Use of Impella CP Device in Off-Pump Coronary Artery Bypass Graft Surgery.

Off-pump coronary artery bypass grafting (OPCABG) may be performed on patients with high surgical risk who are poor candidates for traditional mechanical circulatory support. Hemodynamic support with micro-axial mechanical circulatory devices has been performed with limited but promising results.We report a case of a 66-year-old male with multiple comorbidities and low cardiac output undergoing OPCABG. Impella CP device was deployed for "in-pump" support during surgical coronary revascularization resulting in intraoperative stability and uncomplicated post-operative recovery.Previous reports have described the use of the Impella Recover LP 5.0 device for use during OPCABG. We describe the successful and safe perioperative use of the Impella CP device. Despite lower flow rates, adequate support was achieved and the transfemoral cannulation and smaller outer diameter than the Impella 5.0 device may decrease the risk of complications and expedite recovery. Further research will be necessary to determine the optimal perioperative hemodynamic support strategy to offer hemodynamically unstable, high, and prohibitive risk patients.

Dilation of tricuspid valve annulus immediately after rupture of chordae tendineae in ex-vivo porcine hearts.

PURPOSE: Chordae rupture is one of the main lesions observed in traumatic heart events that might lead to severe tricuspid valve (TV) regurgitation. TV regurgitation following chordae rupture is often well tolerated with few or no symptoms for most patients. However, early repair of the TV is of great importance, as it might prevent further exacerbation of the regurgitation due to remodeling responses. To understand how TV regurgitation develops following this acute event, we investigated the changes on TV geometry, mechanics, and function of ex-vivo porcine hearts following chordae rupture. METHODS: Sonomicrometry techniques were employed in an ex-vivo heart apparatus to identify how the annulus geometry alters throughout the cardiac cycle after chordae rupture, leading to the development of TV regurgitation. RESULTS: We observed that the TV annulus significantly dilated (~9% in area) immediately after chordae rupture. The annulus area and circumference ranged from 11.4 ± 2.8 to 13.3 ± 2.9 cm2 and from 12.5 ± 1.5 to 13.5 ± 1.3 cm, respectively, during the cardiac cycle for the intact heart. After chordae rupture, the annulus area and circumference were larger and ranged from 12.3 ± 3.0 to 14.4 ± 2.9 cm2 and from 13.0 ± 1.5 to 14.0 ± 1.2 cm, respectively. CONCLUSIONS: In our ex-vivo study, we showed for the first time that the TV annulus dilates immediately after chordae rupture. Consequently, secondary TV regurgitation may be developed because of such changes in the annulus geometry. In addition, the TV leaflet and the right ventricle myocardium are subjected to a different mechanical environment, potentially causing further negative remodeling responses and exacerbating the detrimental outcomes of chordae rupture.

Concomitant Left Atrial Appendage Clipping During Minimally Invasive Mitral Valve Surgery: Technically Feasible and Safe.

BACKGROUND: It is believed that most of thrombi form in the left atrial appendage (LAA)before they emboli. Different surgical and percutaneouse approaches were suggested to manage the LAA. In this study we are evaluating the safety of clipping the LAA via minithoractotomy approach. METHOD: All consecutive patients who had minimally invasive mitral valve surgery with concomitant LAA clipping between December 2012 and February 2014 were included in the study. LAA exclusion was performed using AtriClip® LAA Exclusion System (Cincinnati, Ohio, AtriCure®). The patient s' clinical characteristics, intraoperative complications, and in-hospital coarse were obtained by reviewing the medical records. RESULT: Total of 22 patients(50% males) were included in the study. The median ages was 66.0 years (IQR: 50.8 to 81.3). Eight(36%) had mitral valve replacement and the rest had mitral repair surgery. Five(23%) patients needed blood product transfusion during the surgery. No clip related bleeding was observed and no perioperative mortality was recorded. CONCLUSION: During minimally invasive mitral valve surgery, Concomitant exclusion of the left atrial appendage using AtriClip® can be performed rapidly and safely.

Surface Strains of Porcine Tricuspid Valve Septal Leaflets Measured in Ex Vivo Beating Hearts.

Quantification of the tricuspid valve (TV) leaflets mechanical strain is important in order to understand valve pathophysiology and to develop effective treatment strategies. Many of the traditional methods used to dynamically open and close the cardiac valves in vitro via flow simulators require valve dissection. Recent studies, however, have shown that restriction of the atrioventricular valve annuli could significantly change their in vivo deformation. For the first time, the porcine valve leaflets deformation was measured in a passive ex vivo beating heart without isolating and remounting the valve annuli. In particular, the right ventricular apexes of porcine hearts (n = 8) were connected to a pulse-duplicator pump that maintained a pulsatile flow from and to a reservoir connected to the right atrium and the pulmonary arteries. This pump provided a right ventricular pressure (RVP) waveform that closely matched physiological values, leading to opening and closure of the tricuspid and pulmonary valves (PVs). At the midsection of the valve leaflets, the peak areal strain was 9.8 ± 2.0% (mean±standard error). The peak strain was 5.6 ± 1.1% and 4.3 ± 1.0% in the circumferential and radial directions, respectively. Although the right ventricle was beating passively, the leaflet peak areal strains closely matched the values measured in other atrioventricular valves (i.e., the mitral valve (MV)) in vivo. This technique can be used to measure leaflet strains with and without the presence of valve lesions to help develop/evaluate treatment strategies to restore normal valve deformation.

