Initiating a Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Endarterectomy Program Based on a Single Center Experience in Lebanon.

PURPOSE: In 2018, the American University of Beirut Medical Center established the first multidisciplinary Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Endarterectomy program in Lebanon. The study describes the challenges faced in establishing the program and in improving patient referral, evaluation, and perioperative care. METHODS: The program establishment including the preparation phase, clinical evaluation, and team education is discussed. The implementation of the flow of patients referred to the program was established. Education regarding diagnosis and referral were provided to physicians in the community. The initial experience is described in a retrospective analysis of 4 consecutive patients who were diagnosed with CTEPH and underwent PEA. RESULTS: Four patients were diagnosed with CTEPH had PEA performed. The mean age of patients was 64 years. The average CPB and total circulatory arrest times were 244 and 23.9 minutes per side, respectively. No mortalities were encountered perio-operatively. All patients reported significant improvement in functional capacity from NYHA III and IV to a NYHA class of I with an average PASP decrease of 59.5 ± 19.7 mmHg and mPAP drop by 30.2 ± 16.3 mmHg. CONCLUSION: The launch of the first CTEPH and PEA program in Lebanon, with a clear framework, coupled with good surgical outcomes is very encouraging. The program offers a curative solution for CTEPH patients in the region. A clear referral process and an increase in disease and treatment awareness in the community are crucial to the future success of the program, offering a definitive treatment, and avoiding delays to surgery.

Management of a mechanical aortic valve during left ventricular assist device implantation in a previously replaced aortic root.

The use of left ventricular assist device (LVAD) in patients with mechanical aortic valves may result in thromboembolic events due to blood stasis around the valve and intermittent valve opening. Mechanical aortic valves encountered during LVAD implantation are managed by replacement with a tissue valve, or closure of the valve with a patch. Closure of the valve carries the risk of sudden death in cases of LVAD stoppage. Replacing the whole mechanical valve conduit is time consuming and carries a significant risk of bleeding and right ventricular (RV) failure. We describe an alternative technique of replacing a mechanical aortic valve by breaking its inner leaflets and sewing a tissue valve on top of the mechanical valve ring.

Penetrating shrapnel injury to the chest presenting as a delayed tracheoesophageal fistula (TEF). A case report.

Tracheo-esophageal fistulae (TEF) due to trauma are rare. We report a case of a delayed TEF caused by a shrapnel from a blast. A 25-year-old male was admitted to the hospital after sustaining a blast injury. A contrast CT scan of the chest and neck revealed the presence of metallic shrapnel in close proximity to the tracheo-esophageal groove at the level of the thoracic inlet. Bronchoscopy revealed 0.5 cm tear in the membranous trachea while esophagoscopy and contrast swallow were normal. Coughs after starting fluid intake triggered a repeat endoscopy that showed a large TEF at 22 cm from the incisors. He underwent surgical repair through a collar incision and limited sternotomy. The TEF extended for 2 cm. The esophagus was repaired in two layers, the membranous trachea was sutured primarily, and an interposition strap muscle flap was placed. A contrast swallow on postoperative day 7 revealed the presence of a small leak into the trachea that was treated conservatively. Traumatic TEF are rare and should be suspected in patients with injuries to proximal structures. Delay in diagnosis and appropriate management can conceivably lead to death.