Left atrial appendage myxofibrosarcoma: A rare masquerader of myxoma and thrombus-"all that glitters is not gold".

Left atrial appendage mass can occasionally pose a serious challenge to physicians to identify the nature of the mass with the aid of imaging techniques. We present a case of 67-year-old man, who was evaluated for suspected left atria myxoma. Transesophageal echocardiography revealed a heterogeneous density originating from left atrial appendage, thought to be most consistent with a myxoma. Cardiac magnetic resonance imaging, uncharacteristically, gave an equivocal picture, suggesting the mass to be a myxoma on initial imaging and a thrombus with evidence of liquefaction necrosis following postcontrast enhancement. Surprisingly, histopathology of the mass following its surgical excision yielded a rare diagnosis of myxofibrosarcoma.

Salvage peripheral extracorporeal membrane oxygenation using Cobe Revolution(®) centrifugal pump as a bridge to decision for acute refractory cardiogenic shock.

OBJECTIVES: Acute refractory cardiogenic shock with early multisystem organ failure has a poor outcome without mechanical circulatory support. We review our experience with emergent peripheral cardiopulmonary support as a bridge to decision in these patients. METHODS: A retrospective review from January 2009 through December 2010 was conducted of 26 consecutive adult patients at a single institution with acute refractory cardiogenic shock who underwent salvage peripheral cardiopulmonary support. RESULTS: There were 18 men and 8 women with a mean age of 54 years (range 18 to 76). Indications for support: acute myocardial infarction (n = 16), decompensated chronic heart failure (n = 2), refractory arrhythmic arrest (n = 3), acute valvular pathology (n = 4), and unknown (n = 1). Patients with primary postcardiotomy shock were excluded. Median duration of support was 3 days (range 1 to 14). Decisions included: withdraw of support (n = 4), recovery (n = 5), and bridge to a procedure (n = 17). The procedures were percutaneous coronary intervention (n = 4), left ventricular assist device (n = 9), heart transplantation (n = 1), and miscellaneous cardiac surgery (n = 3). Overall survival to discharge was 65%. In the recovery and bridge to a procedure group, 78% were discharged from the hospital and survival at three months was 72%. CONCLUSIONS: Salvage peripheral cardiopulmonary support is a useful tool to rapidly stabilize acute refractory cardiogenic shock permitting an assessment of neurologic and end-organ viability.

Cardiac assist with a twist: apical torsion as a means to improve failing heart function.

Changes in muscle fiber orientation across the wall of the left ventricle (LV) cause the apex of the heart to turn 10-15 deg in opposition to its base during systole and are believed to increase stroke volume and lower wall stress in healthy hearts. Studies show that cardiac torsion is sensitive to various disease states, which suggests that it may be an important aspect of cardiac function. Modern imaging techniques have sparked renewed interest in cardiac torsion dynamics, but no work has been done to determine whether mechanically augmented apical torsion can be used to restore function to failing hearts. In this report, we discuss the potential advantages of this approach and present evidence that turning the cardiac apex by mechanical means can displace a clinically significant volume of blood from failing hearts. Computational models of normal and reduced-function LVs were created to predict the effects of applied apical torsion on ventricular stroke work and wall stress. These same conditions were reproduced in anesthetized pigs with drug-induced heart failure using a custom apical torsion device programmed to rotate over various angles during cardiac systole. Simulations of applied 90 deg torsion in a prolate spheroidal computational model of a reduced-function pig heart produced significant increases in stroke work (25%) and stroke volume with reduced fiber stress in the epicardial region. These calculations were in substantial agreement with corresponding in vivo measurements. Specifically, the computer model predicted torsion-induced stroke volume increases from 13.1 to 14.4 mL (9.9%) while actual stroke volume in a pig heart of similar size and degree of dysfunction increased from 11.1 to 13.0 mL (17.1%). Likewise, peak LV pressures in the computer model rose from 85 to 95 mm Hg (11.7%) with torsion while maximum ventricular pressures in vivo increased in similar proportion, from 55 to 61 mm Hg (10.9%). These data suggest that: (a) the computer model of apical torsion developed for this work is a fair and accurate predictor of experimental outcomes, and (b) supra-physiologic apical torsion may be a viable means to boost cardiac output while avoiding blood contact that occurs with other assist methods.

Strategies and outcomes of cardiac surgery in Jehovah's Witnesses.

