Incidental Finding of an Aspergillus Pseudoaneurysm in the Ascending Aorta of an Immunocompetent Patient.

Pseudoaneurysms of the ascending aorta are rare, yet they are life-threatening conditions and usually associated with poor outcomes due to insidious presentation. Many different etiologies have been associated with aortic pseudoaneurysms including; atherosclerosis, infections, connective tissue disorders, and traumatic causes. In addition, aortic pseudoaneurysms have been reported following thoracic surgeries, including aortic valve replacements, aortic dissection repair, and coronary artery bypass grafting. Aspergillus is amongst the infectious etiologies of pseudoaneurysms. Aspergillus species is a ubiquitous mold (fungus) that is mostly harmless but may result in serious illnesses in immunocompromised hosts with hematologic neoplasms, neutropenia, or immunodeficiency syndromes. In this paper, we report a case of an ascending aortic pseudoaneurysm caused by Aspergillus infection. To our knowledge, this is an exceptionally rare case diagnosed incidentally in an immunocompetent patient, who is surgically free and without any pre-existing risk factors.

Rare combination of bilateral divided atrial chambers and pulmonary vein stenosis with review of the literature.

INTRODUCTION: The term cor triatriatum is used to describe a fibromuscular partition that divides an atrium into two compartments. It was first used by Borst in 1905, although the lesion had been described before by Church in 1868. Both described divided left atrial chamber (also referred to as cor triatriatum sinister). The incidence of the divided left atrial chamber among patients with congenital heart disease is reported at 0.1% and 0.4% in an autopsy study. Divided right atrial chamber - also referred to as cor triatriatum dexter - is even rarer to an extent that there is no reported incidence and only few hundred cases have been reported so far. A search through pubMed library revealed only 90 publications on humans, either under the term "dexter" or "dextrum". We would like to report a new association of bilateral divided atrial chambers and pulmonary vein stenosis, with a review of the literature.

Persistent left superior vena cava remnant causing cyanosis in a post-Fontan patient.

We report the successful surgical closure of a persistent left superior vena cava remnant draining into the pulmonary venous circulation causing cyanosis in a post-Fontan patient who had previously undergone Damus-Kaye-Stansel and bidirectional superior cavopulmonary connection followed by a transcatheter coil occlusion of his persistent left superior vena cava.

Venovenous malformation: a common finding after Kawashima operation.

OBJECTIVES: It has been reported that systemic venovenous malformation (VVM) can develop in patients with interrupted inferior vena cava (IVC) and univentricular type of congenital heart disease who undergo superior vena cava to pulmonary artery connection (Kawashima operation). These malformations can lead to profound systemic desaturation postoperatively. However, there have been few reports that characterise the prevalence, anatomic details and clinical correlations of these systemic VVM arising after Kawashima operation. In this study, we describe our experience with VVM after Kawashima operation, and discuss issues regarding their evaluation and postoperative management. METHODS: Eight patients with median age 19 months (range: 5-238) who underwent Kawashima operation were subjected to postoperative angiography, prospectively. Sites of VVM origin and entry, as well as their course, were documented. The presence of pulmonary arteriovenous malformations (AVMs) was also documented. RESULTS: At median follow-up of 31 months (range: 16-72 months), a total of 14 VVM were found in different supra- and infra-diaphragmatic sites in six patients (75%); four of them had concomitant pulmonary AVM while the remaining two patients had only pulmonary AVM. CONCLUSIONS: Our findings suggest that systemic VVM can occur frequently after Kawashima operation and can produce significant desaturation postoperatively, and hence we support hepatic incorporation. Performing detailed angiographic studies of the supra- and infra-diaphragmatic systemic veins in routine assessment of patients before Kawashima operation is, probably, warranted.

Primary cardiac paraganglioma with dual coronary blood supply presenting with angina chest pain.

Primary cardiac paraganglioma (pheochromocytoma) is very rare, constituting only 1% of cardiac tumours. A case of a 44-year-old woman presenting with angina chest pain and a tumour with dual blood supply from both the right and left coronary arteries is reported.

Late presenters with dextro-transposition of great arteries and intact ventricular septum: to train or not to train the left ventricle for arterial switch operation?

