Incidental Diagnosis of Primary Pleural Liposarcoma in a COVID-19-Positive Patient.

A few cases of primary liposarcoma of pleura have been reported worldwide. We report a young gentleman who was admitted with what was initially thought as coronavirus disease 2019 (COVID-19)-related pulmonary symptoms. His chest CT showed a large pleural effusion causing a mediastinal shift and compressing vital structures. He did not respond to conservative drainage intervention and subsequently underwent a left thoracotomy for his worsening clinical picture. He was found to have a large left pleural mass that was incompletely resected. Histopathology examination showed low-grade soft tissue sarcoma with lipogenic differentiation suggestive of myxoid liposarcoma. He was subsequently given adjuvant chemotherapy but succumbed and died because of the progression of the disease.

Successful Management of Maternal Left Atrial Myxoma in Pregnancy.

A 29-year-old woman (gravida 3, para 2) presented at 28 weeks+2 days of gestation with a two-months history of dyspnea associated with orthopnea and occasional palpitations. On transthoracic echocardiography, she was diagnosed with a 3.2 × 2.7 cm left atrial myxoma. The patient underwent open surgical resection at 30 weeks of gestation. She had an uneventful postoperative recovery and was discharged on the ninth day. At 41 weeks of gestation, she gave birth by cesarean to a healthy baby of normal weight. Both the mother and the baby were discharged in stable condition.

Bronchial Leiomyoma: Importance of Preoperative Biopsy for Lung Preserving Surgery.

Tracheobronchial leiomyoma is a rare tumor of the airway. They arise from the lower respiratory tract tissue of the bronchi, trachea, and lung. Symptomatology is based on the degree of endoluminal bronchial obstruction, and surgical resection is generally the mainstay of treatment. We present the case of a 33-year-old male who suffered from chronic cough and breathlessness for two years caused by large endobronchial leiomyoma diagnosed by preoperative biopsy. The tumor was surgically resected through bronchotomy and complete preservation of the lung parenchyma. We stress the importance of a definitive preoperative diagnosis of this rare tumor to employ lung preserving surgical techniques.

Lung cancer screening in the gulf: Rationale and recommendations.

Lung cancer is the leading cause of cancer-related death worldwide among both men and women. Although advances in therapy have been made, the 5-year survival rates for lung cancer remain poor, ranging from 10% to 20%. One of the main reasons is late presentation, as only 25% of patients are amenable to cure at the time of presentation. Therefore, the emphasis on lung cancer screening (LCS) is growing with the current evidence that has shown benefits with low-dose computed tomography scan of the chest in high-risk populations. LCS remains a debated topic in Gulf Cooperation Council (GCC) countries, possibly due to a lack of local experience. In this article, we explore the rationale and give recommendations on the best approach for LCS in GCC.

Bronchial Mucoepidermoid Carcinoma Misdiagnosed as Adenocarcinoma: A Word of Caution.

Tracheobronchial mucoepidermoid tumors (METs) typically occur in the head and neck region but rarely in the trachea and lung. They are salivary-type tumors that arise from the glandular component of the tracheobronchial epithelium. The most common type, mucoepidermoid carcinoma (MEC) has histological features that overlap with more aggressive lung carcinomas such as adenosquamous carcinoma. It is important to realize the histological features and limitations of a diagnostic biopsy. This case illustrates this point where an initially diagnosed lung adenocarcinoma turns out to be MEC. We report a case of a 43-year-old woman with a one-year history of recurrent episodes of cough and fever. Initial bronchial biopsy diagnosed her as having adenocarcinoma of the lung. However, her surgical biopsy confirmed it was MEC. High clinical suspicion that the diagnosis may not have been correct saved her from a potential pneumonectomy. She instead underwent bi-lobectomy sleeve resection. This case illustrates the importance of recognizing less common and less aggressive lung tumors that may appear histologically as adenosquamous carcinoma. High clinical suspicion, not only biopsy results, from clinical history, imaging and gross appearance is always needed in all cases. The use of intraoperative frozen section is mandatory. It is important to be aware that because of morphological limitations of small endobronchial biopsies, diagnosis of a more common pathology may be favored.

First case report of Mycobacterium canariasense native mitral valve endocarditis.

