Surgical treatment of right ventricle thrombus in a patient with iron-deficiency anaemia.

Right ventricle organized thrombus is a rare pathological condition diagnosed in patients with a risk factor. The most common are right ventricle (RV) failure, autoimmune disease (Behcet disease), hypercoagulable disorder, anaemia, RV pacing leads, pulmonary artery catheters, RV infarction, and ventricular arrhythmogenic cardiomyopathy. The literature describes the impact of iron-deficiency anaemia on thrombosis. We described surgical extirpation of the organized right ventricle outflow tract (RVOT) thrombus in a patient with iron-deficiency anaemia. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01460-w.

Correlation of structural defects in the ascending aortic wall to ultrasound parameters: benefits for decision-making process in aortic valve surgery.

BACKGROUND: Histopathological changes in the ascending aorta wall in patients with severe tricuspid aortic valve (TAV) stenosis were graded and correlated to echocardiographic parameters. Objective was to associate threshold echocardiographic values with structural defects in the ascending aorta providing a tool to improve decision-making process in cases when simultaneous aortic valve replacement (AVR) and ascending aorta replacement is considered. METHODS: Biopsies from 108 TAV stenosis patients subjected to AVR were graded into three grades according to severity of aortic wall changes. Echocardiographic parameters obtained preoperatively and correlated to grade, age, gender and risk factors, were diameters of ventriculo-aortic junction (AA), sinus Valsalva (SV), sinotubular junction (STJ), the largest diameter of the visualized ascending aorta (AscA) as well as indexes: sinus Valsalva (SVI), sinotubular junction (STJI), AscA/AA and STJ/AA. RESULTS: Two echocardiographic parameters portrayed grades with statistical significance: STJ (F = 5.417; p = 0.006 (p < 0.05)) and AscA (F = 3.924; p = 0.023 (p < 0.05)). By using multiple predictors in the setting of Regression analysis, statistically significant differences among grades were reached for AA, SV, STJ, AscA and SVI. With further ROC curves analysis, threshold values for different grades were recognized. Grade 2 is identified in patients with AscA > 3.3 cm, while Grade 3 is identified in patients with values of AscA > 3.5 cm, STJ > 2.9 cm and STJI > 1. CONCLUSIONS: Hemodynamic stress induced by TAV stenosis leads to elastic lamellae disruption in the aortic wall. Those changes could be graded and correlated with echocardiographic parameters of the aortic root and ascending aorta, providing a tool for decision to replace ascending aorta concomitantly with AVR.

A comprehensive morphometric analysis of the internal thoracic artery with emphasis on age, gender and left-to-right specific differences.

AIMS OF THE STUDY: The aim of this analysis was the morphometric description of the internal thoracic artery (ITA) with an emphasis on age, gender and left-to-right specific differences, as well as on age and atherosclerosis related changes of the elastic skeleton. METHODS: Forty eight arteries were obtained during forensic autopsies from 32 persons who had died of non-vascular causes. The following morphometric parameters were analyzed: thickness of the intima, the medial layer and the wall, the intima-to media-ratio and the elastic skeleton parameters. RESULTS: The intima thickness increases significantly with aging (ANOVA F=34.061, p⟨0.001), as does the intima-to-media ratio (ANOVA F=10.831, p⟨0.001). With aging, there is a significant increase in the thickness of the media (F=56.519; p⟨0.001) and of the wall (F=34.094; p⟨0,001). There is a significant increase in the media thickness during the development of atherosclerosis in the ITA (ANOVA F=11.848, p⟨0.001). No significant difference was found when these data were analyzed based on the left-to-right principle or depending on gender of the patients. However, the analysis of the elastic skeleton parameters indicated that the combined effects of aging, atherosclerosis and male gender lead to the degeneration of the elastic skeleton of the ITA. CONCLUSION: The grade of atherosclerosis gradually increases with aging as shown by morphometric analysis. The increase in the medial layer thickness suggests the potential for positive remodeling of the ITA during aging and atherosclerosis. The left/right position has no influence on morphometric parameters of the ITA, while male gender affects parameters of the elastic skeleton.

Successful resuscitation from two cardiac arrests in a female patient with critical aortic stenosis, severe mitral regurgitation and coronary artery disease.

INTRODUCTION: The incidence of sudden cardiac death in patients with severe symptomatic aortic stenosis is up to 34% and resuscitation is described as highly unsuccessful. CASE REPORT: A 72-year-old female patient with severe aortic stenosis combined with severe mitral regurgitation and three-vessel coronary artery disease was successfully resuscitated following two in-hospital cardiac arrests. The first cardiac arrest occurred immediately after intraarterial injection of low osmolar iodinated agent during coronary angiography. Angiography revealed 90% occlusion of the proximal left main coronary artery and circumflex branch. The second arrest followed induction of anesthesia. Following successful open-chest resuscitation, aortic valve replacement, mitral valvuloplasty and three-vessel aortocoronary bypass were performed. Postoperative pericardial tamponade required surgical revision. The patient recovered completely. CONCLUSION: Decision to start resuscitation may be justified in selected patients with critical aortic stenosis, even though cardiopulmonary resuscitation in such cases is generally considered futile.

Mitral valve replacement with posterior transposition of the anterior mitral leaflet which covers and buttresses partially decalcified posterior mitral annular bed.

Mitral valve replacement (MVR) in the presence of the extensive calcification of the mitral annulus is a technical challenge. The heavily calcified annulus can cause great difficulty in the insertion of a prosthetic valve and periprosthetic leakage later on. Vigorous annular decalcification may cause circumflex coronary artery injury, atrioventricular rupture and thromboembolic events. We herein describe a surgical technique for MVR in such cases while focusing on partial decalcification of the posterior mitral annulus and its reinforcement and buttressing with the transferred anterior mitral leaflet (AML). At the same time, the transferred AML supports the posterior annular region and maintains ventricular-annular continuity, thus preserving the left ventricular function.

The internal thoracic artery as a transitional type of artery: a morphological and morphometric study.

Coronary artery by-pass grafting (CABG) with arterial grafts is widely accepted as the procedure of choice in the treatment of coronary ischemic disease. It brings back focus on morphological studies of arteries used as conduits in this procedure. One of the most frequently used CABG grafts is the internal thoracic artery with an excellent graft prognosis and patency rate. The aim of the study was a detailed morphological and morphometric description of the internal thoracic artery with an emphasis on its basic histological structure and its changes in aging and atherosclerosis. Therefore, 42 full-length arteries were obtained during forensic autopsies from 27 persons, aged between 20 and 81 years, who had died from non-vascular causes. The arteries were classified into three different age groups. Analysis of the serial arterial segments has shown that the internal thoracic artery is an artery of the transitional type whose media is organized into two layers: the internal, muscular layer and the external layer with spirally oriented elastic lamellae and smooth muscle cells in between. The number of elastic lamellae progressively decreases throughout the length of the examined arteries. As opposed to previous assumptions, we have proven that the grade of atherosclerosis is independent of the number of elastic lamellae in the external media. Perfectly formed elastic lamellae are not a persistent feature of the internal thoracic artery, as previously claimed. We have confirmed that the thickness of elastic lamellae decreases, while the number and the size of their fenestrations steadily increase with aging.