OBJECTIVE: We report our experience in managing late presenters (older than 4 weeks) with dextro-transposition of great arteries and intact ventricular septum (d-TGA/IVS) in an effort to achieve successful arterial switch operation (ASO) in a third world setting. DESIGN: We retrospectively reviewed the charts of all late presenters with d-TGA/IVS. Patients were divided into two groups: left ventricular training (LVT) group and non-left ventricular training (non-LVT) group. LVT group underwent pulmonary artery banding and Blalock-Taussig Shunt prior to ASO. RESULTS: Twenty-one late presenters were included in the study. In LVT group, 11 patients with median age of 6 months (range, 1-72 months) underwent LVT. Later, 8 patients with median age of 9.25 months (range, 1.33-84 months) underwent ASO. Prior to ASO, left ventricle (LV) collapse resolved in all and left ventricle to systemic pressure (LV/SP) ratio was 0.81 (range, 0.76-0.95) in 4 patients. Two patients who had LVT for < or =14 days required postoperative extracorporeal membrane oxygenation (ECMO) support due to LV dysfunction. Seven patients survived to discharge. In non-LVT group, 10 patients with median age of 2.5 months (range, 1-98 months) underwent ASO. Five patients had LV collapse, and median LV/SP ratio was 0.67 (range, 0.56-1.19) in 5 patients. Seven patients needed ECMO support. Seven patients survived to discharge. CONCLUSION: Late presenters with d-TGA/IVS, who have LV collapse on echocardiography and/or a LV/SP ratio <0.67 on cardiac catheterization, should be subjected to LVT preferably for duration of longer than 14 days in order to avoid potential ECMO use.

A unique milieu for perioperative care of adult congenital heart disease patients at a single institution.

PURPOSE: Adult patients with congenital heart disease presenting for cardiothoracic operation pose special demands for the arrangement of their perioperative care. This study describes the distinctive perioperative setup for adult congenital heart patients. MATERIALS AND METHODS: A retrospective review of 48 adult congenital heart disease cases that received operative intervention from July 2000 to October 2005. Operative procedures and postoperative care were all exercised in the same unit by the same staff handling adult and pediatric cardiothoracic surgery cases. RESULTS: Forty-two patients underwent definitive biventricular repair, and the remainder were subjected to palliative procedures. There were 2 cases of operative mortality: 1 patient died as a result of arrhythmia after Glenn procedure, and 1 died as a result of multiorgan failure secondary to sepsis after ventricular septal defect repair. Complications that prolonged intensive care stay for more than 72 hours were extracorporeal support for systemic right ventricular dysfunction (n = 1); reoperation for ventricular septal patch endocarditis after ventricular septal defect repair (n = 1); respiratory failure (n = 4); renal failure (n = 3); sepsis (n = 2); junctional tachycardia (n = 1); pulmonary hypertension (n = 2); and reperfusion injury of the lung (n = 2). Patients subjected to the Fontan operation had a longer hospital stay (mean = 33 days) as a result of pleural effusions. Forty-six patients were discharged home. CONCLUSION: This distinctive environment allows our group to provide the appropriate care for our adult congenital heart disease patients in a well-integrated discipline. The frequent clinical exposure to both adult and pediatric cardiothoracic procedures has helped in facilitating the provision of optimum care to the patients with adult congenital heart disease.

Modification of Trusler's formula for the pulmonary artery banding.

BACKGROUND: The major difficulty of pulmonary artery banding (PAB) is optimal intraoperative adjustment. In this study, a target intraoperative shunt ratio (Q(p)/Q(s)) was utilised to evaluate a fixed Trusler's formula for the degree of PAB of infants destined for either univentricular or biventricular surgical route. METHODS: Ten consecutive infants (median age, 1.62 months) undergoing PAB through median sternotomy were studied. A fixed Trusler's formula (20mm+1mm/kg body weight) was used to set the initial band size, and subsequent intraoperative adjustment was based on target Q(p)/Q(s) (using oxymetric data). Suitable target Q(p)/Q(s) was set

Expanding the utilization of Contegra for ventricular septal defect repair.

Different patch materials have been utilized in repairing ventricular septal defect (VSD) with great success. In this report, in addition to the right ventricular outflow tract reconstruction, the VSD was repaired successfully in all cases by fashioning a patch from a segment of the Contegra xenograft conduit. The freedom from infection, thromboembolism, and reintervention during follow-up, in addition to the advantage of ready availability and cost-effectiveness offered by using the same bovine material, imply that Contegra xenograft is a promising alternative patch material for VSD repair.

Bovine valved xenograft (Contegra) conduit in the extracardiac Fontan procedure: the preliminary experience.

