Michele D'ALonzo

Frozen elephant trunk (FET) stabilizes the arch and proximal descending aorta, but complete distal remodeling is achieved in only a subset of patients with aortic dissection. Persistent false lumen perfusion, aortic growth, and distal stent graft-induced new entry lead to secondary thoracic endovascular aortic repair (TEVAR), and reported distal reintervention rates range from about 13% at 5 years in pooled data to 33% in a center with routine staging. This narrative review examines the indications for and timing of secondary TEVAR after FET. PubMed was searched to September 2026, and 97 publications were included. Evidence obtained in patients treated with FET is distinguished from evidence extrapolated from primary type B dissection and from the authors’ interpretation. We summarize the predictors of incomplete remodeling, including stent graft length, residual re-entry location, chronicity, aortic diameter at the distal stent level, early remodeling trajectory, and heritable aortopathy, and we contrast planned completion with surveillance-based reactive TEVAR, including technical aspects and spinal cord protection. Direct evidence on timing after FET is limited to retrospective series and one pilot randomized trial of TEVAR 1 to 3 months after type I repair; most data on the time-dependent loss of flap plasticity come from primary type B dissection. No universal timing rule is supported. We propose a phenotype-driven approach, not yet validated, in which timing is referenced to dissection onset and individualized to aortic anatomy, disease progression, and clinical condition.

Background: Libman-Sacks (LS) endocarditis, a nonbacterial thrombotic endocarditis, is the most frequent cardiac manifestation of systemic lupus erythematosus (SLE), particularly when associated with antiphospholipid syndrome (APS). It usually involves the mitral valve and is often clinically silent. Case summary: We present a 25-year-old woman with SLE and APS who developed acute hemodynamic deterioration. Urgent surgery revealed a large endocarditic mass arising from the aortic valve leaflet, extending to the aortic root and obstructing the right coronary ostium. Resection and valve replacement were performed successfully. Discussion: Unlike typical LS endocarditis, which manifests as mild valvular lesions, this case demonstrates rare aortic root involvement with coronary ostial obstruction. A review of the literature confirms that such an extension has not been previously reported, underscoring the heterogeneous and potentially life-threatening nature of LS endocarditis. Take home messages: LS endocarditis can present atypically. Recognition of unusual patterns is critical for timely intervention.

Background and Objectives: The optimal timing for surgical intervention in acute aortic valve infective endocarditis (IE) remains debated. Although European guidelines distinguish emergency, urgent, and delayed indications, some centres postpone surgery, concerned that operating before sufficient antibiotic sterilization could increase IE relapse risk. Materials and Methods: This retrospective, observational, multicenter study included patients with acute aortic valve IE. Patients who were not operated, had non-aortic valve IE, or underwent emergency surgery were excluded. Surgery within 7 days of starting targeted antibiotics was classified as “early”; surgery between 7 and 30 days as “late.” Primary outcomes were in-hospital mortality and 30-day permanent pacemaker implantation. Secondary endpoints included reinfection, reoperation for IE relapse, and mid-term survival. Results: A total of 203 patients included: 104 early and 99 late. In-hospital mortality was comparable (early: 16 patients, 15.4%; late: 16 patients, 16.2%; p = 0.90). Permanent pacemaker implantation was higher in the late group (early: 9 patients, 8.7%; late: 18 patients, 18.2%; p = 0.046). Mid-term survival at four years was similar (early: 67.1 ± 5.8%; late: 59.7 ± 8.1%; p = 0.71). Recurrence of IE (early: 5.7%; late: 4.8%; p > 0.9) and reoperation for recurrent IE (early: 5.7%; late: 4.8%; p > 0.9) did not differ. Conclusions: Delaying surgery for acute aortic valve IE does not improve procedural safety, as in-hospital mortality is similar. Early intervention does not increase reinfection or reoperation risk, and may reduce permanent pacemaker implantation, likely by preventing progressive fibrosis of the cardiac conduction system caused by infection and prolonged antibiotic exposure.

Hereditary epidermolysis bullosa (EB) is a rare group of genetic diseases with structural and functional alterations affecting the epithelium leading to cell detachment with skin and mucosal epithelial damage. Certain EB subtypes are associated with an increased risk of cardiomyopathy. Patients with EB simplex (EBS) due to Kelch‐like 24 (KLHL24) mutation could develop dilated cardiomyopathy (DCM) requiring heart transplantation. However, despite optimal management avoiding skin blisters and mucosal damage, there is an increased risk of infections that lead to life‐threatening complications. This case report describes the clinical management of EB associated to DCM in a patient undergoing successful heart transplantation. EB is not a contraindication to heart transplantation and immunosuppression after transplantation may promote good systemic control of this disease.

