INTRODUCTION Situs inversus totalis, dextrocardia with interrupted inferior vena cava and azygos vein continuation concomitant with symptomatic atrial fibrillation requiring ablation. This case was deemed not suitable for percutaneous ablation due to anatomic variations and the lack of case reports in literature. METHODS AND RESULTS We performed bilateral thoracoscopic epicardial ablation and epicardial left atrial appendage exclusion. The direct vision allowed for a complete box lesion set with bipolar radiofrequency device. Patient remained in sinus rhythm at 12-months follow-up. CONCLUSION Surgical thoracoscopic epicardial ablation is safe and effective also in congenital defects. Multidisciplinary expertise can offer minimally invasive ablation treatments.

Background: Mitral annular calcification (MAC) represents an important risk factor in mitral valve (MV) surgery. Despite several procedures have been described, no surgical treatment of choice has been yet established. Materials and Methods: A systematic review of the literature and meta-analysis on patients undergoing MV surgery associated to MAC was performed. The meta-analysis primary endpoints were 30-day mortality and late overall and cardiac-related mortality. Secondary endpoints were early reintervention, re-exploration for bleeding, postoperative pacemaker implantation, cerebrovascular accident, atrioventricular groove rupture, acute myocardial infarction and late recurrences of mitral regurgitation (MR) or paravalvular leak and reintervention. Primary and secondary endpoints were also evaluated in the subgroup analysis between MV repair and replacement surgery. Meta-regression was used to analyze the influence of decalcification and annular reconstruction on endpoints. Results: Among 1429 papers, 25 papers studying 1327 patients were included. In the pooled analysis, the 30-day mortality event rate was 2.89% (95%Confidence Interval [CI], 1.48%-5.57%) and 7.72% (95%CI, 2.95%-18.71%) for MV repair and replacement respectively. At mid-term follow-up, MV repair revealed a significantly lower incidence rate (IR) of death compared to MV replacement (p=0.043), with a trend of higher reoperation IR compared to replacement (p=0.051) and a trend of higher recurrent MR2+ in MV repair (p=0.071). Annular reconstruction was associated with a significant increase in re-exploration for bleeding at univariate analysis, but not at the multivariate meta-regression. Conclusions: The current meta-analysis suggests that MV repair in MAC patients may provide better short and mid-term survival outcomes when compared to replacement.

OBJECTIVES: Feasibility and results of cardiovascular hub-spoke networks to face COVID19 pandemic. The COVID-19 pandemic in Italy had the primary outbreak in the northern part of the country forcing the regional health care system to expand the availability of beds in the wards and intensive care units and to institute a Hub and Spoke hospital network to ensure assistance continuity for urgencies and emergencies. We report a descriptive analysis of the activity of the first 30 days of the Hub center. METHODS: Role of our Hub center was to guarantee 24/24h 7/7days cardiovascular surgical care for an area of 3.145.312 inhabitants’ area. Hub-spoke reorganization permitted a significant increase of ICU and ward beds availability for COVID patients needing hospitalization in all peripheral centers. Records of all consecutive patients admitted were collected and analyzed. RESULTS: a total of 100 patients were evaluated in the study period . Hub and spoke cooperation have been successful, all patients affected by cardiovascular urgencies or emergencies found a highly specialized hospital and was evaluated and treated. Global reduction of elective and non-deferrable interventions in spoke centers was achieved for both vascular and cardiac surgery while we detected a significant increase of urgent vascular interventions for acute limb ischemia. We did not observe an increase of in-hospital mortality in non-infected patients. CONCLUSION: Hub and spoke network for cardiovascular pathology is an effective way to face healthcare needs during the pandemic.