Systolic prospectively ECG-triggered dual-source CT angiography for evaluation of the coronary arteries in heart transplant recipients.

OBJECTIVES: To assess feasibility, image quality, and radiation dose of prospectively ECG-triggered coronary CT angiography (CTA) in orthotopic heart transplant (OHT) recipients. METHODS: 47 consecutive OHT recipients (40 men, mean age 62.1 ± 10.9 years, mean heart rate 86.3 ± 14.4 bpm) underwent dual-source CTA to rule out coronary allograft vasculopathy in a prospectively ECG-triggered mode with data acquisition during 35% to 45% of the cardiac cycle. Two independent observers blindly assessed image quality on a per-segment and per-vessel basis using a four-point scale (1-excellent, 4-not evaluable). Scores 1-3 were considered acceptable for diagnosis. Multivariate analysis was performed to evaluate differences between image quality scores obtained at different reconstruction intervals. Effective radiation doses were calculated. RESULTS: 671 coronary segments were evaluated. Interobserver agreement on the image quality was κ=0.75. Diagnostic image quality was observed in 93.9%, 95.5% and 93.3% of the segments at 35%, 40% and 45% reconstruction intervals. Mean image quality score was 1.5 ± 0.7 for the entire coronary tree, 1.4 ± 0.7 for the RCA, 1.6 ± 0.8 for the LCA and 1.6 ± 0.7 for the Cx at the best reconstruction interval. Estimated mean radiation dose was 4.5 ± 1.2 mSv. CONCLUSION: Systolic prospectively ECG-triggered CTA allows diagnostic image quality coronary angiograms in OHT recipients at low radiation doses.

Giant left atrial thrombus 17 years after orthotopic heart transplantation.

We present the case of a 66-year-old woman who underwent orthotopic heart transplantation 17 years earlier for dilated cardiomyopathy. After 7 years allograft coronary vasculopathy developed requiring coronary artery angioplasty. In year 15 postoperatively she experienced congestive heart failure and she became symptomatic requiring diuretics and digoxin treatment. In year 16 postoperatively a routine coronary computed tomography (CT) angiography study revealed a giant thrombus in the left atrium. The patient had had no thromboembolic-related symptoms. Anticoagulation therapy was introduced and the patient has not presented any thromboembolic-related complication. As the symptoms of cardiac insufficiency worsened we decided to evaluate the patient for re-transplantation.

Long-term results of ascending aorta-abdominal aorta extra-anatomic bypass for recoarctation in adults with 27-year follow-up.

OBJECTIVE: The surgical treatment of recurrent coarctation in adults supposes a redo left thoracotomy with adhesions and high risk of bleeding and injury of adjacent nerves. The rate of paraplegia in these cases may reach 2.6%. Extra-anatomic aortic bypass avoids these complications. We present our results with ascending-to-abdominal aorta extra-anatomic bypass for recurrent aortic coarctation in adults. METHODS: Between September 1979 and November 2006 12 patients underwent ascending-to-abdominal aorta bypass. There were 10 males and 2 females. Mean age was 36.2+/-11.3 (range 21-57) years old. Mean age at primary repair was 14.3+/-4.2 years old (range 8-21). Operative technique consisted of performing an ascending-to-abdominal aorta bypass via median sternotomy extended into the epigastrium with a supra-umbilical laparotomy through the mid-line abdominal fascia. Concomitant procedures were performed in six patients: three isolated aortic valve replacements (AVR), two ascending aorta graft replacements and one AVR associated with coronary artery bypass graft (CABG). RESULTS: No postoperative mortality was observed. Mean follow-up time was 10.4+/-9.3 years (range 0.3-27.8). No patients had any graft-related complication or death and all grafts were patent at the end of the follow-up. One patient developed a dilated myocardiopathy, dying at 14 years of follow-up. Four patients had persistence of arterial hypertension controlled with one drug therapy and five patients were asymptomatic. CONCLUSIONS: Ascending-to-abdominal aorta extra-anatomic bypass is a safe, effective and less invasive technique for aortic recoarctation in adults with good results at long-term.

Congenital bilateral coronary artery to pulmonary artery fistulas associated with left main trunk stenosis.

A rare case of a 57-year-old patient who presented with an acute coronary syndrome with incidental discovery of bilateral coronary arteriovenous fistulas originating from both coronary arteries to the pulmonary artery trunk and coronary artery atherosclerosis.

Cardiac surgery in nonagenarians: hospital mortality and long-term follow-up.

Nonagenarians represent a growing part of the population. However, it is assumed that they present a poorer functional class to cope with the stress inferred by surgical interventions. The aim of this study was to review our experience with nonagenarians concerning postoperative morbidities, mortality, and long-term survival status. Retrospective data from 30 consecutive nonagenarians who underwent cardiac surgery between January 1990 and December 2002, and their long-term follow-up was analysed. There were 18 women (60%) and 11 men. Left ventricle ejection fraction (LVEF) was 50.3+/-10.5%. Fifty percent of the patients were in NYHA functional class III or IV. There were nine coronary artery bypass grafting (CABG) procedures (30%), 16 aortic valve replacements (AVR), (53%), one double valve procedure and one replacement of infected intracavitary pace-maker leads. In-hospital mortality rate was 20% (6/30). Mean follow-up was 21.5+/-19 months (r: 2.2 to 68). Actuarial survival rate at 12, 24 and 60 months was 67%, 43% and 30%, respectively. Surviving patients referred quality of life as good, all but one were in NYHA functional class I. Nonagenarians undergoing cardiac surgery have higher mortality and morbidity rates than younger patients. However, in a carefully selected group of patients, the operative risk remains acceptable.