Quadruple Valve Replacement in Carcinoid Heart Disease: A Case Report.

This report details a rare case of left-sided carcinoid heart disease (CHD). In CHD, vasoactive substances released from carcinoid tumors cause fibrous tissue formation on the right side of the heart. These substances are usually inactivated by monoamine oxidase A in the lungs, safeguarding the left side of the heart. Exceptions include the presence of a patent foramen ovale (PFO), pulmonary metastasis, or elevated serotonin levels. Intriguingly, our patient exhibited significant left-sided involvement without these factors, ultimately requiring a quadruple valve replacement surgery. After eight months post-operation, the patient is stable with no cardiovascular complications. This rare case of CHD, along with its outcome, hints at potential unidentified etiologies for left-sided CHD and underscores valve replacement as a viable treatment.

Anaerobic treatment of residuals from tanks transporting food and fodder.

The anaerobic digestion of wastewater from the cleaning of tank cars transporting food and fodder was investigated in both bench and pilot scales with a single-stage, mesophilic (39 °C), completely mixed process. The promising results lead to the planning and building of a 1200-m3 full-scale biogas plant at TS-Clean cleaning station in Fahrbinde, Germany. Due to softened water used in the cleaning of the car tanks, the alkalinity in the digester decreased as predicted by the physicochemical model developed for this treatment process. The model showed that 2.4 kg NaHCO3/m3 of wastewater has to be added in order to control digester pH at 7.2 and to maintain the digester alkalinity at 3.1 g CaCO3/L. In a laboratory study, the decrease of alkalinity caused a volatile organic acids accumulation and pH drop below the optimal range. In this case, if chemical buffering was not added into the digester, the digester deteriorated. In a 3-year investigation, we confirmed that the strongly polluted WW from the cleaning of tank cars transporting food and fodder is suitable for an anaerobic treatment if the organic loading rate is controlled below 4 kg COD/m3/day, digester alkalinity is adjusted by NaHCO3, and micronutrients are added despite constant considerable variations in strength and composition of the wastewater. A biogas yield of 35-45 m3 CH4/m3 of wastewater and a COD elimination of 80-90% were achieved in bench- and pilot-scale experiments and are achieved in the full-scale biogas plant. The full-scale biogas plant is working stable with a biogas yield of 68 m3 biogas/m3 of wastewater.

Renal cell carcinoma, metastatic to the left ventricle.

Left ventricular metastases from renal cell carcinoma without vena caval or right atrial involvement are extremely rare. Herein, we present the case of a 69-year-old man who had undergone radical nephrectomy for renal cell carcinoma in 1984. Eighteen years thereafter, we discovered metastatic disease in his left ventricle.When the metastasis was identified, the patient had no symptoms other than shortness of breath. He underwent surgical removal of a highly vascular mass from the left ventricular wall and resection of a nodule in the upper right pulmonary lobe. Upon pathologic examination, both tumors were metastatic renal cell carcinomas. The patient recovered uneventfully and was free of cardiac recurrence more than 6 years after the surgery. We describe our treatment of this patient and discuss some current approaches to the treatment of renal cell carcinoma that has metastasized to the heart.

Point: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: early multicenter results.

OBJECTIVE: The treatment of lone atrial fibrillation can be a minimally invasive procedure using bipolar radiofrequency ablation technologies. Our objectives were to report on the safety and early efficacy of this novel therapeutic modality. METHODS: At 3 North American institutions between February 2005 and August 2007, 100 patients underwent minimally invasive bilateral pulmonary vein isolation, autonomic denervation, and left atrial appendage resection. The mean age was 65 +/- 11 years, and 70% were male. The median duration of atrial fibrillation was 5.0 years; atrial fibrillation was paroxysmal in 39 patients (39%), persistent in 29 patients (29%), and permanent in 32 patients (32%). Indications for surgery included failure of medical therapy or percutaneous ablation and severe symptoms. Mean follow-up was 13.6 +/- 8.2 months. RESULTS: The mean operative time was 253 +/- 65 minutes, and the median hospital length of stay was 5 days. There were no intraoperative conversions and no mortality to report. Postoperative complications included pacemaker requirement in 5 patients (5%), phrenic nerve palsy in 3 patients (3%), hemothorax in 3 patients (3%), transient ischemic attack in 1 patient (1%), and pulmonary embolism in 1 patient (1%). At follow-up, 87% of patients were in normal sinus rhythm (paroxysmal 93%, persistent 96%, permanent 71%; P < .05); antiarrhythmic therapy was discontinued in 62% of patients, and anticoagulation therapy was discontinued in 65% of patients. CONCLUSION: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation is a safe and efficacious therapeutic option in selected patients. Further development is needed to reduce the rate of complications. Long-term prospective results are required to further validate this modality as a therapeutic option to treat lone atrial fibrillation.

