Leiomyosarcoma of inferior vena cava (IVC): do we really need to reconstruct IVC post resection? Single institution experience.

BACKGROUND: Inferior vena cava (IVC) leiomyosarcomas (LMS) are a rare group of retroperitoneal tumors. R0 surgical resection is the only curative modality of treatment. IVC resection for retroperitoneal sarcoma is a complex surgery with no definitive guidelines for reconstruction. METHODS: Retrospective review of all patients who underwent surgical resection of primary leiomyosarcoma of the IVC requiring resection from 2010 to 2020 at our tertiary care center was performed. RESULTS: Among 24 patients who required IVC resection for LMS, only 7 (29%) required reconstruction of IVC. According to Clavien-Dindo classification, there was one grade 3 or more morbidity and 1 post-operative mortality. Seventeen patients underwent R0 resection whereas 7 patients had R1 resection on final histopathology. At a median follow-up of 25 months (range 8-91 months), the median OS was 40 months with median DFS of 28 months. Two patients presented with local recurrence while 13 patients developed systemic recurrence on follow-up. CONCLUSION: Careful preoperative multidisciplinary planning can make IVC resection without reconstruction feasible with acceptable perioperative morbidity, mortality, and oncological outcomes for IVC LMS.

Limb sparing surgery with vascular reconstruction for nonrhabdomyosarcoma soft tissue sarcoma in infants: A novel solution using allogenic vein graft from the parent.

Surgery continues to remain an integral component of treatment, especially for nonrhabdomyosarcoma soft tissue sarcoma as compared to rhabdomyosarcoma owing to their general insensitivity to chemotherapy. A key determinant of outcomes, particularly for extremity tumors includes complete tumor resection with negative margins; however, a significant limitation for limb salvage surgery is the adherence of sarcomas to vital vascular structures. Hitherto, vascular involvement constituted an adequate reason for amputation. However, modern reconstructive techniques and availability of prosthetic grafts in addition to autologous venous grafts have rendered limb salvage surgery possible in a substantial majority of patients. Vascular resection and reconstruction for extremity soft tissue sarcoma in children have not been used routinely for reasons like the small-caliber of native vessels, limited options for conduits and rapid somatic growth. The situation is inconceivable in infants owing to the contemporaneous diminutive caliber of the vessels. We report two infants with lower extremity nonrhabdomyosarcoma soft tissue sarcoma who underwent limb salvage surgery with resection of femoral vessels following which vascular reconstruction was successfully performed using the great saphenous vein allograft harvested from the father.

Nocardial endocarditis in native aortic valve with nocardial sepsis in a case of breast cancer.

Central venous catheter-associated bacteraemia caused by Nocardia species is very rare; the diagnosis of nocardiosis in patients with cancer is challenging because its clinical presentation is varied, sometimes mimicking metastases, and the high index of clinical suspicion is required for prompt institution of therapy. Herein, we report a case of nocardial sepsis with native aortic valve endocarditis in a patient with breast cancer in whom multidisciplinary team involvement and prompt initiation of therapy have led to successful outcome.

Resection of the Inferior Vena Cava for Retroperitoneal Sarcoma: Six Cases and a Review of Literature.

Resection of the inferior vena cava (IVC) for malignancy is a technically demanding procedure. We present a series of six cases of resection of the IVC for retroperitoneal sarcomas, four of which were primary caval tumors. We outline the technical difficulties faced in these complex procedures and discuss the oncological outcomes of these rare tumors. We performed a retrospective review of six patients operated for retroperitoneal masses involving the inferior vena cava between April 2015 and July 2016 at our tertiary care institute. Six patients underwent resection of the IVC, three of which required a multivisceral resection. An artificial prosthesis was used to reconstruct the IVC in three patients, whereas two patients underwent primary repair of the vein wall. One patient did not require any reconstruction. Margins were microscopically positive in two out of six patients. All patients received radiotherapy, either in the neo-adjuvant or adjuvant setting. Two patients developed local recurrences with a median follow-up of 24.5 months. Resection of the IVC for extirpation of retroperitoneal sarcomas is a technically complex and difficult procedure. The availability of a multidisciplinary team of surgeons and state-of-the-art intensive care support is essential for good outcomes.

