Redo sternotomy is a challenging surgical procedure performed with increasing frequency; catastrophic hemorrhage is a rare but highly lethal complication. We report our experience in treating this complication in 3 cases of 307 reoperations and propose a simple method to control catastrophic hemorrhage during sternal reentry.

In this report we present the case of a double aneurysm, which developed 1 week after pericardiocentesis because of cardiac perforation following aortic valvuloplasty in a newborn. The patient underwent successful surgical treatment through normothermic cardiopulmonary bypass with external plication of double aneurysm.

We report the case of a 41-year-old man presenting with a large Kommerell's diverticulum aneurysm in the right-sided aortic arch with retroesophageal component and moderate thoracic aortic dilation. Surgical treatment was performed through left thoracotomy and consisted of aneurysmectomy, closure of the distal aortic arch defect and aorta-left subclavian artery bypass. After 2 years computed tomography showed no modifications in the thoracic aortic morphology and the patency of the graft to the subclavian artery.

The fate of aortic ectasia associated with aortic valve disease is usually derived from the natural history of primitive aortic aneurysm. We evaluated the evolution of untreated aortic dilation following aortic valve replacement and analyzed risk factors for expansion.

Typical atrial flutter is readily abolished by creating a line of block along the isthmus between the tricuspid annulus and the inferior vena cava. However, postablation atrial fibrillation occurs frequently, and its occurrence increases during the follow-up. Preablation atrial fibrillation is the most important risk factor for postablation atrial fibrillation occurrence. Among patients with preablation atrial fibrillation, patients with drug-induced atrial flutter present a lower risk of postablation atrial fibrillation than patients with spontaneous preablation atrial fibrillation. Patients with preablation lone atrial flutter also present a significant risk of atrial fibrillation development as time passes. Hence, they must be advised of the risk of recurrent symptoms and late atrial fibrillation, and closely followed up despite successful transisthmic ablation. Patients with atrial fibrillation after transcatheter isthmus ablation should be offered catheter-based pulmonary vein isolation, particularly if atrial fibrillation occurs despite continuation of antiarrhythmic drug therapy.

The term "cardiorenal syndrome" has been applied to the presence or development of a renal dysfunction in heart failure patients. Renal function that worsens during hospitalization is a major precipitant of decompensation and cause for admissions in heart failure patients and is a more important predictor of adverse outcome than baseline renal function. Despite growing recognition of the frequent presentation of this combined cardiac and renal dysfunction, its underlying pathophysiology has not been well described and its management remains even less well understood.

In patients with acute ST-elevation myocardial infarction (STEMI), in order to shorten the time to definitive treatment, it is essential to coordinate the intervention between the local healthcare system and the hospitals. In 1999, a Working Group for Prehospital Emergency in Cardiology was established in Milan, and a network for 12-lead ECG transmission between advances life support (ALS) ambulances, the headquarter of 118 Rescue Service and the Coronary Care Units (CCU) or Divisions of Cardiology was developed: between February 1, 2001 and May 1, 2005, 6821 patients with suspected heart attack were rescued and their ECG recorded and transmitted (177 patients/month, 20% of them with an ST-segment shift, 11% ST-segment elevation, 9% non-ST-segment elevation, 24% with normal ECG). The rate of false positive automatic diagnosis of acute myocardial infarction was 0.3%, the rate of false negative was 0.8%. Forty-six patients with ventricular fibrillation underwent DC-shock. After May 1, 2004, clinical data of patients with STEMI transferred to the hospitals by ALS ambulances were reported in a database: 82% of the 89 patients were treated with primary angioplasty. The time (median, interquartile ranges) between ECG arrival to the CCU and the ECG report was 2 min (1-5), between ECG arrival to the CCU and patient arrival to the hospital was 34 min (24-42), between ECG arrival to the CCU and primary angioplasty was 69 min (50-93); the door-to-balloon time was 33 min (22-60). The telephone ECG transmission has been demonstrated to be a useful and rapid tool, easy to use; the automatic ECG diagnosis was accurate. In patients with STEMI the telephone ECG transmission shortened the time of delivery of therapy, helped to recover arrhythmic complications, allowed both the coordination between the 118 System and the Divisions of Cardiology and the implementation of the triage for primary angioplasty. Increasing the technological level of the service will be the next step of the program: the protocol will be upgraded in order to increase the number of patients rescued, to shorten the time of operation and to administer prehospital fibrinolytic therapy in selected patients.

We present an evidence-based diagnostic and therapeutic pathway for the treatment of subjects with suspected acute elevated ST-segment myocardial infarction (STEMI). The pathway was developed to aid the reorganization of the emergency service (ES) of the Lazio Region of Italy. Pathway development followed several phases: a) setting up of a multidisciplinary panel comprising all professional figures involved in the management of STEMI subjects; b) drafting of a list of important research questions with a particular focus on areas of clinical and organization uncertainty; c) systematic searches for relevant international scientific evidence to answer research questions; d) assessment, synthesis and classification of identified evidence according to the quality of evidence; e) formulation of management recommendations by their strength according to the methods used by the national guidelines program; f) presentation of draft findings and recommendations; g) external peer review of the draft document; h) editing the final version of the document. Our document identifies possible action scenarios (community, emergency room, major accident and emergency departments) and the following critical points: 1) quick diagnosis and individual risk definition; 2) rapid transmission of the electrocardiogram and vital parameters to the ES control center or to the competent coronary care unit (CCU) depending on where the event took place; 3) a direct link between the ES control center and the competent CCU; 4) the structuring of the regional CCU into a Hub & Spoke model; 5) electronic communication of data between ambulance, ES control center and the competent CCU. Our document also defines Hub regional reference centers and local Spoke centers. The pathway details roles and responsibilities of all players in the emergency chain for STEMI sufferers and critical points for the delivery of the pathway: regional programs on early warning, functions of relevant ES personnel and of emergency room physicians, efficiency of the electronic network and identification and organization of the regional Hub & Spoke network.