A case report of a rapidly growing giant coronary pseudoaneurysm: challenges and lessons learned.

Background: Coronary pseudoaneurysm is a rare, potentially fatal, complication of coronary intervention. A challenging management case of a giant right coronary pseudoaneurysm is presented. Case summary: A 56-year-old man presented with an atypical presentation for ST-elevation myocardial infarction. Initial angiogram showed a crescent-shaped ostial lesion with probable connection to the aorta, which disappeared after placing a drug-eluting stent. A few hours later, patient was found to have staph aureus bacteraemia and infective endocarditis for which he received a prolonged antibiotic course. Patient presented a few weeks later with second degree heart block. Echocardiography showed a large cystic lesion adjacent to the right coronary cusp suspicious for a coronary pseudoaneurysm, which was confirmed with angiography. Attempts to treat it with a covered stent were unsuccessful and patient ultimately underwent surgical resection. Discussion: Coronary pseudoaneurysm develops when there is a contained breach of all three layers of the vessel. It may develop from direct iatrogenic trauma to the vessel wall but can be infectious in aetiology. The treatment approach remains uncertain due to limited evidence. Here, we present the diagnostic and technical challenges of managing such an uncommon entity and discuss an algorithm for management.

Off-Pump CABG in a Patient with Laryngectomy and Permanent Tracheostomy Utilizing Low Midline Skin Incision with Transverse Skin Flaps and Manubrium Sparing Sternotomy.

Patients that have undergone previous laryngectomy with permanent stoma placement are at increased risk of wound infection, mediastinitis, and tracheal injury when undergoing coronary artery bypass grafting (CABG) via standard skin incision and sternotomy. We present a case of off-pump CABG via a low midline skin incision with transverse skin flaps and a manubrium sparing sternotomy. doi: 10.1111/jocs.12771 (J Card Surg 2016;31:439-440).

Postoperative blood transfusion is an independent predictor of acute kidney injury in cardiac surgery patients.

BACKGROUND: Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB) which increases postoperative morbidity and mortality. OBJECTIVES: The study was designed to assess the incidence of AKI and associated risk factors in patients undergoing CPB ancillary to coronary artery bypass grafting (CABG), valve surgery, and combined CABG and valve surgery. PATIENTS AND METHODS: This Intuitional Review Board (IRB) approved retrospective study included patients with normal preoperative kidney function (Serum creatinine [sCr] <2.0 mg/dl) who underwent cardiac surgery with CPB between 2012 and 2014. Patients were divided into 2 groups: group I: Patients with cardiac surgery associated AKI (CS-AKI) (postoperative sCr >2 mg/dl with a minimal doubling of baseline sCr) and group II: Patients with a normal postoperative kidney function. Demographic data, body mass index (BMI), co-morbidities, hematologic/biochemical profiles, preoperative ejection fraction (%EF), blood transfusion history, and operative data were compared between the groups. Mean arterial pressure (MAP) was recorded during the operation and in the postoperative period. Δ-MAP was defined as the difference between pre-CPB-MAP and the CPB-MAP. RESULTS: 241 patients matched the inclusion criteria (CS-AKI incidence = 8.29%). Age, gender, BMI, %EF, and co-morbidities were not predictors of CS-AKI (P > 0.05). High preoperative sCr (P = 0.047), type of procedure (P = 0.04), clamp time (P = 0.003), pump time (P = 0.005) and history of blood transfusion within 14 days postsurgery (P = 0.0004) were associated with risk of CS-AKI. Pre-CPB-MAP, CPB-MAP, Δ-MAP, and ICU-MAP were not significantly different between the 2 groups. Male gender (OR: 5.53; P = 0.048), age>60 (OR: 4.54; P = 0.027) and blood transfusion after surgery (OR: 5.25; P = 0.0054) were independent predictors for postoperative AKI. CONCLUSIONS: Age, gender and blood transfusion were independent predictors of cardiac surgery associated AKI.

Intra-abdominal hypertension causes disruption of the blood-brain barrier in mice, which is increased with added severe head trauma.

BACKGROUND: Although the individual effect of head trauma and intra-abdominal hypertension (IAH) causing blood-brain barrier (BBB) disruption has been studied separately, their combined effect on the integrity of BBB has not been investigated. This study examines the effects of IAH and head trauma, individually and in combination, on the permeability of the BBB in mice. METHODS: Male CD-1 mice weighing 30 to 38 g were used. Control mice were anesthetized for 4 hours. The mice in the experimental group underwent the following: (1) IAH 4 hours, (2) head trauma, and (3) combined head trauma and IAH 4 hours. IAH was induced by intraperitoneal infusion of mineral oil to a pressure of 20 mm Hg. Head trauma was induced using weight drop technique. BBB permeability was quantified using the Evans blue dye extravasation method. RESULTS: BBB permeability was higher in the mice with IAH 4 hours compared with the control group (p < 0.05), higher in the mice with head trauma compared with the control group (p < 0.05), and significantly higher than the IAH and the control groups in the mice with combined IAH 4 hours and head trauma (both p < 0.05). CONCLUSION: The disruption of BBB in mice is produced by IAH and is increased with severe head trauma.