OBJECTIVE: Constructing a competent valve using the xenograft valved conduit (Contegra) in the extracardiac Fontan connection may maintain better forward flow into the pulmonary circulation. The preliminary results and potential advantages of using the Contegra are discussed in this review. METHOD: A retrospective review of 18 patients who underwent the extracardiac Fontan connection using the Contegra conduit from June 2002 to September 2005. RESULTS: Median age at the time of operation was 4.5 year (range 2.5-34 years). In 15 patients (83%) a 4 mm fenestration was created. Overall operative mortality was 11 % (two patients); one patient died because of arrhythmia & sepsis, and the other one due to thrombosed Fontan connection. The ranges of intensive care unit stay, chest tube duration, and hospital stay were 1-18 days (median, 2 days), 4-38 days (median, 7 days), and 5-47 days (median, 12.5 days), respectively. Follow-up is available for 15 (94%) patients at a mean of 15.8 months (range 8-48 months) postoperatively. They were all asymptomatic and their room air oxygen saturation ranged between 88% and 100% (mean, 96.1%). There have been no further thromboembolic episodes during follow up. Echocardiograms demonstrated patent conduit in all patients with no hepatic vein reversal flow except to a minimal degree in five patients; however the valve competency was demonstrated radiologically. CONCLUSIONS: The Contegra xenograft is a potential alternative conduit for the extracardiac Fontan connections. These encouraging preliminary results may support better pulmonary forward flow.

Propranolol: a new indication for an old drug in preventing postoperative junctional ectopic tachycardia after surgical repair of tetralogy of Fallot.

Junctional ectopic tachycardia (JET) is a major cause of postoperative morbidity after complete repair of tetralogy of Fallot (TOF). Propranolol is a known medication used in patients with TOF to prevent and control hypercyanotic spells. Despite this, there is little information regarding the relation between preoperative use of propranolol and the incidence of postoperative JET. The aim of this study was to examine the effect of preoperative use of propranolol on the incidence of postoperative JET after full surgical repair of TOF. A retrospective analysis of 109 patients in whom 57 patients received preoperative propranolol (propranolol group) was compared with 52 patients who did not receive propranolol preoperatively (control group). The incidence of postoperative JET was significantly higher in the control group (38%) than the propranolol group (21%) P=0.042. The propranolol group had significantly less mechanical ventilation time, less ICU stay and less total hospital stay than the control group (P<0.05). Our findings suggest that the preoperative use of propranolol may decrease the incidence of JET after full surgical repair of TOF. A prospective randomized study may help to elucidate the exact relationship between the preoperative use of propranolol and the incidence of postoperative JET.

Concealed neo-aortic incompetence and new right ventricular outflow tract obstruction after arterial switch operation in a late presenter.

We report a 9 year old boy who presented late with cyanosis as a case of dextro-transposition of great arteries, intact ventricular septum and left ventricular outflow tract obstruction (D-TGA/IVS/LVOTO). Arterial switch operation (ASO) with resection of sub-neo aortic membrane and repair of mitral valve were done for the naturally trained LV. On the second postoperative day, the newly discovered right ventricular outflow tract obstruction (RVOTO) was relieved and mitral valve replacement (MVR) was done for significant mixed stenotic/regurgitant mitral valve disease, and intraoperative extra-corporeal membrane oxygenation (ECMO) support was instituted for pulmonary dysfunction for 4 days. Failure of extubation warranted further assessment that revealed significant aortic incompetence (AI) during cardiac catheterisation study, which was underestimated by echocardiography. Aortic valve replacement (AVR) was done on the 11th postoperative day and he was then extubated and had uneventful hospital course in spite of two emergency procedures: drainage of sub-dural haematoma and appendectomy.

Impact of obesity on early outcomes after cardiac surgery: experience in a Saudi Arabian center.

PURPOSE: The prevalence of obesity is a public health concern in most countries, including Saudi Arabia. Obesity has been considered a major risk factor for adverse outcomes after cardiac surgery. MATERIALS AND METHODS: A single-center retrospective review (2001-2005) of adverse outcome after coronary artery bypass grafting (CABG) and valve surgery (total=462) categorized by body mass index (BMI) was performed. The patients with BMI>or=30 were defined as the obese group and patients whose BMI<30 were labeled as the nonobese group. RESULTS: Overall, 315 (68.2%) were classified as nonobese, and 147 (31.8%) were obese. Obese patients were older and more likely to have diabetes and hypertension. There were no significant differences between the two groups with regard to other comorbidity and risk factors. There was no association between the two groups and the outcomes of operative mortality and morbidities. CONCLUSION: This study demonstrated that obesity does not increase the risk of death and most complications after cardiac surgery, aside from the unexplained increased risk of reoperation during the same admission.

