No abstract

Left atrial intramural hematoma (LAIH) is an uncommon entity for which a timely diagnosis is critical for decision making. Cardiac surgical or catheter-based procedures are potential causing factors. Though cardiac computerized tomography and magnetic resonance are highly accurate diagnostic modalities, their role is limited by the lack of widespread availability. The present clinical case illustrates the diagnostic features of LAIH that can be obtained using echocardiography at the bedside in critically ill patients. We report a case of LAIH, that followed a catheter ablation procedure and was complicated by cardiac and cerebral ischemia. Cardiac surgical management was required.

Background and Aim: right antero-lateral minithoracotomy through the 3rd or 4th intercostal space is the classic approach for minimally invasive mitral surgery. We report our experience with an alternative and more cosmetic minimally invasive port-access through a right vertical axillary minithoracotomy (RVAMT). Methods: between July 2016 and April 2018, 60 patients (32 females and 28 males, mean age 66.2 ± 11.1 years) underwent mitral valve surgery through a RVAMT. Forty-six mitral valve repairs were performed, 4 associated to tricuspid repair. Only 14 pathological mitral valves have been replaced. RVAMT was performed by a 5–6 cm incision through the 4th intercostal space placed vertically along the antero-axillary line rather than antero-laterally along the intercostal space. All surgical procedures were performed without an endoscopic system. Results: mean CPB time and aortic cross clamp were 130.2 ± 26.1 minutes and 90.6 ± 16.6 minutes, respectively. There was no approach-related limitation to surgical exposure. Bleeding requiring surgical revision occurred in two patients. Median intensive care unit stay and mean mechanical ventilation time were 24 and 8.3 ± 5.4 hours, respectively. In-hospital mortality was 1.7% (1/60 patients). Overall survival at 6 months follow-up was 100%. Conclusions: RVAMT is a safe alternative, reproducible, cosmetic and minimally invasive approach for mitral valve surgery. It provides an optimal surgical viewing perpendicular to the mitral plane with satisfactory valve exposure and the possibility to perform surgery under direct vision. The cosmetic advantage of the RVAMT is the short incision under the armpit that is often invisible.

Bicuspid aortic valve (BAV) is often associated with coronary abnormalities. The finding of BAV associated with an anomalous circumflex coronary artery (ACCA) originating from the right Valsalva sinus (VS) and surrounding the non-coronary VS is however a rather rare occurrence. We report a case of successful Bentall operation with a composite button technique in a 56-year-old man with aortic root dilatation, BAV insufficiency and coexisting ACCA. In this case a 25 SJM composite graft was implanted in supraannular fashion rather than intraannular to avoid: 1) ACCA injury or obstruction of the proximal course near the annulus by suture ligation, 2) compression by prosthetic ring, 3) distortion of ACCA during ostia reimplantation. We demonstrated that attention to the anatomic relationship of ACCA to the aorta is crucial and prosthesis supraannular implantation technique allows a safe aortic root replacement.

Background and aim: Colloids administration has been associated with post-operative acute kidney injury and bleeding. Aim of the study is to evaluate if the incidence of re-exploration for bleeding was modified by application of perioperative fluid management protocol with careful balanced crystalloids infusion and colloids administration abolition. Methods: We retrospectively analysed data collected in the Institutional database. 784 patients were considered in the analysis. 459 patients (Group A) underwent cardiac operations before perioperative fluid management protocol was strictly applied and 325 patients (Group B) underwent cardiac operations after protocol application. Results: No differences were found for pre-operative characteristics except for hypertension and NYHA class (higher in A Group). Intraoperative variables were similar in both groups. No differences were found between groups for post operative complications, except for the incidence of re-exploration for bleeding (4.3% vs 1.5%; p:0.02), time on mechanical ventilation (31.3 vs 13.4 hours; p:0.006), sternal wound infection (3.9 vs 0.3%; p:0.02), post-operative pneumonia incidence (2.9 vs 0%; p:0.01), mean RBC units transfused (3.8 vs 2.6 Units; p:0.03) and numbers of patients receiving fresh frozen plasma transfusions (13.7% vs 3.7%; p:0.02), which were higher in Group A. Conclusions: Fluid management protocol application and colloids avoidance significantly reduce re-exploration for bleeding and post-operative blood products use after cardiac surgery.