Aortic root enlargement: what are the operative risks?

OBJECTIVE: Despite concern that small aortic valve prostheses can lead to prosthesis-patient mismatch with diminished left ventricular mass regression and poor long-term outcome after aortic valve replacement, there remains reluctance to perform aortic root enlargement procedures. We therefore examined the operative risks of aortic valve replacement with and without root enlargement. METHODS: We reviewed perioperative outcomes among patients undergoing aortic valve replacement at our institution between January 1993 and December 2001. Risk factors for operative death were evaluated by means of multivariable analysis. RESULTS: Of 2366 patients undergoing aortic valve replacement with (1173) or without (1193) concomitant procedures, 249 (10.5%) underwent posterior root enlargement. Patients undergoing complex root enlargement (Konno-Rastan procedures) were excluded. Patients undergoing aortic root enlargement were significantly younger, twice as often female, and more often undergoing a reoperation but were similar with respect to functional class. The mean valve implant size was less in the aortic root enlargement group (21.5 +/- 1.6 vs 23.2 +/- 2.3 mm, P < .0001). As expected, mean crossclamp time and bypass time were somewhat longer with root enlargement. Raw operative mortality was higher with aortic root enlargement (5.6% vs 2.9%, P = .0324); however, by means of multivariable analysis, advanced functional class (P = .0020; odds ratio, 1.87), preoperative congestive heart failure (P < .0001; odds ratio, 3.22), and smaller valve implant size (P = .012; odds ratio, 1.16), but not aortic root enlargement, were independent risk factors for operative death. CONCLUSIONS: Aortic root enlargement itself does not increase operative risk, although it is most often required among high-risk patients. Surgeons should not be reluctant to enlarge the aortic root to permit implantation of adequately sized valve prostheses.

Surgical ostioplasty for isolated left main stenosis.

Left main ostioplasty has been used as an alternative approach to surgical management of patients with isolated left main stenosis without significant calcification. We describe our technique of posterior patch augmentation of the left main ostium.

Update on outcomes of acute type B aortic dissection.

BACKGROUND: The optimal treatment of acute type B aortic dissection remains controversial. This study reports early clinical outcomes of medical management for acute type B aortic dissection. METHODS: Between January 2001 and April 2006, data on 159 consecutive patients (55 women [35%]) with the confirmed diagnosis of acute type B aortic dissection were prospectively collected and analyzed. Mean age was 62 years (range, 29 to 94). On admission, all patients were initiated on an acute type B aortic dissection protocol with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, retrograde dissection, malperfusion (visceral, peripheral), and intractable pain. All patients were followed up after discharge with serial clinical and radiographic examinations. RESULTS: Overall hospital mortality was 8.8% (14/159): 17% (4/23) with procedural intervention, and 7.4% (10/136) when medical management was maintained. Early intervention was required in 23 patients (14.5%), of which 21 (13.2%) were open vascular/aortic procedures, and two (1.3%) were percutaneous aortic interventions. Morbidity included rupture (5.0%), stroke (5.0%), paraplegia (8.2%), bowel ischemia (5.7%), acute renal failure (20.1%), dialysis requirement (13.8%), and peripheral ischemia (3.8%). Mortality associated with complicated dissection (74/159) was 17%, and mortality associated with uncomplicated dissection (85/159) was 1.2% (p < 0.0003). Late vascular related procedures were performed in 11 (7.6%) of 144 cases (9 aortic, 2 peripheral vascular). The only independent risk factors for hospital mortality by multiple logistic regression analysis was rupture (p < 0.0009). Independent risk factors for mid-term death were history of chronic obstructive pulmonary disease (p < 0.002) and glomerular filtration rate at admission (p < 0.0001). CONCLUSIONS: Medical management, especially for uncomplicated acute type B aortic dissection, is associated acceptable outcomes. This study provides current data for initial medical management of acute type B aortic dissection. Alternative strategies for the treatment of acute Type B aortic dissection should be compared with these results.