Cardiac autotransplantation for malignant or complex primary left-heart tumors.

Malignant or complex benign tumors of the left heart can present a formidable challenge for complete resection, due to anatomic inaccessibility. Cardiac autotransplantation (cardiac explantation, ex-vivo tumor resection, reconstruction, and reimplantation) was introduced for complex benign primary left-heart cardiac tumors by Cooley and for malignant left-heart tumors by Reardon. Herein, we update our previously reported experience.From April 1998 through July 2008, 20 patients underwent 21 cardiac autotransplantations for complex left-sided cardiac tumors that were nonresectable by traditional means. Demographics, tumor histology, operative data, and mortality rates were analyzed. Follow-up was complete in all patients.Of the 20 patients, 17 had malignant lesions, and 3 had benign disease. Two patients had left ventricular lesions and the rest had left atrial lesions. Histology showed 7 malignant fibrous histiocytomas, 5 undifferentiated sarcomas, 3 leiomyosarcomas, 1 malignant osteosarcoma, 1 myxoid sarcoma, 2 paragangliomas, and 1 myxoma. Fourteen patients had previous resection of their cardiac tumors, and 1 patient had repeat autotransplantation for recurrent disease. There were no operative deaths in patients undergoing autotransplantation alone (0/15), and 3 operative deaths in patients undergoing combined cardiac autotransplantation and pneumonectomy (3/6, 50%). All 3 patients with benign disease survived surgery and are alive without recurrent disease. Local recurrence occurred in 3/18 patients with malignant disease: 1 underwent successful repeat autotransplantation and 2 are receiving chemotherapy. The mean survival for all patients with sarcoma is 22 months.Cardiac autotransplantation enables complete resection and accurate reconstruction in many primary malignant and complex benign left-heart tumors.

Extracorporeal membrane oxygenation with right axillary artery perfusion.

Extracorporeal membrane oxygenation can be instituted through various cannulation sites. This paper describes a technique for axillary artery cannulation for inflow perfusion in extracorporeal membrane oxygenation and discusses both potential advantages and limitations. Exposure of the artery was achieved through the deltoid-pectoral approach. Both direct cannulation and interposition graft cannulation are possible, but the latter is preferred. Advantages of axillary artery cannulation are related mainly to the establishment of "central" support with antegrade flow and excellent upper body oxygenation. It also affords chest closure after postcardiotomy shock, and easy control of any mediastinal bleeding. These cannulation sites may be options for the institution of venoarterial extracorporeal membrane oxygenation, especially in postcardiotomy and respiratory failure patients and in patients with significant peripheral vascular disease.

Primary adenocarcinoma in a donor lung: evaluation and surgical management.

We report a case of primary non-small cell cancer diagnosed in the donor lung 33 months after bilateral pulmonary transplantation. The tumor was treated surgically. A lingular sparing left upper lobe bisegmental lung resection was performed.

Pediatric physiologic pulsatile pump enhances cerebral and renal blood flow during and after cardiopulmonary bypass.

Controversy over benefits of pulsatile flow after pediatric cardiopulmonary bypass (CPB) continues. Our study objectives were to first, quantify pressure and flow waveforms in terms of hemodynamic energy, using the energy equivalent (EEP) formula, for direct comparisons, and second, investigate effects of pulsatile versus nonpulsatile flow on cerebral and renal blood flow, and cerebral vascular resistance during and after CPB with deep hypothermic circulatory arrest (DHCA) in a neonatal piglet model. Fourteen piglets underwent perfusion with either an hydraulically driven dual-chamber physiologic pulsatile pump (P, n = 7) or a conventional nonpulsatile roller pump (NP, n = 7). The radiolabeled microsphere technique was used to determine the cerebral and renal blood flow. P produced higher hemodynamic energy (from mean arterial pressure to EEP) compared to NP during normothermic CPB (13 +/- 3% versus 1 +/- 1%, p < 0.0001), hypothermic CPB (15 +/- 4% versus 1 +/- 1%, p < 0.0001) and after rewarming (16 +/- 5% versus 1 +/- 1%, p < 0.0001). Global cerebral blood flow was higher for P compared to NP during CPB (104 +/- 12 ml/100g/min versus 70 +/- 8 ml/100g/min, p < 0.05). In the right and left hemispheres, cerebellum, basal ganglia, and brainstem, blood flow resembled the global cerebral blood flow. Cerebral vascular resistance was lower (p < 0.007) and renal blood flow was improved fourfold (p < 0.05) for P versus NP, after CPB. Pulsatile flow generates higher hemodynamic energy, enhancing cerebral and renal blood flow during and after CPB with DHCA in this model.