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To assess the role of the mitral valve apparatus (leaflets, chordae and papillary muscles, (PM)) in left ventricle outflow tract (LVOT) obstruction, and results of the surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM).Twenty-eight consecutive patients (58±11years, 53% female) undergoing HOCM surgery from 2007 to 2016 at our institute were retrospectively reviewed. Endpoints included the involvement of the mitral valve in LVOT obstruction, mortality, and changes in clinical and echocardiographic characteristics after HOCM surgery.Secondary chordae tendineae tractioning the anterior mitral leaflet to the interventricular septum, and systolic anterior motion were detected in 78% of the patients. Anomalous, hypertrophied, and fused PM with muscularis trabeculae hypertrophy were found in 50%, 25%, and 35% of the patients, respectively. Four patients had posterior leaflet redundancy. Secondary chordae (92%), PM, and muscularis trabeculae resection (71%), and PM splitting and elongation (28%) were added variably to septal myectomy (100%). Nine procedures (32%) on mitral valve leaflets were performed, involving six posterior and three anterior mitral leaflets. Long-term follow-up was 4±2.8years. There was no hospital mortality, and NYHA was reduced from 3±0.5 to 1±0.7 (p0.0001), the LVOT gradient from 88±35 to 20±18mmHg (p0.0001), mitral valve regurgitation from grade 3±1 to 1±0.7 (p0.0001), and septum thickness from 18±3 to 14±2mm (p0.0001).The mitral valve apparatus contributes with all its components variably to LVOT dynamic obstruction thus surgical correction in addition to extended myectomy is recommended to achieve the best outcome.

Background Heart transplantation (HTx) improves the quality of life and survival in patients affected by end-stage heart failure. The purpose of the current study is to present the patients' clinical data and results of HTx in a single Center of Sicily. Focus on survival after pre and post HTx mechanical circulatory support use will be performed. Methods. 133 HTx were done from 2004 to the end of 2015.The average donor age was 34±13.5years and the proportion of male donors was 67%. Percentage of use of mechanical circulatory support to bridge patients to HTx was 18%. Results. Overall pre-transplant mechanical circulatory support was not correlated to worse post-transplant prognosis, p=0.757. Severe primary early graft failure requiring extra corporeal membrane oxygenator support strongly impact the early mortality after heart transplantation (p Conclusions. The results of HTx at ISMETT are comparable to those reported in high volume Italian transplant centers as well as in the ISHLT registry. The favorable outcome can be related to focus on multidisciplinary approach, strict recipients' selection and young donor population. Post HTx mechanical circulatory support use in general remains associated with worse post-transplant outcomes. This does not apply to pre-op mechanical circulatory support population.

a Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS— ISMETT (IstitutoMediterraneo per i Trapianti e Terapie ad alta Specializzazione), Via Tricomi 5, 90127 Palermo, Italy b Cardiac Surgery and Heart Transplantation Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS— ISMETT (IstitutoMediterraneo per i Trapianti e Terapie ad alta Specializzazione), Via Tricomi 5, 90127 Palermo, Italy c Research Office, IRCCS — ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Via Tricomi 5, 90127 Palermo, Italy d University of Liege Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liege, Belgium

69-YEAR-OLD WOMAN with a history of diabetes, diffuse joint pain, and previous left anterior descending coronary artery angioplasty was admitted to a community hospital with low-grade fever (37.51C) and vague chest pain associated with respiratory movements. The erythrocyte sedimentation rate and C-reactive protein were both elevated. The cardiac enzymes were normal. The electrocardiogram showed 1.5-mm ST-segment elevation in leads I, aVL, and V3 to V6. An initial transthoracic echocardiogram (TTE) showed a small pericardial effusion (0.8 cm). Suspecting an inflammatory pericarditis, the patient was treated with indomethacin, 50 mg twice a day. Three days later, the patient suffered an episode of orthostatic hypotension with nausea. A followup TTE showed worsening of the pericardial effusion (1.8 cm on the anterior wall, 1.7 cm on the lateral one), traces of fibrin, and collapse of the right atrium. The patient was urgently sent to the authors’ institution with a diagnosis of cardiac tamponade due to inflammatory pericarditis. Upon admission to the authors’ institution, the white blood cell count was 16,000 cells/µL. Another TTE confirmed the cardiac tamponade (Fig 1), and the patient was transported to the operating room for subxiphoid pericardial window during which 350 mL of serous fluid and fibrin adhesions were removed. Postoperatively, the patient remained hemodynamically stable and denied further pain. The white blood cell count rapidly returned to the normal range, and a TTE examination conducted before the patient was discharged from the hospital excluded pericardial effusion. Pathology confirmed the diagnosis of nonspecific pericarditis. The patient returned to the referring hospital to complete the rheumatologic diagnostic workup and physical rehabilitation on the sixth postoperative day. A week later, the authors were consulted again because of purulent drainage from the surgical wound with fever, an elevated white blood cell count, and blood culture positive for methicillin-resistant Staphylococcus aureus (MRSA). In order to define mediastinal involvement, a computed tomography (CT) scan was obtained (Fig 2). What is the diagnosis?

Background Primary graft failure (PGF) remains the strongest determinant of perioperative mortality after heart transplantation (HT). Donor management may play an important role in the incidence of PGF. Materials and methods Multivariate analysis was used to identify PGF determinants after HT. Donor and recipient data were analyzed together with preharvest management information and perioperative results. PGF was defined as the need for mechanical circulatory support immediately post-HT. Results Isolated HT was performed in 54 consecutive patients from January 2006 to June 2009. PGF occurred in 11 (20%) patients. Upon univariate analysis, preoperative mean pulmonary arterial pressure was significantly higher among patients developing PGF (P = .02). The donors for PGF patients had more often been managed with high inotropic support (dopamine > 10 μg/kg/min and/or alpha agonists > 0.06 μg/kg/min; P = .008). In contrast, death for head trauma was more common among donors for patients who did not develop PGF (P = .02). In-hospital mortality was 13% (7/54); 71% of these deceased patients displayed PGF (5/7). Upon multivariate analysis, preharvest high donor inotropic support was the strongest determinant of PGF (P = .01, odds ratio [OR] = 7.5). Donor death due to head trauma showed a protective effect against PGF (P = .03, OR = 0.1). Conclusion PGF remains a lethal perioperative complication despite modern tools for prompt cardiac mechanical assistance. As a result of the organ shortage, many centers accept marginal hearts assuming that donor hemodynamic management shows a reduced impact on PGF. We suggest a timely evaluation of the hazards for PGF whenever high inotropic support is used, especially among donors dying for causes other than head trauma.

In this report we summarize a case of myocardial infarction that developed an apical ventricular aneurysm, which was surgically removed to re-expand and reappear as a pulsating chest wall mass 16 years later.