Stent graft-induced new entry tear after endoluminal grafting for aortic dissection repaired with open interposition graft.

Thoracic endovascular aortic repair is a successful treatment strategy for type B aortic dissections, with low morbidity and mortality compared with the gold standard of open repair. Questions still remain regarding its long-term durability and complication rate. There is a growing awareness of new entry tears induced by the stent graft, a potentially lethal complication. We report the case of a 74-year-old woman with a complicated retrograde type A aortic dissection treated with endovascular stent graft coverage. She required open surgical conversion after she developed a symptomatic, new entry tear induced by the stent graft.

Transseptal mitral valve replacement after transcatheter aortic valve implantation.

We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aortic valve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aortic valve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well.To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aortic valve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aortic valve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.

Pseudoaneurysm of mitral-aortic intervalvular fibrosa: two case reports and review of literature.

The aim of this study was to identify the echocardiographic characteristics of pseudoaneurysm of the mitral-aortic intervalvular fibrosa, which is a rare and life-threatening complication of infective endocarditis. We have demonstrated the difference in clinical presentation and management of acute and chronic types of this pseudoaneurysm, together with a review of literature of the topic. We present two cases, one acute and the other an example of a chronic pseudoaneurysm of the mitral-aortic intervalvular fibrosa. The abscess may enlarge rapidly and rupture, resulting in haemorrhage with a catastrophic outcome. Rarely, the pseudoaneurysm will undergo a subclinical course, thicken and organize into a chronic aneurysm. Transoesophageal echocardiogram demonstrates a false lumen below the aortic valve annulus at the mitral-aortic intervalvular fibrosa with marked pulsatility with systolic expansion and diastolic collapse. The successful management of acute pseudoaneurysm necessitates extensive resection and replacement of the infected areas around the pseudoaneurysm. In chronic pseudoaneurysm, there is structural integrity around the calcified pseudoaneurysm, potentially minimizing the need for an extirpative surgery. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare complication of infective endocarditis, but delay in diagnosis can lead to devastating outcome.

Triage and outcome of patients with mediastinal penetrating trauma.

BACKGROUND: A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT). METHODS: Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera. RESULTS: Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries. CONCLUSIONS: In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.

Hand-assisted thoracoscopic repair of a Bochdalek hernia in an adult.

BACKGROUND: Bochdalek hernias are congenital diaphragmatic hernias that are generally asymptomatic and often discovered incidentally. Surgical treatment is indicated once the diagnosis is made. These hernias have traditionally been repaired by open abdominal or thoracic approaches. MATERIALS AND METHODS: A healthy 24-year-old male presented with an 8-month history of shortness of breath. The patient was noted to have a postero-lateral diaphragmatic hernia, with a 4 cm defect in the left hemidiaphragm seen with computed tomography scan. He underwent hand-assisted video-assisted thoracoscopic surgery, in which the herniated omentum was reduced and the defect was repaired primarily and reinforced with Marlex mesh. The patient recovered uneventfully and was discharged home after a short hospitalization. CONCLUSION: Video-assisted thoracoscopic surgery for repair of Bochdalek hernias offers diagnostic as well as therapeutic advantages as it provides an excellent view of the surgical field, is easily executed, results in minimal surgical trauma, and has excellent cosmetic results and rapid recovery. We report a hand-assisted intracorporeal thoracoscopic repair to be a secure and satisfactory adjuvant to achieve the repair and conclude that thoracoscopic repair of the rare Bochdalek hernia is feasible.

Risk factors for hemorrhage-related reexploration and blood transfusion after conventional versus coronary revascularization without cardiopulmonary bypass.

OBJECTIVE: The premise of coronary revascularization without cardiopulmonary bypass (off-pump CABG) proposes that patient morbidity and, potentially, mortality can be reduced without compromising the excellent results of conventional revascularization techniques (on-pump CABG). It is unknown, however, whether coronary artery bypass without cardiopulmonary bypass (off-pump CABG) is associated with similar hemorrhage related reexploration rates and blood transfusion requirements compared to the on-pump approach. METHODS: Between January 1998 and June 2002, 3646 patients underwent off-pump CABG and were compared with a contemporaneous control group of 5197 on-pump CABG patients. A logistic regression model was used to test the difference in the postoperative hemorrhage related reexploration rates and need for postoperative blood transfusions between the groups, controlling for preoperative risk factors. The patients undergoing off-pump CABG were matched to on-pump patients by propensity score. RESULTS: Hemorrhage related reexploration rates were comparable between the 2 groups (odds-ratio [OR]=0.80, 95% confidence intervals [CI]=0.55-1.09, P=0.15). Off-pump CABG was associated with a lower need for single and multiple unit postoperative blood transfusions (OR=0.30, CI=0.24-0.31, P<0.01 and OR=0.4, CI=0.36-0.51, P<0.01, respectively) compared to on-pump CABG patients. CONCLUSIONS: Off-pump CABG eliminates the risks of cardiopulmonary bypass and the systemic inflammatory response it elicits. A substantially lower need for postoperative blood transfusions and a comparable hemorrhage-related reexploration rate suggests that off-pump CABG may avoid the morbidity and mortality associated with excessive postoperative blood loss.

