Radical sternectomy for osteomyelitis without reconstruction post-coronary artery bypass graft: 10 years on.

Radical sternectomy with sternal reconstruction using synthetic mesh or titanium plates has been described before with excellent results. However, radical removal of the sternum without reconstruction is a rare surgical treatment for complicated deep sternal wound infections (DSWI). The long-term outcome following this radical operation is not well-known due to the limited number of cases in the literature. We report on a patient 10 years after a radical sternectomy for DSWI who presented with shortness of breath. We highlight some of the anatomical and physiological changes the chest cavity may undergo and the fact that this patient had a near normal quality of life in the 10 years following the sternectomy.

Infected Takayasu's arteritis presenting with aortic perforation.

We want to remind Physicians that unusual conditions can present in unusual ways and to keep an open mind always.

Left ventricular outflow tract cyst: What was it and where did it go?

Cyst or thrombus formation in the left ventricular outflow tract of a normal heart is very rare. We present a case of a male who presented with a major stroke and was found to have a freely mobile cystic mass in the left ventricular outflow tract, with an otherwise completely normal heart. He had some risks factors for hypercoagulability (reduced protein C activity and raised fibrinogen), but only received aspirin therapy due to his stroke severity (haemorrhagic transformation). Once his brain imaging suggested it was safe to proceed, repeat imaging showed the mass had gone, so cardiac surgery was avoided. What was it and where did it go?

Analysis of the Performance of Daily Cardiac Surgery Score (CASUS) in Patients with Mixed Racial Profile after Cardiac Surgery: A Single-Center Retrospective Study.

OBJECTIVE: The aim was to look at the Cardiac Surgery Score (CASUS) assessment after cardiac surgery, and compare it with the intensive care unit (ICU) mortality and morbidity, in a racially diverse group of patients, in a single center. DESIGN: Clinical retrospective study analyzing data from 319 patients over a 1-year duration. SETTING: Cardiothoracic intensive care unit (CTICU) of a tertiary care center. PARTICIPANTS: All patients who underwent cardiac surgery between January 1 and December 31, 2017. INTERVENTIONS: Review of electronic patient records. MEASUREMENTS AND RESULTS: Daily CASUS assessments (calculated on an online application and recorded on patient electronic records) were retrieved. The variables of CASUS used for the study were CASUS value on postoperative day 1 (POD1-CASUS), on death/discharge from CTICU (Dis-CASUS), mean of all CASUS values during CTICU stay (M-CASUS), and differential CASUS (Dif- CASUS) [CASUS POD 1 - CASUS on discharge]. The receiver operating characteristic (ROC) curve for the diagnostic level of POD 1-CASUS, indicating mortality, was calculated. A value of >6.5 for POD 1 CASUS had 80% sensitivity and 84% specificity, with area under the curve value 0.756 (95% confidence interval: 0.46 to 1). The mean values of POD1-CASUS (8.6 ± 6), M-CASUS (8.2 ± 5.2), and Dis-CASUS (7.8 ± 5.7) were significantly higher in cases of mortality, compared to the others. POD1-CASUS, M-CASUS, and Dis-CASUS were found to be statistically significantly elevated in patients with acute kidney injury (AKI) and postoperative stroke, and in those who were readmitted to the CTICU after initial discharge. Patients with POD1-CASUS ≥6.5 had a statistically significant association with mortality and postoperative morbidity (p < 0.05). Findings from multivariate logistic regression indicated that body mass index (BMI), ICU readmission, length of mechanical ventilation, and length of ICU stay remained associated significantly with POD1 CASUS ≥6.5. CONCLUSION: This study found that CASUS on POD 1, mean values of CASUS during CTICU stay, and CASUS at death/discharge from CTICU predicted ICU mortality after cardiac surgery in this racially diverse group. The CASUS derivatives can be used to predict unfavorable outcomes after cardiac surgery. A POD1-CASUS value of 6.5 or more could signify mortality and postoperative morbidity.

Successful Surgical Embolectomy for a Rapidly Deteriorating Patient with Pulmonary Embolism and Hemorrhagic Stroke.

Pulmonary embolism (PE) is a life-threatening condition. High-risk PE is defined as pulmonary embolism with either hemodynamic collapse, persistent hypotension, and/or organ hypoperfusion. The overall mortality rate associated with high-risk PE remains at approximately 30%. Intermediate-high risk PE is a new term introduced to identify hemodynamically stable PE patients with evidence of right ventricular dysfunction. Thrombolytics therapy is the first choice for treatment of high-risk PE with hemodynamic instability; however, in a patient who failed thrombolytics or have contraindication to thrombolytics, thrombus removal either with open surgical or catheter embolectomy is a good alternative. We report a case of a patient who presented with hemorrhagic stroke complicated by intermediate-high-risk PE that rapidly deteriorated before undergoing successful surgical embolectomy.