Acute type A aortic dissection complicated by stroke: can immediate repair be performed safely?

OBJECTIVE: Emergency surgical intervention for acute type A aortic dissection complicated by stroke remains controversial. The urgency of immediate repair in this setting is tempered by the concern that cerebral reperfusion may worsen neurologic outcome. The purpose of this study was to report and analyze our results with acute type A aortic dissection complicated by stroke. METHODS: Between September 1999 and March 2005, 151 consecutive patients presented with acute type A aortic dissection. Of this group, 16 (10.6%) patients had sustained a preoperative stroke. Mean age was 56 years (range 43-73 years), with 6 (38%) women. Right hemispheric, left hemispheric, and bilateral strokes occurred in 81%, 13%, and 6%, respectively. Computed tomographic scan or transesophageal echocardiography diagnosed aortic dissection; clinical examination, computed tomographic scan, or transcranial Doppler ultrasound diagnosed stroke. Aortic repair was performed with cardiopulmonary bypass, profound hypothermic circulatory arrest, and retrograde cerebral perfusion. One patient with complete neurologic devastation (coma) was not operated on. RESULTS: Overall hospital mortality was 18.8% (3/16). Mortality in 2 patients who did not undergo surgery (1 patient who was neurologically devastated, and 1 patient whose aorta ruptured while awaiting surgery) was 100% (2/2). Operative mortality was 7% (1/14). Among patients undergoing surgery, neurologic status completely recovered in 2 (14%) patients, improved in 6 (43%) patients, remained the same in 6 (43%) patients, and worsened in none. Median time from onset of stroke to surgery was 9 hours (range 1-240 hours). Eighty percent of patients who underwent surgical repair within 10 hours had improvement in neurologic status, where as none operated on beyond 10 hours improved (P < .02). CONCLUSIONS: In our experience, surgical repair of acute type A aortic dissection can be performed in the setting of preoperative stroke with acceptable mortality. Moreover, no worsening of neurologic condition was observed after surgical repair. Immediate surgical repair is warranted even if acute type A aortic dissection is complicated by stroke.

Gastrointestinal complications after descending thoracic and thoracoabdominal aortic repairs: a 14-year experience.

OBJECTIVE: There is a paucity of data regarding gastrointestinal (GI) complications after descending thoracic and thoracoabdominal aortic (DTA/TAA) surgical repairs. We examined our 14-year experience with these repairs to determine the incidence, outcomes, and risk factors for postoperative GI complications. METHODS: Between February 1991 and February 2005, we repaired 1,159 DTA/TAA. Data were prospectively collected. The mean patient age was 68 years and 36% were women. Complications were classified as biliary disease, hepatic dysfunction, pancreatitis, GI bleeding, peptic ulcer disease, bowel ischemia, and ileus. Risk factors for the occurrence of GI complications were ascertained by univariate and multivariable analysis. RESULTS: Of the 1,159 patients, 81 had 109 GI complications, for a 7% incidence. The mortality associated with GI complications was 39.5% compared with 13.5% (P < .0001) in patients without GI complications. The incidences of complications were bowel ischemia, 2.5% with 62% mortality; biliary disease, 0.3% with 75% mortality; hepatic dysfunction, 1.6% with 38% mortality; acute pancreatitis, 0.3% with 20% mortality; GI bleeding, 1.5% with 29% mortality; peptic ulcer disease, 0.9% with 30% mortality; and ileus, 2.2% with 26% mortality. Postoperative biliary disease (odds ratio [OR], 16.58; P = .001), hepatic dysfunction (OR, 3.58; P = .006), and bowel ischemia (OR, 10.03; P = .0001) were significantly associated with an increased postoperative mortality. Risk factors for the occurrence of GI complications were visceral involvement of the aortic repair (TAA extent II, III, and IV) (OR, 2.08; P = .002) and low preoperative glomerular filtration rate (OR, .98; P = .0002). CONCLUSION: Biliary disease, hepatic dysfunction, and bowel ischemia after DTA/TAA surgical repairs were associated with an increased mortality. Visceral involvement and preoperative renal insufficiency were risk factors for the occurrence of GI complications.

