An Unusual Case of Arterial Embolism in an Adolescent With a Mitral Valve Repair With a Ring.

We report a case of an adolescent young man who presented with embolism of both lower legs. The patient had undergone mitral valve repair with a Kalangos biodegradable ring (Bioring SA, Lonay, Switzerland) 9 months earlier. Bilateral embolectomy was performed. Histopathologic examination revealed minute fragments of synthetic material within the embolus, which otherwise consisted of recent thrombus.

A multidisciplinary approach to unplanned conversion from off-pump to on-pump beating heart coronary artery revascularization in patients with compromised left ventricular function.

Aim. To comparably assess the perioperative risk factors that differentiate off-pump coronary artery bypass (OPCAB) grafting cases from those sustaining unplanned conversion to on-pump beating heart (ONCAB/BH) approach, in patients with left ventricular ejection fraction (LVEF) < 40%. Methods. Perioperative variables were retrospectively assessed in 216 patients with LVEF < 40%, who underwent myocardial revascularization with OPCAB (n = 171) or ONCAB/BH (n = 45) approach. The study endpoints were operative mortality (30-day) and morbidity assessed by length of intensive care unit stay (LOS-ICU), using 2 days as cut-off point. Results. Poor LVEF, increased EuroSCORE II, acute presentation, congestive heart failure, cerebrovascular disease, perioperative renal impairment, clinical status deterioration upon admission and during ICU stay, acute myocardial infarction, and low cardiac output syndrome supported by inotropes and/or balloon-pump counterpulsation were significantly related to ONCAB/BH group (P < 0.05). EuroSCORE II (P = 0.01) and LVEF (P = 0.03) were the most powerful discriminative predictors of intraoperative conversion to ONCAB/BH. Operative mortality was 2.9% in OPCAB and 6.6% in ONCAB/BH group (P = 0.224), while 23.4% participants in OPCAB and 42.2% in ONCAB/BH approach had a LOS-ICU > 2 days (P = 0.007). Conclusions. Patients with LVEF < 40% undergoing ONCAB/BH are subjected to more preoperative comorbidities and implicated ICU stay than their OPCAB counterparts, which influences adversely short-term morbidity, while operative mortality remains unaffected.

Chronic thromboembolic pulmonary hypertension: do not miss the chance for an early diagnosis.

BACKGROUND: Chronic thromboembolic pulmonary hypertension most often results from obstruction of the pulmonary vascular bed by nonresolving thromboemboli. Misdiagnosis of the disease is common because patients often present with subtle or nonspecific symptoms. Furthermore, some features in chest imaging may mimic parenchymal lung disease. The most clinically important mimic in high-resolution chest tomography is air trapping, which can be seen in a variety of small airway diseases. CASE REPORT: We present the case of a 45-year-old woman with a long history of dyspnea and exercise intolerance, misdiagnosed with allergic alveolitis. The diagnosis of CTEPH was finally established with computed tomography (CT) angiography and hemodynamics. CONCLUSIONS: Chronic thromboembolism is under-diagnosed and also frequently misdiagnosed in clinical practice. The present report aims to increase the awareness of clinicians towards an accurate diagnosis of the disease, which is necessary for the early referral of CTEPH patients for operability.

Surgical septal myectomy for hypertrophic cardiomyopathy in Greece: a single-center initial experience.

INTRODUCTION: Surgical septal myectomy is thought to be the gold standard of treatment for obstructive hypertrophic cardiomyopathy (HCM) with obstruction symptoms refractory to optimal medical therapy. In Europe, during the last 2 decades, myectomy has been set aside, while alcohol septal ablation has been widely promoted. In this paper, we analyze our first experience of surgical septal myectomy in a small cohort of patients with HCM coming from a single tertiary center. METHODS: Thirty-two patients (16 male, 50%) with a mean age of 58.1 ± 14.4 (range 12-79 years) underwent myectomy for HCM symptoms refractory to negative inotropic agents. The technique used for the myectomy was the one introduced by Andrew Morrow. Mean follow-up time after procedure was 16.8 ± 13.3 months with a median of 13 months (range 4-58 months). RESULTS: Post-myectomy, there was a significant improvement in patients' NYHA class (from 3.3 ± 0.46 to 1.38 ± 0.49, p<0.0005), while interventricular septum thickness was reduced from 2.3 ± 0.4 cm to 1.6 ± 0.4 cm (p<0.0005), and peak gradient at the site of obstruction from 94.9 ± 29 to 16.7 ± 7.9 mmHg (p<0.0005). During the follow-up period, only 1 out of 32 patients died, from non-cardiovascular causes, with the overall survival post-myectomy being 97.2% (95%CI: 94.5-99.9%) at 1-year follow up. CONCLUSIONS: Surgical septal myectomy in patients with HCM and drug-refractory symptoms is a safe procedure that greatly improves symptoms and quality of life. Further follow-up of our patients is mandatory in order to determine whether the good survival rate achieved at 1 year will persist.