Mycobacterium canariasense is a relatively newly discovered, rapidly growing nontuberculous Mycobacterium first described in 17 patients with fever in the Canary Islands, Spain, in 2004. To date, there have been very few case reports in literature, and to our knowledge, infective endocarditis due to M. canariasense has not been reported. In this case report, we present a 33-year-old man who was an intravenous drug user with native mitral valve infective endocarditis caused by M. canariasense after presenting with septic emboli to the toes and kidneys. The rapidly growing mycobacterium isolated from blood culture and valve tissue was identified by 16S rRNA sequencing as M. cosmeticum but was finally identified as M. canariasense by rpoB gene sequencing. The patient underwent mitral valve replacement surgery and received combined antibiotic therapy of intravenous ciprofloxacin, intravenous amikacin, and oral clarithromycin with a successful outcome. This case highlights the importance of molecular identification of nontuberculous Mycobacterium to guide antimicrobial therapy in such serious infections.

Pre-emptive veno-venous ECMO in advanced tracheal malignancy prior to tracheal stenting.

Extracorporeal membrane oxygenation (ECMO) is helpful in providing ventilatory support when other conventional methods of ventilation fail. We report a case of successful management of advanced tracheal malignancy with impeding airway obstruction where veno-venous ECMO (VV-ECMO) was instituted prior to performing critical endotracheal procedure. After securing the VV-ECMO through right jugular vein and left femoral vein under local anaesthesia, the tracheal stent placement was conducted under flexible bronchoscope and fluoroscope control. Oxygenation and carbon dioxide levels were maintained by the ECMO. VV-ECMO is a useful adjunct in the management of subglottic difficult airway obstruction due to complex tracheal pathology where conventional ventilation may not be possible or adequate.

Redo mitral valve replacement using valve-on-valve technique in a patient with severe posterior mitral annular calcification.

Redo mitral valve replacement surgery due to bioprosthetic valve failure can carry serious surgical challenges. In addition to the usual redo sternotomy risk, there is risk of circumflex coronary artery injury or atrioventricular disruption from explanting the prosthesis. Alternatives to prosthesis explantation may be needed in some cases.We report a case of mitral bioprosthetic valve failure in a young patient who had a history of atrioventricular disruption during the first surgery and had pericardial patch repair of the defect. The risk of explanting the bioprosthesis during redo surgery was very high. Therefore, we performed valve replacement using valve-on-valve technique in which the new valve is implanted within the sewing ring of the previous bioprosthesis without explanting the valve. This technique converted a very highly futile surgery to a conventional redo surgery risk. The patient had a successful surgery with no intraoperative or postoperative complications.

Pulmonary infarction mimicking a lung mass: a case report.

Pulmonary infarction usually appears as a wedge-shaped opacity with its base placed laterally. Rarely, pulmonary infarctions may appear as a well-defined rounded opacity mimicking lung cancer and surgical lung biopsy may often be required for definitive diagnosis. We report a patient who was admitted with submassive pulmonary embolism who had an incidental finding of a well-defined opacity in computed tomography (CT) scan. The lesion was avid on positron emission tomography (PET) scan and the patient was a smoker. So, we investigated him further with a percutaneous and later a thoracoscopic lung biopsy. Tumour-like pulmonary infarction is often a challenge for the clinicians.

Valve Replacement for Massive Hemoptysis in Mitral Stenosis: An Uncommon Course in Modern Practice.

Massive hemoptysis is uncommon in mitral stenosis in contemporary practice. We report a patient without any previous illness presenting with life-threatening pulmonary hemorrhage, who was initially managed as cryptogenic hemoptysis. Once mitral stenosis was confirmed, the patient underwent mitral valve replacement with total and complete cessation of bleeding.

Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus: Case report.

The anomalous origin of the right coronary artery from the left coronary sinus is a rare congenital disorder and can often result in sudden death upon initial presentation. We report a 19-year-old male patient who was referred to the Sultan Qaboos University Hospital, Muscat, Oman, in 2015 with multiple episodes of exertional angina. He was diagnosed as having an anomalous right coronary artery arising from the left coronary sinus following an intraoperative transesophageal echocardiogram. An unroofing ostioplasty of the anomalous right coronary artery was successful. Details of the surgical management of this anomaly are discussed.

Outcomes of a Less-Invasive Approach for Proximal Aortic Operations.

