Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries.

BACKGROUND: Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event". METHODS: We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy. RESULTS: This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis. CONCLUSIONS: We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.

TAVI in a Heart Transplant Recipient-Rare Case Report and Review of the Literature.

The global demand for cardiac transplants continues to rise, even with advancements in assistive devices. Currently, the estimated annual mortality rate stands at 3-5%, and patients often face a waiting time of approximately four years on transplant waiting lists. Consequently, many transplant centers have started to consider heart transplants from donors who may be deemed "less than ideal" or marginal. However, the decision to accept such donors must be highly individualized, taking into consideration the risks associated with remaining on the waiting list versus those posed by the transplantation procedure itself. A potential solution lies in the creation of two distinct recipient lists, matched with donor criteria, allowing marginal donors to provide the lifeline that selected patients require. This paper follows a two-step approach. Firstly, it offers an overview of the current state of affairs regarding the topic of transcatheter aortic valve implantation (TAVI) in orthotopic heart transplant (OHT) patients. Secondly, it presents firsthand experience from our clinical center with a comprehensive case presentation of a patient in this unique medical context. The clinical case refers to a 62-year-old male patient, a smoker with a history of hypertension, dyslipidemia, and a prior OHT a decade earlier, who presented with fatigue during minimal physical exertion. The Heart Team carefully reviewed the case, considering the patient's immunosuppressed status and the heightened risk associated with a repeat intervention. In this instance, transcatheter aortic valve implantation (TAVI) was deemed the appropriate treatment. The TAVI procedure yielded successful results, leading to improved clinical status and enhanced cardiac function. The inclusion of marginal donors has introduced novel challenges related to the utilization of previously diseased marginal organs. TAVI has already demonstrated its efficacy and versatility in treating high-risk patients, including heart transplant recipients. Consequently, it emerges as a vital tool in addressing the unique challenges posed by the inclusion of marginal donors.

Same Clinical Reality of Spontaneous Rupture of the Common Iliac Artery with Pseudoaneurysm Formation-Comparison of Two Therapeutical Solutions, Endovascular Stent-Graft and Open Surgical Correction, for Two Cases and Review of the Literature.

The incidence of isolated iliac artery aneurysms is approximately 2% and common iliac artery pseudoaneurysms are even rarer. A pseudoaneurysm is a localized hemorrhage as opposed to an actual aneurysm, which affects the entire vascular wall. They are typically asymptomatic and only detectable accidentally while looking for other causes. If large and symptomatic, they typically exhibit pressure symptoms as a result of the compression of the structures around them. Common symptoms include generalized stomach pain, urological problems, gastrointestinal bleeding, and neurological symptoms such as leg paralysis or sciatica-like back pain. Rarely, they may exhibit hemodynamic instability together with an aneurysm rupture, which has a high fatality rate. Due to the unique presentation, the diagnosis is typically rarely made and there is little experience with treating it. We report two cases of common iliac artery pseudoaneurysm found in two patients who had no notable medical history and who we chose to repair through the endovascular technique in the first case, an approach that has gained more ground for vascular repair worldwide, making it the current go-to method, and for the second case we chose a more traditional approach, through open surgery.

Delayed Surgical Management of Acute Type A Aortic Dissection in a Patient with Recent COVID-19 Infection and Post-COVID-19 Bronchopneumonia-Case Report and Review of Literature.

Ever since it was first described in 1760, acute type A aortic dissection has created difficulties in its management. The recent COVID-19 pandemic revealed that extrapulmonary manifestations of this condition may occur, and recent reports suggested that aortic dissection may be amongst them since it shares a common physiopathology, that is, hyper-inflammatory syndrome. Cardiac surgery with cardiopulmonary bypass in the setting of COVID-19-positive patients carries a high risk of postoperative respiratory failure. While the vast majority accept that management of type A aortic dissection requires urgent surgery and central aortic therapy, there are some reports that advocate for delaying surgery. In this situation, the risk of aortic rupture must be balanced with the possible benefits of delaying urgent surgery. We present a case of acute type A dissection with COVID-19-associated bronchopneumonia successfully managed after delaying surgery for 6 days.

A Rare Case of Left Ventricular Malignant Peripheral Nerve Sheath Tumour-Case Report and Review of the Literature.

Malignant peripheral nerve sheath tumour (MPNST) is an aggressive and uncommon cancer developing in the peripheral nerve sheath. Primary cardiac MPNST is an extremely rare finding, with no specific imaging and clinical characteristics. Only a handful of cases have been reported in the literature; thus, little is still known about them. Cardiac computed tomography (CT) and cardiac magnetic resonance imaging (CMRI) are important means of assessing cardiac morphology and function. The preferred course of treatment for this pathology is by full surgical resection of the tumour, with negative (clear) margins, followed by adjuvant radiotherapy and chemotherapy. We present the case of a 42-year-old woman with no significant cardiovascular symptoms who was incidentally diagnosed during routine transthoracic echocardiography (TTE) with a cardiac mass located in the left ventricle.

Rare Cause of Severe Mitral Regurgitation after TAVI: Case Report and Literature Review.

Pre-procedure mitral regurgitation (MR) is a frequent coexistent finding in patients undergoing transcatheter aortic valve replacement (TAVR), and most of them (up to 55%) experience a significant improvement in MR after the procedure. Although seldom described, mitral valve perforation after TAVR is a potentially serious complication that physicians should be aware of, as moderate or severe MR in TAVR recipients is associated with a high early mortality rate. We herein describe the case of a 65-year-old man presenting with worsening heart failure symptoms 5 months after TAVR due to an intraprocedural anterior mitral leaflet perforation and discuss the diagnostic process and therapeutic course of the case. Furthermore, we draw attention to the essential role of echocardiography in the management of TAVR procedures, taking into account its ability in detecting early complications, and emphasize the value of CT as a main determinant to predict long-term MR improvement after TAVR and to assess the potential candidates for double valve repair with percutaneous techniques.

A Large Ascending Aorta Thrombus in a Patient with Acute Myocardial Infarction-Case Report.

We present the case of a 50-year-old male, with no cardiovascular risk factors other than smoking, that presented with acute chest pain, revealed to be an acute myocardial infarction with a large thrombus located in the ascending aorta. Such findings are rare in a patient with no other afflictions, such as atherosclerosis, aortic aneurysm, or aortic wall injury (surgical or traumatic). There is no specific pathway regarding the management of ascending aorta thrombus in such a patient; therapeutic options include surgical, interventional, or medical methods. Surgical thrombectomy was performed in this case, considering the high risk of systemic embolism and stroke and the hemodynamic stability of the patient.