Treatment of symptomatic vascular rings in the elderly.

A 76-year-old woman presented with respiratory failure that was later determined to be a result of a right aortic arch with an aberrant left brachiocephalic artery. This vascular ring compressed the trachea, requiring operative intervention. A median sternotomy gave access for an aorta-to-left brachiocephalic artery bypass and division of the vascular ring. This is a unique case, because vascular rings rarely present in elderly patients with such acute life-threatening symptoms. To our knowledge, this is the oldest and heaviest patient ever reported with symptomatic presentation and one of only 4 patients over the age of 50. The current literature on vascular rings of the thoracic aorta in adults is reviewed.

Acute massive pulmonary embolism: role of the cardiac surgeon.

We present the case of a 72-year-old woman who had an acute massive pulmonary embolism after abdominal surgery. The patient had undergone a right hemicolectomy and pancreaticoduodenectomy for locally invasive colonic adenocarcinoma. Six hours postoperatively, she required emergent intubation when she suddenly became cyanotic, severely hypotensive, and tachypneic, with an oxygen saturation of 50%. An acute massive pulmonary embolism was suspected, and an emergency transesophageal echocardiogram confirmed the diagnosis. On the basis of the patient's clinical condition and the echocardiographic findings, we performed an emergent pulmonary embolectomy, with the patient on cardiopulmonary bypass. We evacuated multiple large clots from both pulmonary arteries. The patient recovered and was discharged from the hospital 61 days postoperatively. Herein, we review the current literature on open surgical pulmonary embolectomy. This case supports the use of open pulmonary embolectomy for the treatment of hemodynamically unstable patients on the basis of clinical diagnosis. We discuss the role of emergent transesophageal echocardiography in the diagnosis and management of massive pulmonary embolism.

Management of intramural hematoma of the ascending aorta and aortic arch: the risks of limited surgery.

We present the case of a 57-year-old woman who had an intramural hematoma of the ascending aorta and aortic arch. After initial blood pressure control and imaging studies, the patient underwent limited surgical repair that consisted of ascending aortic replacement. One week postoperatively, the aortic arch hematoma progressed to a full dissection that extended into the proximal descending aorta. Emergent aortic arch replacement was required. Current world medical literature regarding thoracic aortic intramural hematoma is presented. This case supports the treatment of intramural hematomas of the ascending aorta and arch by surgical replacement of both segments with a Dacron graft, with the patient under deep hypothermic circulatory arrest.

Silastic drains vs conventional chest tubes after coronary artery bypass.

STUDY OBJECTIVES: To investigate differences in drainage amounts and early clinical outcomes associated with the use of Silastic drains, as compared with the conventional chest tube after coronary artery bypass grafting (CABG). DESIGN: Retrospective nonrandomized case control study. SETTING: A tertiary teaching hospital. PATIENTS AND PARTICIPANTS: Outcome data from 554 patients who underwent postoperative pericardial decompression using small Silastic drains were compared with those from 556 patients who had conventional chest tubes after first-time CABG at our institution between January 1 and August 1, 2000. MEASUREMENT AND RESULTS: Univariate analysis of preoperative characteristics was used to ensure similarity between the two patient groups. Operative mortality, mediastinitis, reoperation for bleeding, and early and late cardiac tamponade occurred in 9 patients (1.6%), 6 patients (1.1%), 6 patients (1.1%), 6 patients (1.1%), and 1 patient (0.2%), respectively, in the Silastic drain group, compared with 11 patients (2.0%), 9 patients (1.6%), 4 patients (0.7%), 2 patients (0.4%), and 6 patients (1.1%) in the conventional group. No statistically significant differences between the two drains were identified. Drainage amounts (mean +/- SD) were 552.2 +/- 281.8 mL and 548.8 mL +/- 328.7 mL for the Silastic and conventional groups, respectively (p = 0.51). Postoperative length of stay was longer for the conventional chest tube group (median, 5 d; range, 1 to 119 d) when compared to the Silastic drain group (median, 4 d; range, 1 to 66 d; p = 0.01). CONCLUSIONS: We demonstrated that small Silastic drains are equally as effective as the conventional, large-bore chest tubes after CABG with no significant risk of bleeding or pericardial tamponade. Additionally, use of Silastic drains allows more mobility than the conventional chest tubes. As a result of this study, there was a change in our clinical practice toward the exclusive use of Silastic drains after all cardiac surgical procedures.

Beating heart surgery in a patient with dextrocardia and complete situs inversus.

We present a 65-year-old female patient with dextrocardia and situs inversus who underwent successful coronary artery bypass without cardiopulmonary bypass. Vessels revascularized included right internal mammary artery to the left anterior descending artery and a saphenous vein graft to the first obtuse marginal branch. The procedure was performed on a beating heart through a median sternotomy with the use of a compression epicardial stabilizer. The patient was discharged to her home after an uneventful recovery. Only 12 similar cases of myocardial revascularization in patients with dextrocardia have been reported so far, and this is one of the first procedures, in patients with dextrocardia, performed off pump.