BACKGROUND: Less-invasive techniques have previously been described for mitral and aortic valve operations; however, few studies have examined their benefit for aortic root and ascending aorta reconstruction. Using propensity matching, we compared outcomes of patients undergoing proximal aortic operations through a J incision compared with full sternotomy. METHODS: From January 1995 to January 2014, 8,533 patients underwent proximal aortic operations at Cleveland Clinic. The study population comprised 1,827 patients after those with prior cardiac operations, emergency procedures, endocarditis, or circulatory arrest were excluded; 568 (31%) underwent a J incision. A propensity score based on 57 variables was generated to account for differences in characteristics of full-sternotomy and J-incision patients, producing 483 matched patient pairs (85% of possible) for comparison of outcomes. RESULTS: Among propensity-matched patients, in-hospital mortality (0 [0%] J incision vs 2 [0.41%] full sternotomy; p = 0.2), renal failure (3 [0.62%] vs 6 [1.2%]; p = 0.3), stroke (3 [0.62%] vs 3 [0.62%; p > 0.9), reoperation for bleeding (17 [3.5%] vs 15 [3.1%]; p = 0.7), intraoperative blood products (60 [15%] vs 78 [19%]; p = 0.08), and postoperative transfusions (97 [20%] vs 103 [22%]; p = 0.6) were similar. Intensive care unit (median 24 vs 26 hours) and postoperative hospital stays (median 5.2 vs 6.0 days) were shorter (p < 0.0001) for the J incision, and operative and postoperative direct technical costs were 6% less. CONCLUSIONS: A J incision is a feasible technique for primary isolated elective proximal aortic operations, with a low risk of complications similar to those of full sternotomy, but with the advantages of shorter intensive care unit and hospital stays, lower costs, and better cosmesis.

Ortner's syndrome: Cardiovocal syndrome caused by aortic arch pseudoaneurysm.

72-year-old hypertensive presented with two weeks history of left sided chest pain and hoarseness. Workup demonstrated a pseudoaneurysm in the lesser curvature of the distal aortic arch opposite the origin of the left subclavian artery from a penetrating atherosclerotic ulcer. Following a left carotid-subclavian bypass, endovascular stenting of the aorta was performed excluding the pseudoaneurysm. Patient had excellent angiographic results post-stenting. Follow up at 12 weeks demonstrated complete resolution of his symptoms and good stent position with no endo-leak. Ortner's syndrome describes vocal changes caused by cardiovascular pathology. It should be included in the differential diagnosis of patients with cardiovascular risk factors presenting with hoarseness. This case demonstrates the use of endovascular stents to treat the causative pathology with resolution of symptoms. In expert hands, it represents low risk, minimally invasive therapeutic strategy with excellent early results in patients who are high risk for open procedure.

Combined transcervical and thoracoscopic mediastinal parathyroid adenoma resection.

The routine approach for excision of a parathyroid adenoma is transcervical, but this approach is inadequate when the gland is located in the mediastinum. Traditionally, these cases have required a sternotomy or thoracotomy. We used a combined transcervical and video-assisted thoracoscopic surgery approach to resect a parathyroid adenoma that extended to the middle mediastinum.

"Open" approach to aortic arch aneurysm repair.

Aortic arch aneurysm is a relatively rare entity in cardiac surgery. Repair of such aneurysms, either in isolation or combined with other cardiac procedures, remains a challenging task. The need to produce a relatively bloodless surgical field with circulatory arrest, while at the same time protecting the brain, is the hallmark of this challenge. However, a clear understanding of the topic allows a better and less morbid approach to such a complex surgery. Literature has shown the advantage of selective cerebral perfusion techniques in comparison with only circulatory arrest. Ability to perfuse the brain has allowed circulatory arrest temperatures at moderate hypothermia without the need for deep hypothermia. Even though cannulation site selection appears to be a minor issue, literature has shown that the subclavian/axillary route has the best outcomes and that femoral cannulation should only be reserved for no access patients. Although different techniques for arch anastomosis have been described, we routinely perform the distal first technique as we find it to be less cumbersome and easiest to reproduce. In this review our aim is to outline a systematic approach to aortic arch surgery. Starting with indications for intervention and proceeding with approaches on site of cannulation, approaches to brain protection with hypothermia and selective cerebral perfusion and finally surgical steps in performing the distal and arch vessels anastomosis.

Long-term durability of bicuspid aortic valve repair.

BACKGROUND: Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, occurring in 1% to 2% of the population. Eventually, 20% develop clinically important valvar regurgitation requiring surgical intervention. Aortic valve repair avoids anticoagulation and prosthetic valve-related complications. This study evaluated long-term durability of BAV repair. METHODS: From 1985 to 2011, 728 patients, mean age 42±12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0±6.2 years (median, 8.3). Factors associated with repair durability (expressed as aortic valve reoperations and echocardiographically estimated gradients and regurgitation) and survival were identified. RESULTS: Hospital mortality was 0.41% (n=3), and stroke occurred in 0.27% (n=2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function. CONCLUSIONS: BAV repair is safe and durable with low mortality, low prevalence of reoperation, and good long-term survival. Cusp prolapse from technical errors and natural progression of disease are the most common causes for reoperation, but progressive natural increase in valve gradient accounts for a substantial proportion as well.