Iatrogenic diversion of inferior vena cava into left atrium after surgery for a rare combination of congenital heart diseases

Atrial septal defect [ASD] is a common congenital anomaly that has low surgical mortality and morbidity. We report a very rare case of a low-lying ASD, combined with the drainage of the inferior vena cava and the left superior vena cava into the left atrium. This combination was associated with an unroofed coronary sinus. We also describe an iatrogenic surgical diversion of the inferior vena cava into the left atrium with its complication. The patient presented with moderate cyanosis and was referred for elective ASD repair. He underwent surgical repair of the ASD after transthoracic echocardiography. Early postoperative right-to-left shunting with cyanosis and hypoxia was associated with abdominal complications. Surgical re-exploration revealed the diversion of the inferior vena cava into the left atrium, which was repaired with a pericardial patch. Peptic ulcer perforation was repaired after abdominal laparotomy. The patient had an uneventful recovery and was discharged home on the 17[th] postoperative day. One-year follow-up revealed no recurrence of cyanosis or residual ASD on echocardiography

Combination of a giant dissected ascending aortic aneurysm with multiple fistulae into the cardiac chambers caused by prosthetic aortic valve endocarditis

The combination of a dissected ascending aortic aneurysm [AA] with multiple fistulae to the periaortic root structures is a life-threatening complication that occurs rarely after infective endocarditis of the prosthetic aortic valve. Many risk factors are potentially associated with this complication, including aortic diameter, connective tissue disease of the aortic wall, hypertension and infection. We report a rare case of dissected ascending AA with fistulae to the left atrium and pulmonary artery and a paravalvular leak in a 47-year-old woman with a history of an aortic valve replacement. The patient had presented to the Imam Ali Hospital, Kermanshah, Iran, in January 2015 with clinical features of heart failure. After initially being treated for congestive heart failure, she underwent open-heart surgery via a classic Bentall procedure and double fistula closure. She was discharged 23 days after the operation in good condition. A six-month follow-up showed normal functioning of the composite conduit prosthetic valve and no fistulae recurrence

Right ventricular thrombus and cerebral artery aneurysm in a patient with Behcet's disease

We report a 35-year-old woman referred to the Imam Ali Hospital, Kermanshah, Iran, in July 2014 for evaluation of postoperative dyspnoea after neurosurgery performed seven days previously for a ruptured cerebral artery aneurysm. She was known to have Behçet's disease with a history of recurrent oral and genital aphthous ulcers and uveitis. At referral, her symptoms included vertigo, dysarthria, palpitations and chest pain. Transthoracic echocardiography [TTE] revealed a large thrombus in her right ventricle outflow tract and open-heart surgery was performed eight days after the previous surgery to remove the clot. The postoperative period was complicated by transient acute renal failure, which resolved spontaneously. The patient was discharged 13 days after the cardiac surgery on warfarin, prednisolone, azathioprine and cyclophosphamide. Cyclophosphamide and azathioprine were discontinued after three months as the symptoms had completely resolved; however, prednisolone was continued due to recurrent uveitis. A 10-month follow-up TTE scan revealed no thrombus recurrence and treatment with warfarin and prednisolone was continued

Milky pleural effusion, a rare complication of left atrial myxoma

We report a rare case of bilateral chylothorax, associated with huge left mass in a 45-year-old woman who presented with preoperative dyspnea, fever and weight loss. Transe esophageal echocardiography [TEE], gross, and microscopic features of the mass were consistent with myxoma. Biochemical analysis of bilateral effusion revealed chylothorax in pre - and post - operative periods. We conclude that myxoma-induced mitral stenosis and pulmonary hypertension should be included in the differential diagnosis of bilateral pleural effusion and chylothorax. In addition, pulmonary pressure should be monitored before and during diagnosis, in therapy of any effusion derived from myxoma

Comparison of treatment outcomes in off-pump coronary artery bypass graft and medical therapy in patients with triple-vessel coronary artery disease and severe ventricular dysfunction

Introduction: Heart failure is a major hazard for public health. Despite recent advance in medical therapy, there is not enough information on the outcome of off-pump coronary artery bypass [OPCAB] and medical therapy on the patients with severe ventricular dysfunction and triple-vessel [CAD]. This study aimed to compare treatment outcomes and mortality rate in patients undergoing off-pump coronary artery bypass [OPCAB] surgery and medical therapy who presented with severe ventricular dysfunction and triple-vessel coronary artery disease [CAD]