Hyperplastic cardiac sarcoma recurrence.

Primary cardiac sarcomas are rare tumors with a median survival of 6-12 months. Data suggest that an aggressive multidisciplinary approach may improve patient outcome. We present the case of a male who underwent resection of cardiac sarcoma three times from the age of 32 to 34. This report discusses the malignant nature of cardiac sarcoma and the importance of postoperative multidisciplinary care.

Left Ventricular Outflow Tract Pseudoaneurysm after Aortic Valve Replacement.

Left ventricular outflow tract pseudoaneurysm is an uncommon complication following aortic valve replacement (AVR), occurring most frequently secondary to endocarditis. We present a case of a 47-year-old female with a history of intravenous drug abuse and a past surgical history of two AVRs (2001 and 2009 with aortic root replacement for endocarditis) who presented with symptoms of lower extremity weakness. Subsequent radiologic imaging revealed the presence of a left ventricular outflow tract pseudoaneurysm, which was surgically managed with a homologous conduit.

CASE REPORT Anomalies Associated With Congenitally Corrected Transposition of Great Arteries: Expect the Unexpected.

OBJECTIVE: Congenitally corrected transposition of great arteries (CCTGA) is characterized by atrioventricular and ventriculoarterial discordance. Characterizations of these anomalies are important because they may influence surgical approach and management. METHODS: We present a case of newly diagnosed CCTGA at the age of 50. He presented with sudden onset of shortness of breath for the first time and was diagnosed with CCTGA. Echocardiogram, magnetic resonance imaging, and cardiac catheterization were utilized to elucidate the pathology. RESULTS: Intraoperatively, patient's CCTGA and ventricularization of the right ventricle were confirmed. The severe systemic atrioventricular valve regurgitation was replaced with a bioprosthetic valve (Medtronic Mosaic No. 29) with placement of epicardial ventricular leads for possible future placement of automatic implantable cardioverter defibrillators. Pathology report confirmed a degeneration of the systemic atrioventricular valve. CONCLUSIONS: Significant coronary artery anomalies have also been described in literature with CCTGA. The variances encountered in this case are excellent examples of the intricacies associated in diagnosis and surgical care in patients with CCTGA.

An unusual case of giant cardiac fibroelastoma mimicking left atrial myxoma in a patient presenting with syncope.

Cardiac papillary fibroelastomas are the most common primary valvular tumors. Generally benign, they account only for about 10% of all primary cardiac neoplasms, can occur in normal or diseased hearts, and are associated strongly with open heart surgery and radiotherapy. They are, in most cases, incidental findings, but can be discovered after syncope. We report the case of an elderly female, who was referred for syncope and was found to have a large fibroelastoma at the mitral valve annulus, intermittently obstructing the left ventricular inflow tract, and mimicking the presentation of left atrial myxoma. This case illustrates another potential mechanism of syncope in patients with fibroelastomas.

CASE REPORT Papillary Fibroelastomas and the Conundrum of the Benign Intracardiac Mass.

Cardiac papillary fibroelastomas are a rare form of benign, primary cardiac tumor. They tend to develop from the valvular endocardium, with nonvalvular locations being uncommon. They are primarily found on either the mitral or aortic valve. They account for 7% of all primary cardiac tumors. Papillary fibroelastomas are usually identified through either transthoracic echocardiography or transesophageal echocardiography. The latter is more likely to provide a clearer diagnosis. Management remains controversial. The benign histology notwithstanding, the prevailing consensus is toward excision of left-sided cardiac lesions due to the risk of coronary and cerebral embolization. While the diagnosis of cardiac papillary fibroelastomas is relatively rare, the likelihood of encountering a right-sided lesion with rapid growth in a 6-month period is extraordinary. We highlight a case where an 84-year-old man with coronary artery disease was found to have a right atrial mass attached to the tricuspid valve. This mass grew by more than 1 cm in a 6-month period.

Resolution of recurrent chest pain with resection of papillary fibroelastoma.

Papillary fibroelastoma (PFE) is a benign primary tumor of the heart usually originating from the heart valves. Nonvalvular fibroelastomas are rare, and reported cases have presented either incidentally or with cerebral embolic phenomena; none have reported recurrent anginal symptoms. We are reporting a case of a 53-year-old female with history of significant radiation exposure to the chest in the past, who presented with recurrent chest pain and was found to have left atrial nonvalvular PFE managed with surgical excision.

Left atrial appendage lipoma: an unusual location of cardiac lipomas.

Cardiac lipomas are benign neoplasms of the heart and accounts for 8.4% of all primary tumors. They can occur sporadically at any age with no sex preference. The tumor originates mostly in the subendocardium and subepicardium but very rarely within the myocardium. Clinically this tumor is asymptomatic and found incidentally in the vast majority of cases. On occasion large lesions can lead to mechanical obstruction and pericardial effusions if located in the epicardium. Although lipomas can occur at different atrial or ventricular locations, it was never reported at the level of the left atrial appendage (LAA). Usually a mass in the LAA represents a thrombus, however there are few case reports of LAA tumors mainly representing fibroelastomas, myxomas, hemangiomas, and malignant tumors. To our knowledge there are no reported cases of left atrial appendage lipomas (LAAL) in the medical literature. We report the first case of LAAL discovered incidentally on transesophageal echocardiogram during off pump coronary artery bypass grafting.