BACKGROUND: Jehovah's Witnesses (JW) are a Christian faith, with an estimated 1.1 million members in the United States, well recognized for their refusal of blood and blood products. JW may not be considered for cardiac surgery due to perceived higher risks of morbidity and mortality. This study reviews our contemporary strategies and experience with JW undergoing routine and complex cardiac surgery. METHODS: From November 2001 to April 2010, 40 JW were referred for cardiac surgery at a single quaternary referral institution. A retrospective analysis of demographic data, perioperative management, and clinical outcomes was examined. Published validated clinical risk calculator and model for prediction of transfusion were used to identify high-risk patients (risk of mortality >6% or probability of transfusion >0.80). RESULTS: The mean age was 70 (± 9.5) years with 21 men and 19 women. Patients were classified as high risk (45%, n = 18) and low risk (55%, n = 22) with demographics and comorbidities listed in Table 2. Operative procedures included: isolated coronary artery bypass grafting (CABG) (n = 19), isolated valve replacement/repair (n = 7), valve/CABG (n = 7), reoperative valve replacement (n = 4), reoperative CABG (n = 2), valve/ascending aorta replacement (n = 1), and CABG/ascending aorta replacement (n = 1). All JW were evaluated by The Department of Bloodless Medicine to individually define acceptable blood management strategies. The mean preoperative hemoglobin was 14.1 g/dL (±1.6). Overall mortality was 5% (n = 2) all of which were in the high-risk group. DISCUSSION: Using a multidisciplinary approach to blood management, JW can safely undergo routine and complex cardiac surgery with minimal morbidity and mortality.

Limb-threatening ischemia secondary to a congenital acromioclavicular remnant.

Upper extremity vascular compromise from thoracic outlet syndrome is rare and is usually the result of a "cervical rib," anterior scalene muscle abnormality, or clavicular trauma. We report a case of acute axillary artery thrombosis secondary to a congenital acromioclavicular remnant in a 40-year-old woman.

Improvement of sternal closure stability with reinforced steel wires.

BACKGROUND: Sternal dehiscence occurs when steel wires pull through sternal bone. This study tests the hypothesis that closure stability can be improved by jacketing sternal wires with stainless steel coils, which distribute the force exerted on the bone over a larger area. METHODS: Midline sternotomies were performed in 6 human cadavers (4 male). Two sternal closure techniques were tested: (1) approximation with six interrupted wires, and (2) the same closure technique reinforced with 3.0-mm-diameter stainless steel coils that jacket wires at the lateral and posterior aspects of the sternum. Intrathoracic pressure was increased with an inflatable rubber bladder placed beneath the anterior chest wall, and sternal separation was measured by means of sonomicrometry crystals. In each trial, intrathoracic pressure was increased until 2.0 mm of motion was detected. Differences in displacement pressures between groups were examined at 0.25-mm intervals using the paired Student's t test. RESULTS: The use of coil-reinforced closures produced significant improvement in sternal stability at all eight displacement levels examined (p < 0.03). Mean pressure required to cause displacement increased 140% (15.5 to 37.3 mm Hg) at 0.25 mm of separation, 103% (34.3 to 69.8 mm Hg) at 1.0 mm of separation, and 122% (46.8 to 103.8 mm Hg) at 2.0 mm of separation. CONCLUSIONS: Reinforcement of sternal wires with stainless steel coils substantially improves stability of sternotomy closure in a human cadaver model.

Validation of a bone analog model for studies of sternal closure.

BACKGROUND: The incidence of serious sternal wound complications may be reduced with improvements in closure methods. Biomechanical testing of median sternotomy closures in cadavers has proven useful but is limited by availability, high cost, and wide variations in the material properties of the sterna. This study tests whether artificial sterna can be used to replace whole cadavers in sternal closure testing. METHODS: Two common wire closure techniques were tested using both whole cadavers and artificial sternal models formed from bone analogue material. Sternal models were molded from polyurethane foam (20 lbs/ft3) to simulate the mechanical properties observed in human cadaveric sterna. The force vector previously identified as the most detrimental to sternal cohesion (lateral traction) was used to stress the closures. Separation of the incision site was measured at the manubrium, midsternum, and xiphoid and data were compared between cadaver and bench test groups. RESULTS: Sternal separations recorded in cadavers were found to be similar to bench test results for both closure types. Data variability within test groups was found to be consistently lower using artificial sterna, where peak standard deviations for sternal motion averaged less than half that measured in cadavers. CONCLUSIONS: Results suggest that anatomic sternal models formed from solid polyurethane foam can be used to approximate the biomechanical properties of cadaveric sterna and that reliable information regarding sternal closure stability can be secured through this means. Moreover, bench test data were shown to be less variable than cadaveric results, thus enhancing the power to detect small differences in sternal fixation stability.