Materials and Methods: This retrospective cohort study was conducted on patients with severe ventricular dysfunction and triple-vessel CAD during 2010-2011 in the Imam Ali Hospital of Kermanshah University of Medical Science. Patients were divided into two groups of medical therapy [group one] and OPCAB [group two]. Follow-up data were collected after 30 months. Survival estimation was performed using Kaplan-Meier survival analysis and Cox regression model

Results: Of the 276 enrolled patients, 139[50.4%] underwent group one and 137[49.6%] group two. Study groups were homogenous in baseline characteristics, with the exception of hyperlipidemia [P=0.005]. A significant difference was observed in cardiac mortality rates between the study groups [hazard ratio: 0.260; 95% confidence interval: 0.105-0.644; P=0.004]. However, no significant difference was observed between the groups regarding the frequency of admission due to decompensate heart failure [P=0.17]. In addition, the rate of admission due to acute coronary syndrome [ACS] in the first group was higher than the second group, significantly [P=0.001]. Level of ejection fraction [EF] had a significant increase after coronary artery bypass graft [CABG] [28.50] compared to the preoperative stage [27.59] [P=0.042]. However, no significant increase in the level of EF was observed in the first group before and after medical therapy [27.28 and 27.20, respectively] [P=0.83]

Conclusion: According to the results of this study, the mortality rate associated with OPCAB was lower compared to medical therapy, ACS and EF enhancement in patients with triple-vessel CAD and severe ventricular dysfunction

Cardiogenic shock and anterior papillary muscle rupture caused by blood supply to diagonal artery

Acute mitral regurgitation accounts for 9% cases of cardiogenic shock following myocardial infarction and results from papillary muscle infarction. This complication occurs early following myocardial infarction. The etiologies of this devastating complication include left ventricular failure, right ventricular failure and acute mitral regurgitation that mitral regurgitation usually results from papillary muscle rupture. We reported a 41 year old male with first diagonal branch stenosis and dominant left circumflex and complete transaction of anterolateral papillary muscle that had not been reported in literature

Anterolateral papillary muscle rupture caused by Brucella endocarditis

Brucellosis is a common zoonosis in Iran, transmitted to humans by direct contact with infected animal materials like fleece, animal excrement, leather, butchery or by the consumption of contaminated animal products [e.g. fresh cheese, unpasteurized milk or dairy products, and raw meat and raw liver that is consumed semi-roasted by kebab sellers in Iran. A 21-year-old woman presented with respiratory failure due to pulmonary edema from severe acute mitral valve regurgitation in the setting of acute Brucella endocarditis. She was found to have a ruptured anterolateral papillary muscle from necrosis caused by corroding large vegetations on the anterior mitral valve leaflet. This occurrence is an exceptionally rare phenomenon, in Brucella mitral endocarditis. Urgent transesophageal echocardiography [TEE] revealed large mobile vegetation on the anterior papillary muscle with severe mitral valve regurgitation. The patient underwent mitral valve replacement. During valve replacement surgery, anterior mitral valve vegetation and rupture of the AL-PM were confirmed. We also considered that prolonged post-operative antibiotic treatment was indicated in our patient to protect the newly implanted prosthetic valves

Use of right ventricular support with a centrifugal pump in post-valve surgery right ventricular failure: a case series

The optimal treatment method for right ventricular failure after valve surgery complicated by a low cardiac output has not been determined, although several case reports have been published on patients with ventricular failure and arrhythmia who were bridged to cardiac transplantation using biventricular or left ventricular assist devices. This case series illustrates successful circulatory support of 4 patients with prolonged low cardiac outputs and right ventricular failure and arrhythmias after valvular heart surgery with or without severe pulmonary hypertension. In-hospital death occurred in one patient and 3 patients were discharged from the hospital with good general condition. At two years' follow-up, 2 patients were in functional class one but another patient underwent laparotomy for multiple splenic abscesses and died from multiple organ failure