REMOVED: Newly developed right ventricular outflow tract obstruction after arterial switch operation in a late presenter.

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High resolution spiral CT scan in the diagnosis of pseudoaneurysm of ascending aorta.

Pseudoaneurysms of the ascending aorta are rare (<1%), and extremely rare from aortic vent site, but can be a lifethreatening complication. The basic methods of diagnosis are computed tomography scan and aortography. We report high resolution spiral CT may provide the best less invasive means in the diagnosis of the pseudoaneurysm of the ascending aorta originated from the aortic vent site.

Repair of complete atrioventricular septal defects: results with maintenance of the coronary sinus on the right atrial side.

BACKGROUND: This study was undertaken to determine that maintaining coronary sinus on the right atrial side during the surgical repair of complete atrioventricular septal defect (AVSD) does not increase the risk of postoperative complete heart block. METHODS: This is a retrospective study of 51 consecutive patients who underwent biventricular repair of complete AVSD from September 2000 to January 2005. Electrocardiograms and operative data were analyzed. RESULTS: The mean age was 13.3 months (4 to 60). In all the 51 patients, except 13 cases, repair was performed using the two-patch technique. All atrial septal defects were closed using the patch technique with the coronary sinus maintained on the right atrial side in 48 (94%) cases. The cleft in the neomitral valve was closed in all patients. Associated lesions were repaired in four patients (7.8%); coarctation of aorta in two patients; multiple ventricular septal defects (VSD) with coronary sinus type-total anomalous pulmonary venous drainage and right-sided diaphragmatic eventration in one patient; and tetralogy of Fallot in one patient. There were five deaths (9.8%) in a series. The mean hospital stay was 11.8 days. During the same hospitalization, reintervention was required in two cases: one for residual VSD and the other for a severely dysplastic regurgitant mitral valve. Mean follow-up was 11.3 months. One patient required reoperation for residual VSD, residual atrial septal defect, and moderate mitral regurgitation 5 months after the initial repair. Except for first-degree heart block documented in nine cases and right bundle branch block in two cases, all patients remained in sinus rhythm on follow-up electrocardiography as preoperatively documented. No patient required prolonged cardiac pacing in the postoperative period. CONCLUSION: We believe that maintenance of the coronary sinus on the right side can be safely accomplished in the majority of complete AVSD repair as long as careful attention is paid to the anatomy of the conduction system. This technique did not increase the risk of postoperative heart block and permanent pacemaker insertion was not required.

Is preoperative delineation of coronary artery pattern a prerequisite for arterial switch operation?

OBJECTIVE: To determine the effect of preoperative echocardiographic delineation of coronary artery pattern on the immediate postoperative result of arterial switch procedures. METHODS: A retrospective review of a consecutive series of children who underwent the arterial switch operation at a single institution from February 2001 to December 2004. RESULTS: Sixty-six children underwent an arterial switch operation. The median age at the time of repair was 1.17 months (range 0.2-96 months). Fifty-five patients (83%) were diagnosed to have dextro-transposition of the great arteries, and 11 patients (17%) had double outlet right ventricle of the Taussig-Bing type. Associated left-sided obstructive lesions were present in 12 cases (18.3%). The dominant coronary pattern was 1 LCX; 2R (60.6%), and followed by 1L; 2RCX (24.2%). The techniques used for coronary transfer were the trapdoor flap, circular buttonhole transfer, or combined technique in all patients except for one case. Preoperatively, the coronary artery anatomy was adequately delineated in only 26 cases (39.4%). Forty patients (60.6%) had either different coronary description or non-documented coronary artery pattern. Myocardial ischemia was not observed in any case postoperatively and no patient in the series required reoperation for coronary revision. There were 10 in-hospital deaths (15%) not related to the coronary pattern. Follow-up is available for 49 of the surviving patients (87.5%) at a mean of 10.1 months. There has been no readmission or reintervention for myocardial ischemia. CONCLUSIONS: The trapdoor flap and circular buttonhole techniques are the most practical and reproducible maneuvers of coronary transfer during arterial switch operation. Both techniques can compensate for inadequate preoperative echocardiographic delineation of coronary artery pattern.