Heyde's Syndrome - An Enigma.

Heyde's syndrome (HS) is described as the association between recurrent bleeding from angiodysplasia of the gastrointestinal tract and aortic stenosis. Aortic valve replacement has been reported to stop the bleeding. In unfit patients, the options available are interventional or conservative management. We hereby report an elderly obese patient with severe comorbidity with complicated HS involving a narrow aortic root. She underwent left ventricular outlet myomectomy and aortic root replacement to promote better forward flow and prevent restenosis and recurrence of symptoms. She was discharged home symptom-free despite being on coumadin anticoagulants.

Multiple Migrated Superior Vena Cava Stents With Cardiac Injury - A Stepwise Open Cardiotomy Strategy to Mitigate Potential Fatality.

Iatrogenic injuries with migrated interventional stents can sometimes be life-threatening. The interventional retrieval management is generally the treatment of choice, as surgical procedures carry a high mortality risk with only a few cases reported. We report a patient with two stents migrated into the right atrium from superior vena cava resulting in cardiac perforation. She was successfully treated using pericardiocentesis followed by surgical intervention with rapid post-operative resolution of symptoms. The technique presented here substantiates the steps for a safe and effective removal of these multiple displaced stents with minimal postprocedural complications.

Absent pericardium and lung hypoplasia in a child with severe mitral regurgitation.

An 8-year-old girl with severe mitral regurgitation presented with symptoms of heart failure. Clinical investigations did not raise suspicion of an absent left pericardium. Congenital defects of the pericardium are rare and frequently associated with other cardiac lesions. We describe a case of severe mitral regurgitation in a child in whom an absent left-sided pericardium with hypoplasia of left lung was found incidentally during surgery to repair the mitral valve. We believe such associations with other heart diseases is usually circumstantial but can influence the perioperative morbidity, length of hospital stay, and even alter the surgical management.

Factor VII deficiency: do all need replacement for cardiac surgery?

In cardiac surgery, supplementation with recombinant factor VIIa is the treatment of choice for patients with factor VII deficiency, but overzealous administration can be associated with thromboembolic side-effects. A 53-year-old man with factor VII activity 15.2%, international normalized ratio 2.9, and acute thrombotic critical coronary anatomy, underwent coronary artery bypass surgery and a thoracotomy with decortication 5 months later. He was managed successfully without recombinant factor VIIa supplementation. This case demonstrates that current bedside and laboratory tests such as thromboelastography, prothrombin time or international normalized ratio, and factor VII activity may not predict replacement therapy in these patients.

Management issues during postinfarction ventricular septal defect and role of perioperative optimization: A case series.

The development of a myocardial infarction ventricular septal rupture is a rare fatal complication, and the surgical repair is the treatment of choice. In most of the scenarios, the operation will be done as an emergency procedure that carries high mortality. Prognosis of these patients depends on prompt echocardiographic diagnosis and the proactive medical and surgical therapy. More recently, various options have been put forward including the timing for surgery, percutaneous closure devices, and the improved outcome with initial stabilization with medical treatment including mechanical support. In this retrospective case series, we are presenting the management of these patients who presented us in different clinical scenarios and trying to identify the risks for the poor outcome and to formulate a strategy to improve the outcome.

Is baseline cerebral oximetry a better predictor than carotid scan for postoperative delirium in cardiac surgery?

Guidelines recommend screening patients for carotid-artery stenosis, but unfortunately, measurement of baseline cerebral oximetry levels is still not a routine practice prior to cardiac surgery. We report a 41-year-old woman who presented with a normal carotid scan and unexpectedly low baseline cerebral oximetry levels. She had delayed postoperative recovery and discharge from hospital following her coronary-artery bypass surgery. This case report reiterates the prognostic significance of cerebral oximetry in the preoperative checkup and the association of low intraoperative values to postoperative cerebral impairment. It can also be identified as a comparatively better tool for preventing cognitive disturbances after cardiac surgery.

Cerebral oxygenation monitoring in patients with bilateral carotid stenosis undergoing urgent cardiac surgery: Observational case series.

BACKGROUND: Patients with significant bilateral carotid artery stenosis requiring urgent cardiac surgery have an increased risk of stroke and death. The optimal management strategy remains inconclusive, and the available evidence does not support the superiority of one strategy over another. MATERIALS AND METHODS: A number of noninvasive strategies have been developed for minimizing perioperative stroke including continuous real-time monitoring of cerebral oxygenation with near-infrared spectroscopy (NIRS). The number of patients presenting with this combination (bilateral significant carotid stenosis requiring urgent cardiac surgery) in any single institution will be small and hence there is a lack of large randomized studies. RESULTS: This case series describes our early experience with NIRS in a select group of patients with significant bilateral carotid stenosis undergoing urgent cardiac surgery (n = 8). In contrast to other studies, this series is a single surgeon, single center study, where the entire surgery (both distal ends and proximal ends) was performed during single aortic clamp technique, which effectively removes several confounding variables. NIRS monitoring led to the early recognition of decreased cerebral oxygenation, and corrective steps (increased cardiopulmonary bypass flow, increased pCO 2 , etc.,) were taken. CONCLUSION: The study shows good clinical outcome with the use of NIRS. This is our "work in progress," and we aim to conduct a larger study.

Severe antiphospholipid syndrome and cardiac surgery: Perioperative management.

Antiphospholipid syndrome is an antiphospholipid antibody-mediated prothrombotic state leading to arterial and venous thrombosis. This condition alters routine in-vitro coagulation tests, making results unreliable. Antiphospholipid syndrome patients requiring cardiac surgery with cardiopulmonary bypass present a unique challenge in perioperative anticoagulation management. We describe 3 patients with antiphospholipid syndrome who had successful heart valve surgery at our institution. We have devised an institutional protocol for antiphospholipid syndrome patients, and all 3 patients were managed according to this protocol. An algorithm-based approach is recommended because it improves team work, optimizes treatment, and improves patient outcome.