Pulmonary hypertension as a rare cause of postoperative chylothorax

Chylothorax in adult occurs most commonly in the wake of cardiac and thoracic procedures. Injuries to the common thoracic duct in the thorax or its branches in the mediastinum, injuries to the thymus tissues, dissection of the superior vena cava or ascending aorta, dissection of the aortic arch, disruption of the accessory lymphatics in the left or right thorax, and increased pressure in the systemic vein exceeding that of the thoracic duct [usually in the superior vena cava thrombosis, Glenn Shunt, and hemi-Fontan] have been proposed as the possible causes of chylothorax after surgery for congenital heart disease. However, pulmonary hypertension is an exceedingly rare cause of chylothorax in adults. We present a case of chylothorax after atrial septal defect surgery in a 30-year-old female patient with pulmonary hypertension. The postoperative period was complicated by chylothorax, which was confirmed by the high lipid content of chylous effusion. The patient was treated conservatively with diet therapy, and the effusion was abolished completely after two weeks. No recurrence of chylothorax was detected at 3 months' follow-up

Off-pump repair of a post myocardial infarction ventricular septal defect

Refractory cardiogenic shock meant that traditional patch repairs requiring cardiopulmonary bypass would be poorly tolerated and external sandwich closure of post myocardial ventricular septal defect [VSD] appears to be simple and effective after initial myocardial infarction [MI]. The three cases presented with a VSD after of acute MI with or without thrombolysed with streptokinase during patient admission. The general condition of the three patients was poor with pulmonary edema, low cardiac output and renal failure. The heart was approached through a median sternotomy. Off-pump coronary artery bypass grafting of the coronary artery lesion was done first using octopus and beating heart surgery method and latero - lateral septal plication was performed using sandwich technique. Low cardiac output managed with intra-aortic balloon pump in these patients accompanied with inotropic drugs. Post-operative transesophageal echocardiography revealed that VSD was closed completely in one patient and in two patients small residual VSD remained. More experience is required to ascertain whether this technique will become an accepted alternative to patch repairs

Coronary arteries bypass grafting surgery in elderly patients

The incidence of coronary artery bypass grafting surgery [CABG] in elderly patients has been increasing. There are contradictory reports on the early outcome of elderly coronary artery patients as compared with their young counterparts. We designed this retrospective study to address this issue. We retrospectively analyzed the results of 1489 on-pump CABG cases performed at our hospital during a 4.5-year period. Perioperative data such as demographic, medical, clinical, operative, and postoperative variables were collected and compared between patients 70 years old or younger [Group A, n = 1164] and patients above 70 years of age [Group B, n = 325]. Statistical analysis was performed using the t-test for the continuous and the X[2] tests for the categorical variables. Significant variables according to the univariate analysis [X[2] and t-test] were further analyzed using multivariate logistic regression analysis. The variables of weight [P value < 0.001], preoperative PO[2] [P value = 0.005], ejection fraction > 30% [P value = 0.001], body surface area [P value = 0.003], and hypercholesterolemia [P value = 0.007] were higher in Group A, whereas preoperative myocardial infarction [P value < 0.001], postoperative low cardiac output syndrome [P value = 0.019], emergent surgery [P value = 0.003], inotropic drug use [P value < 0.001], preoperative heparin use [P value < 0.001], re-exploration for bleeding [P value = 0.015], hospital stay [P value < 0.001], low ejection fraction [ 1.5 mg/dl [P value < 0.001], chronic obstructive pulmonary disease [P value < 0.001], intra-aortic balloon pump use [P value < 0.001], infection [P value < 0.001], pulmonary complications [P value < 0.001], atrial fibrillation [P value < 0.001], postoperative renal complications [P value < 0.001], and death [P value = 0.012] were more frequent in Group B. CABG in the elderly patients had certain surgical risks such as chronic obstructive pulmonary disease, preoperative myocardial infarction, emergent surgery, and death. Also, postoperative complications such as pulmonary complications, inotropic drug use, intra-aortic balloon pump use, and infection were more frequent in the elderly than in the younger patients

Hemi-fontan or bidirectional cavopulmonary shunt for right ventricular failure after mitral valve replacement and acute ascending aortic dissection: report of two cases