This case report depicts a rare clinical scenario where emergency cardiac surgery was required following a firearm wound resulting in traumatic aortic arch

Mitral annular calcification makes conventional mitral valve surgery extremely challenging and has led to growing interest in less invasive alternatives such as transcatheter mitral valve replacement. Alongside percutaneous approaches, some centers have explored open transatrial implantation of transcatheter heart valves in patients with heavily calcified annuli. This systematic review examines the current evidence on this hybrid “valve-in-MAC” technique, tracing its clinical evolution, technological refinements, patient outcomes, and ongoing debates. Key themes emerging from the literature include the adaptation of existing balloon-expandable and mitral-specific devices to the complex anatomy of calcified mitral annuli, the open transatrial approach as a safer alternative to extensive surgical debridement, and advances in imaging and device design aimed at reducing left ventricular outflow tract obstruction and paravalvular leak. Persistent uncertainties remain, particularly regarding patient selection, long-term valve performance, and comparisons with conventional surgical repair or replacement. Although open transatrial implantation appears technically feasible and provides favorable hemodynamic results compared with fully percutaneous procedures, reported 30-day mortality remains high (approximately 19–27%). This reflects the advanced age, frailty, and multiple comorbidities typical of this patient group rather than procedural shortcomings. Current evidence is limited, with few comparative studies and little data on valve durability. Future work should prioritize multicenter prospective registries and well-designed comparative studies to better define the role of this emerging salvage strategy.

Background/Objectives: Despite growing awareness of mitral annular disjunction’s (MAD) clinical significance, robust data regarding the outcomes of surgical interventions on MAD remain sparse. This meta-analysis aims to systematically evaluate the current evidence on the efficacy and safety of mitral valve (MV) surgery in patients with MAD. Methods: A systematic review was conducted from inception until May 2025 for studies comparing patients undergoing MV surgery with and without MAD and was registered in PROSPERO: CRD42025649821. Results: Patients with MAD were generally younger (59.3 ± 5.0 vs. 63.4 ± 2.2 years, standardized mean difference: −0.3073), had fewer comorbidities but more complex valve lesions (41.0% vs. 13.7%, risk difference: 0.2627) compared to those without MAD. MV replacement was performed less frequently in the MAD group than in the No-MAD group (risk ratio, RR: 0.690 [95% confidence interval, CI: 0.508; 0.937], p = 0.017), probably related to the significant difference in age between the two groups. The MAD cohort demonstrated a higher incidence of ventricular arrhythmia both after surgery (RR: 7.255 [95%CI: 1.231; 42.763], p = 0.029) and during follow-up (incidence rate ratio, IRR: 2.750 [95%CI: 1.372; 5.512], p = 0.004). Although the MAD group experienced more arrhythmic events over time, this did not translate into a significant difference in overall mortality compared to patients without MAD (IRR: 0.573 [95%CI: 0.072; 4.555], p = 0.599). Conclusions: This meta-analysis revealed significant baseline differences between the populations. Our findings suggest that patients with MAD remained at significantly higher risk for both postoperative and long-term arrhythmias. These results highlight the need for close arrhythmic surveillance in this population.

Iatrogenic aortic regurgitation after mitral valve surgery is the consequence of either direct stitching-related perforation or indirect distortion of aortomitral fibrous continuity by the mitral ring/prosthesis. This review aims at describing the reported cases of iatrogenic aortic valve regurgitation following mitral valve surgery, focusing primarily on its management. PubMed, ScienceDirect, DOAJ, and Cochrane databases were searched from inception until December 2023 for case reports and case series describing iatrogenic aortic valve regurgitation following mitral valve surgery. The literature review found 17 articles describing 20 cases of new onset aortic valve regurgitation after mitral valve surgery. Among them, 5 patients did not undergo reoperation, either due to medical decision or patient refusal. The non-coronary cusp was predominantly affected (11 cases), the left coronary cusp involved in 4 cases, and a mixed mechanism occurred in 5 cases. Subsequent surgical interventions included aortic valve replacements in 5 cases and aortic valve repair in 4 cases. A suggested management decision algorithm is finally proposed. Iatrogenic aortic valve regurgitation after mitral valve surgery remains an unfortunate complication. Attention should be given to prevent this complication. Intraoperative transesophageal echocardiography plays a crucial role for early detection. Management strategies vary from medical therapy to surgical interventions. The reparative strategy requires a surgical procedure associated with significant mortality.