pazienti con malattia tricuspidale isolata, a causa dell’elevata mortalità ospedaliera, soprattutto in caso di sostituzione. Ciò evidenzia come sia necessario ridefinire i criteri di selezione dei pazienti e le tempistiche per le procedure chirurgiche isolate. Negli ultimi anni sono state sviluppate diverse opzioni di trattamento percutaneo simili a quelle usate per la patologia mitralica, ovvero con plicatura dei lembi, rimodellamento dell’anulus o sostituzione valvolare. Gli studi scientifici pubblicati finora hanno mostrato dati promettenti in termini di sicurezza ed efficacia. In futuro il trattamento percutaneo potrà rappresentare una valida alternativa per un ampio numero di pazienti con IT inoperabili o ad alto rischio per la chirurgia convenzionale, ma attualmente non è disponibile per un uso generale a causa di limitazioni anatomiche e la necessità di tecniche di imaging avanzate. Lo scopo di questo lavoro è quello di analizzare gli aspetti eziopatogenetici, diagnostici e prognostici dell’IT e di riassumere le opzioni terapeutiche attualmente disponibili alla luce delle moderne acquisizioni tecnologiche nel trattamento percutaneo di una valvulopatia per molti anni sottovalutata.

We present a 49-year-old man who required extraction of a cardiac resynchronization device due to lead infection. While 2 leads were successfully retrieved by a transvenous approach the third one with active fi xation and entrapped into a coronary sinus side-branch

Background We aimed to evaluate size changes of the thoracic aorta during the cardiac cycle with dynamic computed tomographic angiography (CTA) at specific anatomic landmarks in patients who previously underwent ascending aorta repair because of type A dissection, and to correlate aortic wall motion with several cardiovascular risk factors. Methods From December 2008 to December 2010, 18 patients (14 men and 4 women, mean age 64 ± 12 years) with previous aortic repair underwent electrocardiography-gated CTA follow-up. Aortic systolic and diastolic diameter and cross-sectional area were measured at 4 levels: 1 cm proximal (level A) and 1 (B), 3 (C), and 10 cm (D) distal to the origin of the left subclavian artery. RESULTS were assessed according to age and presence of diabetes, hypertension, and smoking. Results This morpho-functional evaluation of aortic wall motion demonstrated a significant influence (P 55 years. Conclusions Smoking, diabetes, and hypertension play a role in impairing aortic size variations. These variations might predict wall structural alterations due to cardiovascular risk factors before they become morphologically evident. This might influence timing of surveillance following repair of acute dissection, allowing it to be specifically tailored for any single subject.

We report the case of a 66-year-old woman admitted to the intensive care unit (ICU) for ongoing dyspnea and hemoptoe. She was operated upon in 1979 for aortic coarctation by the interposition of a 14 mm Dacron prosthesis from the left subclavian artery to descending aorta. Clinical evaluation performed over the years was normal with no signs of cardiac failure or prosthesis malfunctioning. The computed tomography scans (CT) showed a progressive increase of the descending aorta diameters and the onset of a pseudo-aneurysm of 50 mm in diameter. Patient was re-operated through a median sternotomy enlarged by a left thoracotomy and intra-operative findings revealed the pseudo-aneurysm originating from a dehiscence of the proximal suture. In order to allow a safe reconstruction of the dilated subclavian artery, a T-shaped composed graft was confectioned and then sutured to the descending aorta and the subclavian artery, respectively. Post-operative course was uneventful and three months CT scan showed a normal position of the composed graft.

A 40-year-old female of African origin presented in the 32nd week of her second pregnancy with thrombosis of a bileaflet mechanical prosthesis implanted in the mitral position. After an emergency cesarean section, she was successfully treated by means of a multidisciplinary approach.

In patients with infective endocarditis (IE), splenic involvement is a rare but well-known adverse event. The treatment of patients with IE and splenic abscesses is still challenging and controversial. We report 3 patients with IE and splenic abscesses who underwent successful valve replacement and splenectomy. Our experience confirms that in such a patient, a valve operation combined with splenectomy can be performed with excellent results during the same hospitalization. The timing of splenectomy and the type of surgical approach should be based mainly on the stability of a patient's hemodynamic condition.

