Delayed Aortic Valve Perforation Caused by Blunt Trauma.

Traumatic aortic regurgitation (AR) is a rare complication of blunt chest trauma. We described the case of a 35-year-old male who presented to our hospital with shortness of breath 7 years after sustaining blunt chest trauma associated with a motorcycle accident. Transthoracic and transesophageal echocardiogram detected severe AR with two separate jets. The patient was diagnosed with congestive heart failure due to severe AR, and surgical aortic valve replacement was performed. A large perforation of the right coronary cusp likely sustained during the initial blunt chest trauma injury was confirmed surgically. As AR caused by blunt chest trauma can gradually worsen, it is necessary to confirm if there is a history of trauma in patients with severe AR of unknown origin.

Cocaine-Related Myocardial Infarction and Ventricular Rupture.

Cardiovascular complications following cocaine use are well described. We present a case of myocardial infarction and ventricular rupture in a young individual with limited underlying coronary disease and habitual cocaine use. The role of each is discussed.

Left Ventricular Mechanical Support with the Impella during Extracorporeal Membrane Oxygenation.

Background: Venoarterial extracorporeal membrane oxygenation (ECMO) provides systemic arterial support without directly unloading the left heart, which causes an elevated left ventricular (LV) pressure. The aim of the present study was to investigate the adjunctive application of the Impella device for LV unloading in patients during ECMO. Methods: This retrospective cohort study included patients who received Impella support in addition to venoarterial ECMO between April 2012 and December 2015. ECMO cannulation was performed peripherally or centrally, while the Impella device was surgically inserted into the femoral artery or the right axillary artery. Results: Among 62 patients, 10 (16.1%) received an Impella device during ECMO support. Following Impella support, right atrial pressure improved from a median of 18 (IQR, 14-24) mmHg to 13 (IQR, 10-15) mmHg and pulmonary wedge pressure improved from 30 (IQR, 26-35) mmHg to 16 (IQR, 12-19) mmHg in all the patients (p value < 0.001). Follow-up transthoracic echocardiograms (n = 6) showed a median decrease of 0.8 cm in LV end-diastolic volume (p value = 0.021). There were 5 (50%) in-hospital deaths due to sustained brain injury (n = 3) and refractory cardiogenic shock (n = 2). The remaining 5 patients were discharged and successfully bridged to more permanent LV assist device (n = 2) or heart transplantation (n = 3). Conclusion: The findings of the present study indicate that the application of the Impella device during ECMO support is effective in LV unloading and confers optimal hemodynamic support.

Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism.

BACKGROUND: Extracorporeal Membrane Oxygenation (ECMO) has been suggested for cardiopulmonary support in patients with massive pulmonary embolism (PE) refractory to other treatment or as bridging to embolectomy. The survival benefit from ECMO in patients with massive PE remains unclear. METHODS: Here, we describe 5 cases in which ECMO was used as cardiopulmonary support following massive near-fatal pulmonary embolism. RESULTS: The overall mortality in patients with massive PE that received ECMO support was 40%. Death occurred secondary to ECMO-related complication in one case and due to inability to maintain adequate cerebral perfusion despite ECMO support in the second case. CONCLUSIONS: ECMO can be considered as a treatment modality for patients with massive PE.

Extracorporeal membrane oxygenation in transcatheter aortic valve replacement.

Background Patients undergoing transcatheter aortic valve replacement can experience severe perioperative complications leading to hemodynamic instability and death. Venoarterial extracorporeal membrane oxygenation can be used to provide cardiorespiratory support during this time. Methods From 2012 to 2015, of 247 patients who underwent transcatheter aortic valve replacement, 6 (2.42%) required extracorporeal membrane oxygenation support. Their mean age was 82 ± 7.4 years, mean Society of Thoracic Surgeons score was 9.4 ± 6.6, and mean aortic gradient was 28.3 ± 12 mm Hg. Rescue extracorporeal membrane oxygenation was required for hemodynamic instability due to ventricular fibrillation ( n = 1), respiratory failure ( n = 1), left ventricular wall rupture ( n = 2), and aortic annulus rupture ( n = 1). In one patient, prophylactic extracorporeal membrane oxygenation was required due to advanced heart failure. Additional procedures included valve-in-valve implantation ( n = 1), conversion to an open procedure ( n = 3), and intraaortic balloon pump insertion ( n = 1). Results The median hospital stay was 20 days. There were 2 hospital deaths in patients whose hospital course was complicated by left ventricular wall rupture or aortic annulus rupture with resulting tamponade. Among the 4 survivors, one required continuous ventilator support following discharge, and 3 experienced no major complications during the first month after discharge. Conclusions Extracorporeal membrane oxygenation can be considered a viable option for high-risk patients undergoing transcatheter aortic valve replacement and those who develop cardiac complications following this procedure and require cardiorespiratory support.

Benign metastasizing leiomyomatosis of the lungs presenting a miliary pattern.

Benign metastasizing leiomyomatosis is a very rare and significantly interesting pathology of the lungs. It is a challenge to clinicians when presenting a miliary pattern in preoperative radiologic imaging because it could be any other interstitial disease or infectious in etiology such as miliary tuberculosis. We report a case of innumerable tiny nodular densities spread evenly throughout both lungs in a patient with history of hysterectomy for a fibroid uterus.

Extracorporeal membrane oxygenation support after Ivor-Lewis esophagectomy for esophageal adenocarcinoma.

Respiratory failure after Ivor-Lewis esophagectomy results in poor outcomes. Limited treatment strategies are available to manage this severe complication. One possibility is extracorporeal support. We report the successful use of extracorporeal support as a successful strategy for refractory respiratory failure.

Stab wound of the heart with unusual sequelae.

A 31-year-old woman was admitted to the emergency department with a stab wound to the heart. She was initially stable but rapidly developed hypotension. While the operating room and staff were in preparation, she underwent pericardiocentesis. She was then rushed to the operating room by the general surgical trauma team, who performed a bilateral anterior thoracotomy to control the bleeding. In the recovery room, the patient was still hypotensive, so cardiothoracic surgery was consulted. An echocardiogram revealed severe hypokinesis of both ventricles. The cardiothoracic surgeons returned her to the operating room and discovered that the anterior pericardium had been completely removed by the trauma team. This had caused the posterior pericardium to form a "bowstring" that almost totally obstructed pulmonary venous return and restricted right ventricular outflow of blood, inducing right-sided heart failure. This pericardial string also strangulated the left atrium posteriorly, forming 2 compartments. We repositioned the patient's heart and implanted ventricular assist devices bilaterally to provide temporary circulatory support. The patient made a good recovery. We suggest that bilateral assist device placement can be beneficial in the recovery of a stunned but otherwise normal heart.