Right aortic arch with mirror image branching found incidentally during coronary surgery.

Right aortic arch with a left innominate (brachiocephalic) artery with mirror image branching (RAMI) is a rare congenital anomaly, and it is unusual to diagnose it in adulthood. There are very few cases of cardiac surgery being performed for acquired cardiac disease on a congenital RAMI patient. We present a patient who had an incidental finding of a RAMI anomaly found during coronary artery bypass surgery. Post-operatively computerised tomography showed both his congenital lesions and his bypass grafts.

A tale of three pumps and a mechanical heart.

Temporary mechanical circulatory support device (tMCS) failure could qualify patients with advanced heart failure to receive a long-term solution. We report on a patient who presented with cardiorespiratory arrest that required a tMCS and developed acute type A aortic dissection. Data Sources: our case adds further evidence regarding the support of a patient with a second (or more) incidence of tMCS. This patient subsequently underwent left ventricular assist device insertion and type A aortic dissection repair, as a combined procedure, with a satisfactory outcome.

SARS-CoV-2 (COVID-19) PCR cycle threshold: can it help in the timing of urgent cardiac surgery?

BACKGROUND: The COVID-19 pandemic has resulted in a significant reduction in urgent cardiac surgery due to concerns about safety for both patients and care givers. The timing of safe cardiac surgery is yet to be clarified in the setting of COVID-19 diagnosis. METHODS: Due to the urgency of the cardiac conditions on presentation, we have operated on four patients who exhibited the spectrum of COVID-19 disease from asymptomatic to severe COVID-19 pneumonia. With the evolving knowledge about SARS-CoV-2 and its genetic determinants as well as the cycle threshold levels obtained from real-time reverse transcription polymerase chain reaction, we have attempted to develop a strategy to deal with these patients. RESULTS: All four patients underwent urgent cardiac surgery following a thorough evaluation and multidisciplinary team approach with guidance based on the virus cycle threshold values obtained by reverse transcription polymerase chain reaction. CONCLUSION: We have shown that, with thorough preparations, consideration of the significance of the cycle threshold obtained on reverse transcription polymerase chain reaction and meticulous timing, COVID-19 diagnosed patients may undergo open heart surgery safely.

Off-pump coronary artery bypass grafting in a heparin-induced thrombocytopenia type II patient using hirudin.

Heparin is routinely used for anticoagulation during cardiopulmonary bypass; it is fast acting, is easily monitored, and has an antidote. Heparin-induced thrombocytopenia (HIT) can be a life-threatening condition requiring an alternative anticoagulant (hirudin) if cardiac surgical intervention is considered. At full anticoagulant doses, the effects of hirudin are difficult to monitor; therefore, we present a case in which off-pump coronary artery bypass grafting was performed in an HIT patient in whom the lower doses of hirudin could safely be monitored with easily available tests.

Endothelial dysfunction: cardiovascular risk factors, therapy, and outcome.

Endothelial dysfunction is a well established response to cardiovascular risk factors and precedes the development of atherosclerosis. Endothelial dysfunction is involved in lesion formation by the promotion of both the early and late mechanisms of atherosclerosis including up-regulation of adhesion molecules, increased chemokine secretion and leukocyte adherence, increased cell permeability, enhanced low-density lipoprotein oxidation, platelet activation, cytokine elaboration, and vascular smooth muscle cell proliferation and migration. Endothelial dysfunction is a term that covers diminished production/availability of nitric oxide and/or an imbalance in the relative contribution of endothelium-derived relaxing and contracting factors. Also, when cardiovascular risk factors are treated the endothelial dysfunction is reversed and it is an independent predictor of cardiac events. We review the literature concerning endothelial dysfunction in regard to its pathogenesis, treatment, and outcome.

Aspergillus aortitis: a cause for aortic perforation in a patient following combined aortic valve surgery and liver transplantation.

We report a case of aspergillus fumigatus aortitis in a patient following combined aortic valve replacement and orthotopic liver transplantation for significant aortic stenosis and alcoholic liver cirrhosis. At operation, a suspicious excavating lesion was found on the native aortic valve and specimen sent for culture. The ascending aorta and aortic sinuses were found to be normal. Routine immunosuppression was commenced post transplant. Urgent valve microscopy was highly suspicious of fungal growth, and antifungal therapy was instituted. Day 18 post-surgery the patient unexpectedly arrested. Post mortem findings showed ascending aortic perforation with multiple fungal lesions noted. Microscopy demonstrated aspergillus fumigatus invading the aortic wall. This is the first case report illustrating a dormant phase of aspergillus fumigatus endocarditis that was activated following surgery and immunosuppression leading to aortitis and subsequent perforation.