Total transatrial correction of tetralogy of Fallot: no outflow patch technique.

BACKGROUND: The aim of this study was to analyze the feasibility and early results of transatrial total correction of tetralogy of Fallot (TOF). METHODS: Of the 860 patients undergoing total correction for TOF between January 2000 and July 2005, 334 patients were considered morphologically suitable for transatrial total correction. The ventricular septal defect (VSD) closure, infundibular resection, and pulmonary valvotomy were performed through the right atrium without a right ventriculotomy. Age ranged from 6 months to 40 years (median, 2.8 years), and weight ranged from 5.5 to 70 kg (median, 14 kg). RESULTS: Peroperatively, 34 patients required right ventriculotomy and transannular patch; hence, they were excluded from the study. In addition, pulmonary arteriotomy was required in 71 patients (22.9%). There were 4 hospital deaths. There were 4 early reoperations (residual/additional VSD in 3 and tricuspid regurgitation in 1). Two patients had complete heart block requiring permanent pacemaker. Echocardiography at discharge showed a peak right ventricular outflow tract gradient of 20 +/- 5.2 mm Hg. Mean follow-up was 26.8 +/- 4.2 months (range, 1 to 52 months). The right ventricular outflow tract gradients reduced to 13 +/- 4.2 mm Hg after a mean interval of 18.8 +/- 5.2 months. Follow-up New York Heart Association class was I in 240 cases (82%), II in 49 (16%), and III in 7 (2%). There were no late deaths or reoperations. CONCLUSIONS: Transatrial total correction of TOF can be accomplished in selected patients with good early results. In 300 cases (90%), the feasibility of transatrial total correction could be predicted accurately.

Inflammatory aneurysm of the ascending aorta.

Inflammatory aneurysms of the aorta are usually seen in the infrarenal abdominal aorta and very rarely in the ascending aorta. We present the case of a 76-year-old male with inflammatory aneurysm of the ascending aorta.

Outcomes of medical management of acute type B aortic dissection.

BACKGROUND: Currently, the optimal treatment of acute type B aortic dissection remains controversial. The purpose of this study was to report early clinical outcomes of medical management for acute type B aortic dissection. METHODS AND RESULTS: Between January 2001 and March 2005, 129 consecutive patients with the confirmed diagnosis of acute type B aortic dissection were studied. Mean age was 61 years (range, 29 to 94), with 33.3% (43/129) female. Acute type B aortic dissection protocol was instituted with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, malperfusion, and intractable pain. All patients were followed-up after discharge. Hospital mortality was 10.1% (13/129), 19% (4/21) when vascular intervention was required, and 8.3% (9/108) when medical management was maintained. Early intervention was required in 21 cases (16.2%), 19 (14.7%) open vascular/aortic cases and 2 cases (1.6%) of percutaneous aortic interventions. Morbidity included rupture (4.7%), stroke (4.7%), paraplegia (8.5%), bowel ischemia (7%), acute renal failure (21%), dialysis requirement (13%), and peripheral ischemia (4.7%). Late vascular-related procedures were performed in 5.2% (6/116) of cases. Univariate risk factors for early mortality were rupture (P<0.0001), need for laparotomy (P<0.008), acute renal failure (P<0.0001), need for dialysis (P<0.0001), and lower extremity ischemia (P<0.0004). The only independent risk factors for hospital mortality by multiple logistic regression was rupture (P<0.0009), and independent risk factors for midterm death were history of chronic obstructive pulmonary disease (P<0.002) and low glomerular filtration rate (<57 mL/min; P<0.0001). CONCLUSIONS: Medical management for acute type B aortic dissection is associated acceptable outcomes. Outcomes of other management strategies, eg, endovascular stenting, for acute type B aortic dissection need to be compared with these results.

Redo mitral valve surgery-a long-term experience.

