Aortic arch replacement with simultaneous antegrade cerebral and systemic perfusion using a single centrifugal pump driven 'split arterial line' extracorporeal circuit design.

The ability to provide antegrade cerebral and systemic perfusion simultaneously may negate the requirement for any prolonged period of circulatory arrest during complex aortic arch reconstruction procedures, depending on the cannulation strategy. We describe the development and successful implementation of a custom 'split arterial line' extracorporeal circuit configuration to facilitate complex aortic surgery. This circuit design offers a wide range of cannulation and perfusion strategies, is safe, adaptable, simple to manage, and avoids the use of roller pumps for blood delivery, which are associated with deleterious haematological complications during prolonged cardiopulmonary bypass cases. The split arterial line approach has now become the standardised methodology for facilitating complex aortic surgery at our institution.

Right upper lobe pulmonary sequestration masquerading clinically and radiologically as malignancy: a case report.

Bronchopulmonary sequestration is a rare disease in which a non-functional region of pulmonary tissue receives an aberrant vascular supply and lacks normal communication with the tracheobronchial tree. We present the case of a 30-year-old female with a primary complaint of unexplained weight loss and no other additional signs or symptoms. In view of this, computed tomography imaging was ordered, showing a 33HU mass in the right upper lobe. A specialist radiologist reviewed the images and concluded that the most likely differentials were mediastinal lymphoma or thymic malignancy. Video-assisted thoracoscopic surgery was performed, when it was seen that no malignancy was present, but rather a bronchopulmonary sequestration. Histology confirmed the diagnosis; the patient fared well post-operatively. Bronchopulmonary sequestration is a rare pathology, with most cases occurring in the lower lung lobes. This case is highly atypical, due to the lack of clinical features and the lesion radiologically mimicking the appearance of malignancy.

Successful medical treatment of aortic intramural hematoma (Stanford type B) in a patient with aberrant right subclavian artery: A case report.

Intramural Hematoma (IMH) forms part of the acute aortic syndrome, aortic dissection, and penetrating aortic ulcer. It is a life-threatening aortic disease that warrants prompt diagnosis and management. Like aortic dissections, it is classified using the Stanford classification system as type A (proximal to the origin of the left subclavian artery) and type B (distal to the origin of the left subclavian artery). Patients with type A IMH is generally managed surgically, and uncomplicated type B IMH is managed medically. The right subclavian artery arises typically from the brachiocephalic trunk. Aberrant right subclavian arteries (ARSA) are rare and derive directly from the aortic arch distal to the left subclavian artery. In this case report, a 73-year-old female presented with right-sided chest pain and shortness of breath. On examination, her heart rate was 100 bpm and blood Pressure was 185/85 and her ECG showed sinus rhythm. Following a CT scan, she was found to have a type B Aortic IMH with an ARSA. She was medically managed with vigorous blood pressure control. After a period of intravenous blood pressure treatment, she was treated with oral medication. Her subsequent CT scan showed that the hematoma was stable. She was followed up with MRI scanning 1 year later, which showed complete healing of the aorta with no changes in diameter. This case illustrates the importance of strict blood pressure management and follow-up imaging in patients presenting with type B IMH. It is important to monitor these patients regularly and where blood pressure control alone is not sufficient, further intervention may be required. Even though the complete resolution may be achieved as in this case, these patients will need to be kept under surveillance with repeated scans to monitor for any changes.

Managing iatrogenic aortic dissection during primary percutaneous coronary intervention of the left main stem.

Iatrogenic aortic dissection post primary percutaneous coronary intervention (PCI) is rare but yet a serious complication. In this report, we present a case of a 40-year-old lady who had an aortic dissection post PCI which was initially missed by the conventional contrast images and required a gated computerized tomography aortogram to confirm the diagnosis. The patient was managed with strict blood pressure control resulting in complete healing of the dissection after 72 hours of the management. The case illustrates the importance of selecting the correct imaging to make an accurate diagnosis when aortic dissection is suspected and outlines the importance of blood pressure control in treating iatrogenic aortic dissections.

