Background: Failure of the native aortic valve and degenerative anatomy of ascending aorta in patients with previous Tirone-David operation may represent a clinical challenge, because sometimes the risk of reoperation is prohibitive.Case: We described the case of a patient suffering from severe aortic valve regurgitation and pseudoaneurysm of the aortic arch, 6 years after cardiac surgery operation. The aim of this clinical case was to assess if the complex anatomy of aortic pseudoaneurysm and aortic root geometry can be accurately reproduced from contrast-enhanced computed tomography scan into a three-dimensional (3D) printed model. Based on this procedural method, with the aid of transesophageal 3D ultrasound, we efficaciously treated the patient percutaneously with a combination of transcatheter occluder device plus microcoil embolization and transfemoral aortic valve implantation. The patient was free from complications and the need to redo cardiac surgery.Conclusion: To the best of our knowledge, this is the first description of two simultaneous complications and their staged treatment in a patient with previous aortic valve-sparing operation. This is a useful report in a single 3D model applying such specific technology to these two simultaneous clinical settings.

Introduction The prognostic role of RV function assessment in severe AS has been demonstrated in previous studies. However, the role of 2D speckle tracking RV evaluation in the context of severe AS has not been completely clarified. Methods We retrospectively evaluated consecutive patients with severe AS referred to TAVI at our institution. Exclusion criteria were severe aortic regurgitation, severe mitral stenosis and poor acoustic window for a correct 2D speckle tracking right chamber evaluation. The echocardiographic exams were analyzed off-line with a semi-automatic software (Tomtec Arena, Autostrain ®) to assess RVFW strain and LV GLS. Additionally, a conventional echocardiographic evaluation was made in both right and left chambers (LVEF, FAC, LVEF). Prevalence of conventional RV disfunction was defined as a TAPSE<17 mm or FAC<35%. RVFW impairment cuf-off was defined below 20%. Multivariate regression models were elaborate to assess the major determinants of RV function. Moreover, logistic regression analysis has been made to analyze if RV function could predict high-risk clinical features in the context of severe AS. Results Our cohort was composed of 110 consecutive patients. Mean RVFW was 21±7%, TAPSE 21±4 mm, FAC 44±11% and mean RV area 10±4 cmq/mq. The prevalence of RV disfunction defined by standard echocardiography was 26% (29 patients), instead, RVFW was impaired (below 20%) in 53 patients (40%). At multivariate regression analysis, the main RVFW determinants were MR, AS severity, LVMI, GLS and E/e’ (R2 0.68, p<0.001 including AVA; R2 0.53, p<0.001 including mean gradient). At logistic regression analysis RVFW strain was associated with previous HF hospitalization admission independently from TAPSE (CI 95% 1.03–1.22, p=0.008). Furthermore in a second model, RVFW strain was a significant predictor of advanced NYHA class independently from FAC (CI 95%, 1.01–1.18, p=0.0036). Conclusion The major determinants of RV function in patients with severe AS were MR and LV function. A pressure overload driven by the MR-LV dysfunction combination on right sided heart could impact profoundly negatively on RV function. RVFW strain in this study resulted a more sensitive parameter that conventional RV assessment in highlighting more symptomatic severe-AS patients.

Introduction Intracardiac echocardiography (ICE–Abbot ViewFlex) is used increasingly as an alternative to transoesophageal echocardiography (TEE) to guide left atrial appendage closure (LAAC). ICE allows LAAC to be carried out under local anesthesia and can be performed by the interventional cardiologist, as sole operator. Previous works on ICE–guided LAAC are registry studies with self–reported data. We aimed to investigate the efficacy and safety of ICE–guided LAAC with the novel Watchman FLX device (Boston Scientific, Marlborough, Massachusetts) in a single–center study. Methods This is a rigorous study of patients undergoing LAAC with the Watchmann FLX device. Procedures were guided by ICE from left atrium with local anesthesia. Atrial fibrillation (AF) patients with CHA2DS2VASc score ≥2 and a clinical indication for LAAC were eligible for the study. Procedural preplanning with either cardiac CT or TEE within 7 days prior to LAAC was mandatory, to exclude the presence of LAA thrombus. ICE was used to guide the transseptal puncture and intraprocedurally was carried out with a single transseptal access directly from the left atrium to guide the procedure and device implantation. The primary outcome was the rate of significant peri–device leaks (>5 mm) at 45–days TEE. Safety outcome was a composite of periprocedural complications. Results Twenty–four patients were enrolled over 2 years. Mean age was 75±8 years, CHA2DS2VASc score 4.0±1.3 and HASBLED score 3.4±0.9. The incidence of the primary outcome of significant peri–device leak (>5 mm) was 0,04%; all patients had effective LAAC at 45–days. All patients had a Watchman FLX implanted and technical success was 100%. The number of devices per case was 1.0±0.2. ICE successfully guided assessment of device release criteria, including mean device compression of 21%, which was within the recommended 10–30% range. No subject required conversion to TEE. The only procedural complications were 3 access site bleeds. There were no episodes of stroke, transient ischemic attack, systemic embolization, pericardial effusion, device embolization or device–related thrombus during the procedure or 45–days follow–up. Conclusions ICE can be used to successfully guide LAAC with Watchman LFX with excellent procedural success, a high rate of effective LAAC and minimal peri–procedural complications. The efficacy and safety results are comparable to those reported for TEE–guided Watchmann FLX implantation.

In this case report, we describe a giant coronary aneurysm (CAAs) of the right coronary artery occasionally found in a patient that underwent Bentall procedure 18 years earlier for acute aortic dissection. A 77–year–old man, former smoker, with type II diabetes, hypertension, dyslipidaemia, and obesity, was referred to our echo lab for echocardiography in December 2020. His medical history included anteroseptal non–Q–wave myocardial infarction (1983), type A acute aortic dissection treated with Bentall procedure and implantation of mechanical aortic valve (2002), and reparation of abdominal aortic aneurysm (2003). During the echocardiogram a paracardiac mass was incidentally found, in close contact to the right atrium and with a diameter of 60 mm in A4Ch–view, with the appearance of a cystic formation (Figure A). After a few days, a CT angiography was performed, with evidence of 61.6 mm–sized giant aneurysm located in the proximal right coronary artery, characterised by calcified walls, eccentric thrombosis, and compression of the right atrium (Figure B). The patient was subsequently evaluated by the Cardiac Surgery Division. Conservatively management with regular follow–up was performed, because of the high surgical risk of redo and the lack of symptoms. In November 2022 we performed a follow–up echocardiography with evidence of stability of the size of coronary artery aneurysm (Figure C). CAAs are defined as giant when the diameter of the vessel is greater than 20 mm. These pathological entities are extremely rare, with an incidence rate of 0.02%, and aetiologies are various. The most frequent aetiologies comprehend atherosclerosis (about 50% of cases), congenital (17%), arteritis (e.g., Kawasaki disease), connective tissue disease. Our case is characterised by the occasional diagnosis of CAA 18 years after Bentall Surgery, in absence of inflammatory vessels disease. To the best of our knowledge, It’s the largest giant CAA described in literature after Bentall cardiac surgery. Therefore, cardiologists should consider these rare entities when approaching an incidental echocardiographic finding of paracardiac mass, especially in patients with high burden of atherosclerotic disease. This case report underlines furthermore the importance of an integrated approach in the differential diagnosis of a paracardiac mass.