Aorto-atrial fistula 10 days after dissection repair in giant cell arteritis.

Active aortitis caused by giant cell arteritis occurs more commonly than has been previously appreciated, and ascending aortic dissection may occur despite medical therapy, without a preexisting aneurysm or ectasia. We report a case of acute type A aortic dissection in a patient already treated for giant cell arteritis. The aortic root was left intact during the initial surgery, but was completely removed 10 days later after an early postoperative aorto-atrial fistula. Complete removal of the aortic root (Bentall procedure) has been advocated in these patients to prevent late additional aortic complications.

Staged anesthesia for combined carotid and coronary artery revascularization: a different approach.

OBJECTIVE: Combined coronary artery bypass graft (CABG) surgery and carotid endarterectomy (CEA) are performed in an attempt to reduce the risk of postoperative stroke after CABG surgery in patients with significant or symptomatic carotid artery stenosis. The choice between regional and general anesthesia for CEA is still under debate. Regional anesthesia offers an excellent monitoring technique of the neurologic status of the awake patient during carotid clamping. In an attempt to improve monitoring of the neurologic status and avoid the use of temporary shunting in patients undergoing the combined procedure, a different approach is described combining regional anesthesia for CEA followed immediately by general anesthesia for CABG surgery. DESIGN: Prospective nonrandomized case series. SETTING: University hospital. PARTICIPANTS: Twenty patients scheduled for combined CEA and CABG surgery underwent a "staged" anesthetic approach from January to December 2004. INTERVENTIONS: Pulmonary, femoral artery, and urinary catheters were inserted under local anesthesia. A deep cervical plexus block was then performed and supplemented by a superficial cervical plexus block. The patient was draped for standard combined CEA and CABG surgery. CEA was then performed using standard techniques. Without altering the surgical field, general anesthesia was given and endotracheal intubation performed following the successful CEA. Coronary revascularization was then completed. MEASUREMENTS AND MAIN RESULTS: CEA and CABG surgery were completed successfully in all patients. There was no need for conversion from local to general anesthesia. Endotracheal intubation was easily performed in all patients. There was no hospital mortality in this series. No neurologic events were observed during the CEA. A reversible ischemic stroke, ipsilateral to the CEA, occurred postoperatively on awakening from CABG surgery in 1 patient. CONCLUSIONS: This staged anesthetic approach for combined CABG and CEA surgery is an alternative in this complex subset of patients.

Mitral valve repair or replacement in elderly people.

PURPOSE OF REVIEW: Much has been published so far to describe and praise the benefits of mitral valve repair, and to compare it with valve replacement. Now, with mitral valve surgery in elderly people gaining greater acceptance worldwide, repair or replacement remains a controversial issue. This is especially true in the ageing population, in whom many of the complications associated with a mechanical valve can be avoided by using a bioprosthesis. This review will try to assess the latest views in the field and come up with possible answers to this ongoing question. RECENT FINDINGS: The causes of mitral regurgitation in this age group are separately reviewed and discussed in the light of our better understanding of the pathophysiology of the disease. Mitral surgery is recommended when the effective regurgitant orifice reaches 40 mm. Repair in degenerative disease seems to be feasible, with good long-term results. In chronic ischaemic regurgitation, the concept of a tethered 'normal valve' is changing. The 'poor' ventricle may be able to withstand surgery as long as the subvalvular apparatus is preserved; on the other hand, repair and replacement seem to have the same survival advantage in high-risk patients. SUMMARY: Mitral valve surgery is well tolerated in elderly people. Early intervention leads inevitably to better outcome. The majority of valvular disorders in this age group are amenable to repair, with good reproducible results. Replacement with a bioprosthesis remains a viable option for complex regurgitant jets.

Postoperative intravenous iron used alone or in combination with low-dose erythropoietin is not effective for correction of anemia after cardiac surgery.

OBJECTIVES: The aim of this study was to examine whether intravenous iron III-hydroxide sucrose complex (IHSC) used alone was sufficient to provide rapid correction of anemia after cardiac surgery and whether additional stimulation of erythropoiesis is possible by means of a single low dose of recombinant-human erythropoietin (r-HuEPO) administration. DESIGN: Prospective, randomized, double-blind study. SETTING: The study was conducted in a university hospital. PARTICIPANTS: One hundred twenty American Society of Anesthesiologists II or III patients, who underwent elective cardiac surgery using cardiopulmonary bypass and in whom postpump hemoglobin ranged between 7 and 10 g/dL. INTERVENTIONS: Patients were divided into 3 groups: group I = control; group II received postoperative intravenous iron supplementation with an iron III-hydroxide sucrose complex (IHSC); and group III received IV iron and a single dose of r-HuEPO (300 U/kg). MEASUREMENTS AND RESULTS: No significant difference in transfusion needs was observed among the 3 groups (22%, 25%, and 17% of patients transfused in groups I, II, and III, respectively). Hemoglobin levels, reticulocyte counts, and serum ferritin levels were evaluated at different time intervals (until day 30 postoperatively). No side effects because of iron administration were noted in the study. Reticulocyte counts increased rapidly at day 5 (2.24% +/- 1.11%, 1.99% +/- 1.44%, and 3.84% +/- 2.02% in groups I, II, and III, respectively) and decreased after day 15 in the 3 groups. Ferritin levels increased significantly at day 5 in the 2 treated groups (899.33 +/- 321.55 ng/mL in group II, 845.75 +/- 289.96 ng/mL in group III v 463.15 +/- 227.74 ng/mL in group I). In group I, ferritin levels, after a slight elevation on day 5, decreased at day 15 to lower than baseline levels. No significant difference in hemoglobin increase was noted among the 3 groups. CONCLUSION: Postoperative intravenous iron supplementation alone or in combination with a single dose of r-HuEPO (300 U/kg) is not effective in correcting anemia after cardiac surgery.

Periareolar mediastinoscopy: a new technique.

Biopsy of anterior mediastinal or aortopulmonary nodes is usually accomplished through a left anterior mediastinostomy. Cosmetic concerns expressed by patients about scars in the neck or the upper chest led us to consider a new periareolar approach for mediastinoscopy. This technique has been used successfully in 10 patients.

Recurrence of left ventricular outflow tract obstruction after left anterior descending coronary artery revascularization in a patient with hypertrophic obstructive cardiomyopathy.

A patient with known hypertrophic obstructive cardiomyopathy presented with an anteroseptal myocardial infarction which resulted in the disappearance of his subaortic pressure gradient. Surgical revascularization of his left anterior descending coronary artery after the viability of his myocardium had been documented led to the recurrence of his left ventricular outflow tract obstruction and subaortic pressure gradient.

Aortic valve papillary fibroelastoma.

Cardiac papillary fibroelastomas are rare tumors of the heart and affect primarily the cardiac valves. These lesions are responsible for embolic accidents that clinically manifest as neurological and cardiovascular symptoms. We describe the case of a 40-yr-old woman who presented with a neurological deficit caused by a papillary tumor of the aortic valve. Diagnosis was made by transesophageal echocardiaphy and the tumor was surgically removed.

Primary isolated chronic chylopericardium.

Primary isolated chylopericardium is a rare entity. Its exact pathophysiology is still unknown. A case of chronic isolated primary pericardium diagnosed 12 years after the initial diagnosis of an asymptomatic pericardial effusion is reported. The diagnosis was established incidentally during surgery for resection of a papillary fibroelastoma of the aortic valve.