BACKGROUND: Our experience with reoperative mitral valve (MV) surgery over a 27-year period is presented here. METHODS: From January 1975 to June 2002, 11,908 operations were performed for MV disease. Out of these 744 were reoperations. The mean age at primary operation was 23.6 +/- 10.1 years (range 2 to 53 years) and at reoperation was 36.0 +/- 11.0 years (range 6 to 65 years) with a mean interval of 11.5 +/- 2.5 years. Mitral valve replacement (MVR) was performed following previous closed mitral valvotomy (CMV) in 408 patients, open mitral commissurotomy (OMC) in 21 patients, and MV repair in 58 patients, MVR in 80 patients, homograft mitral valve replacement (HMVR) in 11 patients. The reasons for reoperation were mainly progression of lesions. Valve thrombosis and endocarditis were indications for reoperation following MVR. Twenty-eight patients underwent redo CMV, 53 patients underwent OMC, and 14 patients underwent MV Repair. RESULTS: Early mortality was 5.64% (n = 42). Hemorrhage and low cardiac output were the major causes. Follow-up was 124.8 +/- 30.5 months (2 to 300 months). Follow-up was 88%. There were no late deaths in the valve repair group. There were three episodes of thromboembolism in this group (0.3% per patient-year). In the valve replacement group there were six late deaths; three due to valve thrombosis, one due to infective endocarditis, and two due to anticoagulant-related hemorrhage. There were 13 episodes of thromboembolism in this group (0.6% per patient-year). CONCLUSION: Redo MV surgery is safe and can be undertaken with acceptable mortality and morbidity.

Open mitral commissurotomy in the current era: indications, technique, and results.

BACKGROUND: The present retrospective study is focused on indications, techniques, and results of open mitral commisurotomy in the current era. METHODS: Of the 1,280 patients undergoing open-heart surgical procedures for rheumatic mitral stenosis between January 1990 and July 2000, 276 (21.6%) patients underwent open mitral commissurotomy. Major indications included presence of left atrial thrombus/clot (n = 82, 29.7%), severe subvalvular disease (n = 110, 39.8%), mitral valve calcification (n = 42, 15.2%), mild mitral regurgitation (n = 28, 10.0%), associated aortic valve disease (n = 55, 19.9%), organic tricuspid valve disease (n = 20, 7.2%), and failure or restenosis after closed or balloon mitral valvuloplasty (n = 55, 19.9%). Age of patients ranged from 7 to 67 years (mean, 30.2 +/- 12 years). The majority (76%) were in New York Heart Association class III or IV, and 6.9% were in congestive heart failure. Atrial fibrillation was present in 134 (48.6%) patients. Mitral valve area ranged from 0.3 to 0.7 cm2 (mean, 0.52 +/- 0.12 cm2). Mid-diastolic gradients across the mitral valve ranged from 8 to 34 mm Hg (mean, 14.5 +/- 6.2 mm Hg), and end-diastolic gradients ranged from 8 to 42 mm Hg (mean, 15.2 +/- 5.7 mm Hg). Open mitral commissurotomy was performed using standard cardiopulmonary bypass. Associated aortic valve procedure was performed in 55 patients, and either tricuspid valvotomy or repair was performed in 28 patients. RESULTS: There were four early deaths. All these patients had associated aortic valve procedure (Ross procedure in 2 and homograft aortic valve replacement in 2). Three patients developed severe mitral regurgitation in early postoperative period (< or = 30 days) and required reoperation. Predischarge echocardiography showed mitral valve area from 1.4 to 3.5 cm2 (mean, 2.6 +/- 0.6cm2) and moderate mitral regurgitation in 4 patients. Follow-up ranged from 1 to 130 months (mean, 64.5 +/- 28.6 months). There was no late death. There were three reoperations for mitral valve failure, and an additional 2 patients developed severe mitral stenosis (mitral valve area < 1.0 cm2). In operative survivors, freedom from mitral valve failure at 10 years was 87.0% +/- 3.5%. In patients with isolated open mitral commissurotomy, the incidence of thromboembolism was 0.5%/patient-year. CONCLUSIONS: Open mitral commissurotomy provides excellent early and long-term results in a selected group of patients.