Endovascular stent-graft repair is emerging as the treatment of choice for complicated type B aortic dissection. In this report we describe a patient who presented with type B aortic dissection involving a right-sided aortic arch (RAA), a rare congenital vascular anomaly. The initial aggressive medical treatment proved unsuccessful due to false aneurysm expansion. Given the greater complexity of conventional surgical repair and the limited experience with this rare malformation, endovascular repair was preferred and successfully performed. We report the first case of endovascular repair of type B dissection involving RAA, confirming that endovascular treatment is technically feasible also when the dissection involves this unusual vascular malformation.

Background . The aim of this study was to determine whether short-term clinical improvement after isolated transmyocardial holmium laser revascularization (TMLR) in patients with coronary artery disease not amenable to traditional treatment is maintained through a longer follow-up. Methods . Between November 1995 and June 1999 34 patients underwent TMLR (mean age, 67 ± 7 years); previous revascularization procedures had been performed in 76%. Preoperatively, mean angina class was 3.6 ± 0.5 in 12 patients with unstable angina; mean left ventricular ejection fraction was 47% ± 9%. Results . There was 1 early death due to low cardiac output. Mean duration of TMLR and of the entire operation was 25 ± 12 minutes and 125 ± 43 minutes, respectively. There were no major postoperative complications; mean hospital stay was 8 ± 4 days. There were 8 late deaths caused by stroke (2 patients), cardiac failure (1 patient), and myocardial infarction (5 patients). Follow-up of current survivors ranges from 4 to 48 months (mean, 32 ± 12 months). At 1-year follow-up mean angina class was 1.8 ± 0.8; but at a later follow-up (mean, 35 ± 10 months) it significantly increased to 2.2 ± 0.7 ( p = 0.005). Three-year actuarial survival was 76% ± 8% and freedom from cardiac events 44% ± 10%. Conclusions . Our results show that after initial clinical improvement many patients experience return of angina or cardiac events; this questions the long-term symptomatic benefit of TMLR.

Ventricular septal defect (VSD) and papillary muscle rupture are severe complications of myocardial infarction which are usually observed individually although their simultaneous occurrence has been observed in pathological studies. An 82-year-old female underwent repair of a post-infarction VSD and 13 days later required mitral valve replacement due to delayed papillary muscle rupture. Mechanical complications of myocardial infarction can occur in the same patient even in delayed fashion and a two-stage correction may be successfully accomplished.

The evaluation of coronary reserve within a few hours of aortocoronary bypass surgery could be of extreme utility for the follow-up or therapeutical management of these patients. In 11 men patients who underwent aortocoronary bypass surgery, a dipyridamole echocardiography stress test was carried out before (1 to 3 days), early after (68 to 130 minutes), and 1 week after surgery. The first and third tests were performed using a standard transthoracic approach, while the second was performed by a transesophageal approach. Dipyridamole was administered intravenously at a dose of 0.56 mg/kg body weight (low dose) and eventually adding 0.28 mg/kg body weight (high dose), always in the absence of antiischemic therapy. An arbitrary wall motion score (0 = eukinesia; 1 = hypokinesia; 2 = akinesia; 3 = dyskinesia) was assigned to the seven different myocardial regions in which the left ventricle was divided in order to have a semiquantitative score. Under basal conditions wall motion score per patient in the three series of tests did not change significantly (1.6, 1.4, and 1.5, respectively), while the mean score during dipyridamole administration showed significant differences (3.6, 1.9, and 1.9, respectively), indicative of the results obtained by surgical repair. The test, positive in all patients before surgery, showed wall motion abnormalities and ischemic ECG changes in two patients immediately after surgery by the transesophageal approach. One patient who had a normal basal contraction pattern and an abnormal response after the test developed in the following days a perioperative myocardial infarction, while a second patient in the follow-up period developed low-level effort angina. Furthermore, by the transthoracic approach it was possible to document in three patients the reversibility of myocardial contraction abnormalities seen under basal conditions, the so-called “hibernating phenomenon.” It is worthwhile to stress that the results obtained by the test performed 1 week after surgery were the same as those obtained 2 hours after surgery, indicating that the changes in coronary circulation have stabilized by the early hours after surgery. In conclusion, our data, although preliminary, demonstrate that with the transesophageal approach it is possible to evaluate the changes induced by coronary bypass surgery even in the early phases, allowing better patient management and permitting risk stratification.