Right ventricular failure due to right coronary artery disease, right ventricular hypertrophy, stunning, abnormal septal motion, myocardial infarction, or non-homogeneous distribution of cardioplegia is an uncommon but serious complication of open heart surgery. We report a patient with severe right ventricular hypertrophy secondary to severe mitral valve stenosis and another patient with detachment of the right coronary artery due to the dissection of the ascending aorta. The patients developed right ventricular failure, which persisted after surgery and rendered weaning from cardiopulmonary bypass unsuccessful. Through a hemi-Fontan, or bidirectional cavopulmonary shunt, and an intra-aortic balloon pump, the patients were successfully weaned from cardiopulmonary bypass. This shunt may be an alternative to a right ventricular assist device in some patients with right ventricular failure. The long-term outcome and the indication of bi-directional cavopulmonary shunt has not been confirmed, although it is believed to be effective for saving the life of patients with low cardiac output and acute right ventricular failure. In our cases, six months following the operation, there was some degree of recovery of the right ventricular function. In long-term follow-up, however, it would be interesting for the authors to know if the improved right ventricular function, with better antegrade pulsatile flow in the pulmonary artery, in any way interferes with the functioning of the bidirectional cavopulmonary shunt

Myxoma of the superior vena cava origin presented as a right atrial mass

Myxomas are the most common benign cardiac tumors. Myxomas are more common in the left heart chamber than the right side chamber. An extracardiac origin presenting as a right atrial mass is very rare. We present a case of myxoma originating in the superior vena cava [SVC] in a 24-year-old man, who underwent surgical resection. Preoperative two-dimensional echocardiography demonstrated a mass in the right atrium. Intraoperatively, the tumor was found to have originated from the SVC orifice. The tumor was excised from the SVC by opening the one-third proximal portion of the SVC. Pathological examination revealed a myxoma, and one-year follow-up showed no evidence of the recurrence of any tumors in the SVC

Congenital saccular aneurysm of coarctation of aorta: a case report

True saccular aneurysm is exceptional in coarctation of aorta in children. A 6-year-old girl with headache and systemic arterial hypertension referred to our center for cardiovascular evaluation. Physical examination revealed high blood pressure and weak lower extremity pulses. Two-dimensional and Doppler echocardiography and angiography demonstrated a saccular aneurysm of the descending aorta, 5×4 cm in size, associated with aortic coarctation. Aneurysmectomy was performed without cardiopulmonary bypass. The section of the aorta containing the coarctation and the aneurysm was resected and replaced with a 15 mm woven polyester graft. Histological examination revealed a thin walled aneurysm with hyalinosis changes and decreased elastic fibers. One-year echocardiographic follow-up revealed no gradient across of Dacron tube and hypertension decreased to normal level

Right atrial angiosarcoma with severe biventricular dysfunction and massive pericardial effusion

This paper presents the case of a 35 year-old woman with symptoms of heart failure from the last month. A physical examination at admission showed paleness, dyspnea, peripheral edema and fatigue. In a two-dimensional echocardiography and transesophageal echocardiography, normal thickness but severe left and right ventricular dysfunction with severe pericardial effusion and thickened pericardium were found. In the enlarged right atrium, an oval-shaped structure was found with features of continuity with lateral right atrial wall and also a bulging of the structure through the orifice of the tricuspid valve to the right ventricle. In the echocardiography, we did not saw any blocking of the tricuspid valve or the inflow from inferior vena cava [IVC] or superior vena cava [SVC] or coronary sinus. On the basis of the echocardiography examination and clinical presentation, tentative diagnosis of the right atrium myxoma was made. A coronary angiography revealed normal coronary arteries and no feeding of tumor by branch of right coronary artery [RCA]. Surgical removal of the tumor was performed without complication. The histopathological examination confirmed the diagnosis of angiosarcoma. In the follow-up echocardiography carried out after three months, severe left ventricular [LV] and right ventricular [RV] dysfunction continued and was demonstrated. Magnetic resonance imaging revealed no lymphadenopathy or re-growth of the tumor in the mediastinum or pericardium

A Giant Hydatid Cyst in the Interventricular Septum with Papillary Muscle Involvement

We present here a 44-year-old male patient with hydatid disease who was referred to our hospital due to dyspnea and chest pain for the last 2 month before admission. Using echocardiography and contrast-enhanced computed tomography the heart hydatid was diagnosed. However, hydatid disease of the interventricular septum is rare; particularly, the involvement of mitral apparatus with mitral regurgitation (MR) is an exceptionally rare presentation. Early diagnosis and an integrated treatment strategy are crucial. Surgical excision was performed and the patient had an uneventful recovery and follow-up at 3 months.