European registry of type A aortic dissection (ERTAAD) - rationale, design and definition criteria.

BACKGROUND: Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient's conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. METHODS: Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient's comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. DISCUSSION: The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073 .

Diaphragmatic and intercostal muscle tear after an episode of violent sneezing: spontaneous diaphragmatic injury.

Spontaneous diaphragmatic injuries are rare, accounting for approximately 1% of all diaphragmatic injuries. We report a case of a 69-year-old male with a concurrent lower respiratory tract infection who sustained diaphragmatic and intercostal muscle injuries after an episode of violent sneezing. To our knowledge, this is the first reported case of spontaneous diaphragmatic injury after sneezing.

The short saphenous vein: a viable alternative conduit for coronary artery bypass grafts harvested using a novel technical approach.

A multitude of vascular conduits are available to the Cardiac Surgeon performing Coronary Artery Bypass Graft operations. The Internal Mammary Artery, Radial Artery (RA), and the Long Saphenous Vein (LSV) have proven to be excellent conduits, especially in the current era of statin usage. However, previous stripping or varicosities of the LSV and calcification of the RA, coupled with the need for multiple vessel grafting, requires an alternative candidate. We describe a novel harvesting technique for bilateral simultaneous Short Saphenous Vein harvest and propose this, often forgotten vein, as a viable alternative conduit.

Acute Right Coronary Ostial Stenosis during Aortic Valve Replacement.

We report a rare case of acute right coronary artery stenosis developing in a patient undergoing aortic valve replacement. We present a case report with a brief overview of the literature relating to coronary artery occlusion associated with cardiac valve surgery - the theories and treatments are discussed. A 85 year-old female was admitted under the care of the cardiothoracic team with signs and symptoms of heart failure. Investigations, including cardiac echocardiography and coronary angiography, indicated a critical aortic valve stenosis. Intraoperative right ventricular failure ensued post aortic valve replacement. Subsequent investigations revealed an acute occlusion of the proximal right coronary artery with resultant absence of distal flow supplying the right ventricle. An immediate right coronary artery bypass procedure was performed with resolution of the right ventricular failure. Subsequent weaning off cardiopulmonary bypass was uneventful and the patient continued to make excellent recovery in the postoperative phase. To our knowledge this is one of the few documented cases of intraoperative acute coronary artery occlusion developing during valve surgery. However, surgeons should be aware of the potential for acute occlusion so that early recognition and rapid intervention can be instituted.

A rare case of giant coronary artery aneurysm in the context of multiple arterial aneurysms.

INTRODUCTION: Whilst the incidence of CAA has been reported as up to 5%, giant CAA (>2cm) is rare. PRESENTATION OF CASE: We present a rare case of 3cm×4cm giant coronary artery aneurysm (CAA) in the context of aorto-iliac aneurysmal disease, treated by staged open surgical repair. DISCUSSION: Abdominal aortic aneurysm (AAA) and CAA share risk factors and aetiological mechanisms, therefore should be considered, particularly when CAA is diagnosed in the first instance. CONCLUSIONS: Surgical intervention for diagnosed giant CAA appears to be the treatment of choice in the reported literature, with the order of intervention when AAA co-exists remaining a point for debate.

Not the typical winter cough.

We report on a young adult with a foreign body lodged in the right main bronchus for at least 5 days, with no alleged recollection of aspiration despite the size and shape of the object, which was removed successfully by rigid bronchoscopy.

Not the typical winter cough.

We report on a young adult with a foreign body lodged in the right main bronchus for at least 5 days, with no alleged recollection of aspiration despite the size and shape of the object, which was removed successfully by rigid bronchoscopy.

Comparative analysis of the Bonanno catheter and tube thorocostomy in effective aspiration of pleural effusion.