Minimally invasive transapical aortic valve implantation and simultaneous major pulmonary resection.

We report a 71-year-old male who underwent successful minimally invasive transapical aortic valve implantation to treat severe aortic stenosis, with simultaneous pulmonary resection for the treatment of lung cancer. At five-year follow-up the patient remains free of symptoms (NYHA I) and recurrence.

Cerebral oxygenation impairment and S-100ß protein release during off-pump coronary artery revascularization.

OBJECTIVE: To elucidate the magnitude of global cerebral oxygenation impairment, using cerebral oxygenation indices and S-100ß protein as potential markers, during off-pump coronary artery bypass grafting (OPCAB). DESIGN: Prospective cohort study. SETTING: Tertiary cardiac center. PARTICIPANTS: Thirty-five patients undergoing OPCAB. INTERVENTIONS: Jugular bulb and arterial blood samples for cerebral oxygenation indices (arterial oxygen and carbon dioxide partial pressures, jugular bulb oxygen saturation, arterial-jugular bulb oxygen content, arterial-jugular carbon dioxide partial pressure, brain oxygen extraction ratio, and estimated respiratory quotient) and S-100ß protein determination were collected at anesthesia induction; anterior, inferior, and posterior wall anastomoses; after sternal closure; and 6 hours postoperatively. Concomitant hemodynamic data were obtained. The S-100ß determination was extended to 12 and 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Heart positioning for the target vessel exposure induced significant hemodynamic deterioration (p < 0.001). Although cerebral oxygenation indices were influenced adversely by a low-cardiac-output state mainly during vertical heart dislocation (p < 0.001), they remained within normal limits. Hemodynamic and cerebral oxygenation statuses reverted to baseline within 6 hours postoperatively. Similarly, S-100ß jugular bulb and arterial protein levels presented a gradual increase, which peaked by the end of surgery (means, 0.54 and 0.62 µg/L, respectively; p < 0.001) and then decreased by the first postoperative day. Jugular bulb-arterial S-100ß levels were maximized during posterior wall anastomosis (0.098 µg/L; p < 0.01). CONCLUSION: Although exposure of the 3 main coronary arteries during OPCAB promotes derangement of the cerebral oxygen indices and S-100ß release, this seems to be transient, remains within the near-normal range, and is reversible almost completely 6 hours postoperatively.

Mechanical assistance of the circulation during cardiogenic shock.

PURPOSE OF REVIEW: Cardiogenic shock still has a grave prognosis. We present the recent advances in mechanical circulatory support (MCS) for the treatment of refractory cardiogenic shock. RECENT FINDINGS: The contraindications for short-term MCS in rapid-onset cardiogenic shock are becoming fewer and the threshold for its application has been progressively lowered. Short-term MCS is increasingly used in refractory cardiac arrest and will be probably integrated as the last means in the advanced cardiopulmonary resuscitation algorithm (provided there is experienced team and technical support). Improved device technology has contributed to improved results of long-term MCS. Emergent application of long-term MCS in patients with critical cardiogenic shock after a long history of progressively deteriorating end-stage chronic heart failure should be interpreted as delayed application associated with increased mortality. SUMMARY: Although MCS can be life saving in cardiogenic shock, the results are still suboptimal. Mortality is associated with the critical presupport state and the adverse events during MCS. Early initiation of support that meets the patient's requirements, potent support in the early phase, adverse event prevention, global combined management (surgical, interventional, medical), balanced support duration, bridging to further therapeutic modalities including heart transplantation or longer-term support, and advanced technology could offer improved results.