Off-pump coronary bypass grafting causing stunned myocardium

The term "stunned myocardium" refers to abnormalities in the myocardial function following reperfusion and is common in on-pump coronary artery bypass grafting [CABG] and is exceedingly rare in off- pump CABG. A 53-year-old man presented with unstable angina due to the severe stenosis of the left anterior descending coronary artery [LAD] and the obtuse marginal. Laboratory findings and Chest X-ray revealed nothing abnormal. The intraoperative course was uneventful. The patient left the operating room without any inotropic support. Six hours later, however, he developed low cardiac output .At exploration, cardiac tamponade was excluded and flowmetry showed that the graft had adequate function. Cardiac enzymes were normal. High-dose adrenalin and Dobutamine were administrated and an intra-aortic balloon pump was used. After hemodynamic stabilization, the patient left the Intensive Care Unit without an intra-aortic balloon pump and inotropic support. On the fifth postoperative day, coronary angiography showed patent grafts and correct anastomotic sites. On the seventh postoperative day, the akinetic lateral wall of the left ventricle changed to dyskinesia. Finally after hospital discharge on the thirtieth postoperative day, an echocardiogram showed normal left ventricular function without regional wall motion abnormalities.

Suppression of myocardial injury markers following percutaneous coronary interventions by pre-treatment with carvedilol

Retrospective studies and clinical trials have indicated that beta -receptor blockers have an influential role in improving survival and reducing risk of recurrent infarction in patients with myocardial infarction. However, there is still controversy regarding the effects of beta -receptor blockers on the markers of myocardial infarction following percutaneous coronary interventions [PCI]. The aim of this study was to evaluate the pre-treatment effect of Carvedilol on markers of myocardial injury in patients undergoing elective PCI. In this clinical trial patients undergoing elective PCI were categorized randomly in the Carvedilol group including 100 patients who received two doses of 12.5 mg, 6 and 12 hours prior to PCI, and the control group [105 patients]. Blood samples were obtained to analyse cardiac biomarker, 12 and 24 hours after PCI. The clinical features were not significantly different between the two groups. A increase in the level of Troponin I was observed in the control group 24 hours following PCI [P=0.042], whereas this rise in troponin I was slight and insignificant in the Carvedilol group [P>0.05]. some difference was observed between the two groups in regard to the level of CPK-MB after PCI [P=0.041]. The findings of our study indicate that pre-treatment with Carvedilol confers cardio-protection by limiting the rise of markers of myocardial injury following PCI

Locked-in syndrome and blue toe syndrome caused by cardiopulmonary bypass

Severe inflammation after cardiopulmonary bypass with the vasculitis of the acral extremity and vertebro-basilar arterial system leads to the locked-in syndrome and blue toe syndrome. In broad terms, systemic, idiopathic, and environmental factors provoke syndromes that present with digital discoloration or the blue toe syndrome. Painful digital discoloration, accompanied by ulceration, suggests vasculitis, involving small blood vessels. Definitive diagnosis usually requires histological documentation because vasculitic syndromes have no pathognomonic clinical features or laboratory test results. The case introduced herein is that of a woman who developed the locked-in syndrome in conjunction with quadriplegia, loss of facial movement, speech loss, and loss of horizontal eye movements. She had initially presented with severe mitral stenosis and left atrial clot and undergone mitral valve replacement and clot extraction. The patient expired from multiple organ failure despite prolonged ventilatory support, including tracheotomy, and meticulous nursing care and antibiotic prophylaxis. Given the previously reported partial recovery from this syndrome with the use of steroids, we would advocate the use of such pharmacological agents

Suction tip migration to internal iliac vein during cardiac surgery

During the cannulation of the inferior vena cava in a 29-year-old patient undergoing mitral and aortic valve replacement, the pump suction tip was inadvertently lost in the right atrium. After starting CPB and cardioplegic arrest of the heart, the right atrium and ventricle were searched for the foreign body, but it became evident by reontgenography that the foreign body had migrated to the pelvic veins. At the end of the operation, extraction with a Fogarty catheter was attempted but was not successful and the foreign body was extracted via laparatomy