BACKGROUND AND METHODS: In our earlier report, we suggested the Bonanno catheter (a 14-gauge suprapubic catheter) as a less traumatic but equally effective alternative for drainage of a variety of fluid collections, including pleural effusion. This study aims to evaluate the efficacy of the Bonanno catheter compared with closed-tube thoracostomy in draining pleural effusion in 38 patients following routine cardiac surgery between 2003 and 2004. Twenty patients were managed using the Bonanno catheter and 18 were treated with standard tube thoracostomy. Data were collected retrospectively and statistical analysis was performed using the SPSS software. P < .05 was considered significant. RESULTS: There were 20 (53%) male and 18 (47%) female patients with a mean age of 63.5 years (range, 31-83 years). Significant differences were observed with regards to the amount of lignocaine administered locally, intra-procedure pain score, post-procedure pain score after 15 minutes, and amount of analgesia used on a regular basis (P < .05 in each case). Statistically, significant differences were also noted during 2 to 3 weeks follow-up between the 2 groups with regards to pain score. In the the tube thoracostomy group, 22.2% developed infection of the procedure site, requiring antibiotic treatment, whereas no infection was reported in the Bonanno group (P < .001). CONCLUSION: This study provided evidence that smallbore drains such as the Bonanno catheter are safe and better tolerated than standard chest drains. This is consistent with the British Thoracic Society guidelines that strongly recommend small-bore drains for the drainage of pleural effusions as they are more comfortable than larger-bore tubes.

Ethnic differences in the management of coronary heart disease patients: lessons to be learned in indo-asians.

OBJECTIVES: To examine the impact of ethnicity on the outcome of coronary artery bypass grafting (CABG) for myocardial revascularization. SUBJECTS AND METHODS: We evaluated retrospectively 7,226 Caucasian (CC) and 650 Indo-Asian (IA) patients who underwent isolated first-time CABG surgery over 5 years. The relationship between ethnicity (IA vs. CC) and 30-day mortality, 6-month mortality and complications were analysed. RESULTS: After adjustment for baseline characteristics, IA and CC patients had similar 30-day [IA/CC odds ratio (OR) 1.07; 95% confidence interval (CI) 0.84-1.35; p = 0.59] and 6-month mortality risk (IA/CC OR 1.10; 95% CI 0.91-1.34; p = 0.31). However, IA patients were more likely to experience complications following surgery (OR 1.28; 95% CI 1.14-1.45; p < 0.01). CONCLUSION: Ethnicity does not appear to be a strong risk factor for adverse outcomes following CABG surgery in the IA patients. However, future studies are needed to elucidate the specific reasons for higher complication rates in IA patients and to devise strategies to reduce complications following the operation for these patients.

Liver blood flow during cardiac surgery.

OBJECTIVE: Impairment of liver blood flow and, therefore, potentially liver function, has important short-term consequences because of the liver's key metabolic importance and role in drug metabolism. The objective of this study was to quantify the effect of cardiac surgery on liver blood flow from before the induction of anaesthesia to 24 hours postoperatively. METHOD: Ten patients with no history of liver impairment, moderate or good left ventricular function, and undergoing routine hypothermic coronary artery bypass graft surgery, were entered into the study. Liver blood flow was determined by the clearance of indocyanine green (ICG), expressed as a percentage disappearance rate (PDR). RESULTS: The mean baseline percentage disappearence rate (PDR) of indocyanine green (ICG) was 19.84 +/- 4.47%/min. This increased marginally to 20.42 +/- 6.67%/min following the induction of anaesthesia, but after 15 min of cardiopulmonary bypass, the PDR fell to 13.51 +/- 3.69%/min; this was significantly lower than all other PDRs measured throughout the study. Prior to extubation, the PDR increased again to 20.01 +/- 3.72%/ min, and this level was maintained at 12 hours (PDR 20.32 +/- 3.53%min) and 24 hours (PDR 20.51 +/- 2.27%/min). CONCLUSION: The induction of anaesthesia and positive pressure ventilation do not affect liver blood flow. Cardiopulmonary bypass at 30 degrees C is associated with a significant reduction in liver blood flow, which returns to normal within 4-6 hours of surgery and remains normal for up to 24 hours after surgery.