Percutaneous valvotomy is now more often considered for the treatment of mitral stenosis in poor risk patients. The aim of this study was the evaluation of the morphological changes produced by a similar procedure on the mitral valves of nine nonconsecutive patients undergoing a mitral valve replacement because of calcific isolated or prevalent mitral stenosis. The mitral valve was dilated through the left atriotomy before the valve excision with the same balloon catheter used in the percutaneous procedure. The pathological condition of the valve had been studied before dilatation by means of doppler echocardiography, cardiac catheterization and a visual examination performed by the surgeon before insertion of the balloon. At that time, the orifice area was measured with a Hegar dilator. A new measurement was performed after one or two dilatations performed at a balloon pressure of 2.7 atm. After excision, the valve was examined, photographed and X-rays were taken for evaluation of valve calcification. The pre-dilatation mean mitral valve orifice area was 1.3 +/- 0.4 cm2 and after the procedure was 2.8 +/- 0.3 cm2. In only one patient did the orifice area, originally 2.4 cm2, not increase. There was only one fused and calcified commissure, the other was normal. Before dilatation, the two commissures were fused in 17/18 cases and in 9/18, calcified. After dilatation, 5/17 commissures were completely open (not all were calcified), 10/17 incompletely opened and 2/17 remained fused (one in the above-mentioned patient).(ABSTRACT TRUNCATED AT 250 WORDS)

The use of an intracoronary stent is usually indicated after the acute closure of a coronary vessel following percutaneous transluminal coronary angioplasty. Plaque disruption and dissection, with subsequent spasm and thrombosis, can be contained by this device. In the reported case, acute closure of the left anterior descending coronary artery and of a diagonal branch were caused by the entrapment of a stent proximal to the coronary lesion that it was supposed to treat. An emergency coronary artery bypass graft procedure was required together with removal of the device because of the impending closure of the left main trunk (the site of the stent entrapment). This was successfully performed by means of an easy method, which did not require direct incision of the left main trunk. The less invasive procedure described simplified the operation and probably played an important role in its favorable outcome.

The object of this study was to assess the usefulness of the dipyridamole-echocardiography test in the early evaluation of coronary artery bypass grafting, when the use of an exercise stress test is precluded. We studied 39 consecutive patients (37 men and two women, mean age 57.3 years) referred to our institute for elective coronary artery bypass. Five patients had single, 12 patients double, 20 patients triple vessel disease, and two had left main stem disease. Nineteen left internal mammary artery grafts, 20 sequential grafts, and 39 single vein grafts were performed. All the patients were subjected to the test before (time range 1 to 3 days) and after (time range 6 to 10 days) the operation in the absence of therapy. Dipyridamole was administered intravenously 0.56 mg/kg over 4 minutes (low dose); if no effect was apparent, an additional 0.28 mg/kg over 2 minutes (high dose) was given. During the test, blood pressure and a twelve-lead electrocardiogram were monitored. An arbitrary wall motion score was derived by dividing the left ventricle into six regions and grading from 0 to 3-normokinetic, hypokinetic, akinetic, and dyskinetic zones. Preoperatively the test was positive in 38 patients as evidenced by wall motion abnormalities (36 patients had electrocardiographic changes) and in one patient by electrocardiographic changes and chest pain; 22 tests were positive after the low dose and 17 after the high dose. Angina was present in 33 patients. Mean wall motion score was 1.64 per patient in the basal condition and 4.03 per patient after the test (p less than 0.001). After coronary bypass in three patients the test was positive at the same dosage that was used preoperatively, as shown by wall motion abnormalities (in two patients by electrocardiographic changes, as well). Four patients had symptoms. Furthermore, at 6 months' follow-up, a treadmill stress test performed in these three patients was positive for ischemia and angina. The wall motion score was 1.25 per patient in the basal condition and 1.53 per patient after the test (no significant difference). When the preoperative wall motion score obtained after dipyridamole echocardiography was compared with the postoperative score, a statistically significant difference was seen: 4.03 per patient versus 1.53 per patient (p less than 001). In eight patients we observed an improvement of basal myocardial contractility after the operation, which indicates the reversibility of wall motion abnormalities observed before coronary bypass. In conclusion our data show that the dipyridamole-echocardiography test is a suitable method for the early assessment of bypass grafting when other methods, exercise dependent, are not indicated.(ABSTRACT TRUNCATED AT 400 WORDS)