Acquired atrioesophageal fistula: Need it be lethal? Sizing up the problem, diagnostic modalities, and best management.

BACKGROUND AND AIM OF THE STUDY: An atrioesophageal fistula is a devastating complication of ablation for atrial fibrillation. For the surgeon facing this dreaded complication, it may be a 'once in a lifetime' case. This review aims to describe the clinical problem and evaluate the outcome of different surgical techniques to start guiding cardiothoracic surgeons toward those which offer the best chance of survival. METHODS: An electronic search retrieved 125 articles containing 195 cases of atrioesophageal fistula secondary to atrial fibrillation ablation. Reports of pericardio-esophageal or mediastino-esophageal fistula were excluded. RESULTS: The median age was 61 and 143 (73%) cases occurred in males. Fever (n = 147; 75%) and neurological dysfunction (n = 151; 77%) were the most common symptoms. The median time from ablation to symptom onset was 21 days (interquartile range: 12-28). The most sensitive thoracic imaging modality was computed tomography (n = 135/153; 90%). Immediate deterioration occurred during 11/58 (19%) oesophago-gastro-duodenoscopies. Mortality was lower in patients who had surgery (39%) compared with endoscopic intervention (94%) or conservative management (97%). Patients who had atrial repair combined with esophageal repair or oesophagectomy were more likely to survive than those who had atrial repair alone (OR 6.97; p < .001). Isolation of the esophageal aspect of the fistula conferred an additional survival benefit (OR 5.85; p = .02). CONCLUSIONS: Fever, neurological symptoms, and chest pain in the context of recent ablation should prompt immediate evaluation. Urgent CT thorax should be arranged and repeated if initially unremarkable. Esophageal instrumentation should be avoided due to the risk of catastrophic air embolism or massive hemorrhage. The best way forward is emergency surgical repair; the combination which offers the best survival benefit is atrial repair combined with esophageal surgery and isolation of the esophageal aspect of the fistula.

Early Outcomes After Mitral Valve Repair versus Replacement in the Elderly: A Propensity Matched Analysis.

BACKGROUND: To compare early outcomes of mitral valve repair versus replacement in elderly patients with degenerative mitral valve disease. METHODS: A retrospective review of prospectively collected clinical data of patients over 75 years of age, who underwent mitral valve surgery for degenerative disease, between 2010 and 2013, was carried out. Those undergoing mitral valve repair and replacement were propensity matched to adjust for baseline clinical differences. RESULTS: A total 260 patients were identified: mitral valve repair was undertaken in 145 and replacement in 115 patients. After propensity matching, 78 patients were included in each group. In the entire, unmatched population, in-hospital mortality was significantly higher in those undergoing replacement compared with those undergoing repair (9.6% vs 1.4%, p=0.003). In-hospital death occurred in six (7.7%) of the propensity matched replacement group and none in the repair group (p=0.012). Amongst the propensity matched groups, probability of survival at 1, 2 and 3 years were 0.94, 0.90 and 0.86 respectively for the repair group and 0.85, 0.77 and 0.69 for the replacement group: the HR for death between replacement and repair is 2.5 (1.2-5.4), p=0.012. CONCLUSIONS: Within the limitations imposed by retrospective analyses, our study demonstrates that, in elderly patients with degenerative disease of the mitral valve, repair is associated with improved short-term and mid-term outcomes compared with mitral valve replacement.

The effect of pulsatile cardiopulmonary bypass on the need for haemofiltration in patients with renal dysfunction undergoing cardiac surgery.

OBJECTIVES: The aim of our study was to investigate the effects of pulsatile cardiopulmonary bypass (CPB) on renal function and the need for haemofiltration in patients with preoperative renal impairment undergoing cardiac surgery. METHODS: Clinical data were collected prospectively for patients undergoing cardiac surgery with pulsatile CPB (Group A, n=66) and compared to matched patients with standard non-pulsatile CPB (Group B, n=66). Patients included in the study had mild renal impairment and at least moderate risk from surgery as defined by logistic EuroSCORE. Emergency operations were excluded. RESULTS: Patients in Groups A and B had similar age (71 ± 10 versus 70 ± 10 years), sex distribution, mean preoperative renal function (creatinine clearance 63.9 ± 28 versus 67.7 ± 27.3 ml/min) and overall risk profile as predicted by the logistic EuroSCORE (8 ± 8.3 versus 11.05±13.3, p=0.122). Intraoperative variables were comparable with respect to bypass and cross-clamp times (96 ± 37 minutes and 64 ± 28 minutes versus 103 ± 40 minutes and 70 ± 33 minutes in Groups A and B, respectively). A smaller proportion of patients in Group A (4.5% versus 15%, p=0.076) required haemofiltration in the postoperative period. Postoperative mortality was low in both groups (Group A 1.54% versus Group B 3.03%, p=1.00). CONCLUSION: Within the limitations imposed by retrospective analyses, our study demonstrates that pulsatile CPB may confer a reno-protective effect in higher-risk patients with pre-existing mild renal dysfunction undergoing cardiac surgery.

Renal recovery with eculizumab in atypical hemolytic uremic syndrome following prolonged dialysis.

Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy (TMA) which encompasses hemolytic anemia, thrombocytopenia, and organ impairment. Around 10% of cases are atypical HUS (aHUS), a rare disease with poor outcomes caused by uncontrolled activation of the alternative complement pathway. This case describes a young woman with clinical manifestations compatible with TMA during childhood and adolescence who was formally diagnosed with aHUS at the age of 21. She was managed with intensive plasma exchange and hemodialysis, which failed to improve her severe acute kidney injury and other hematological manifestations of aHUS. This was further compounded by several episodes of flash pulmonary edema and the posterior reversible encephalopathy syndrome (PRES). Treatment with the monoclonal anti-C5 inhibitor, eculizumab, improved all hematological parameters with almost full renal recovery following 3.5 months of dialysis. So far, long-term use of eculizumab (> 11 months) continues to be effective and without complication. Our case illustrates the difficulty but importance of early consideration of aHUS in patients presenting with TMA. More importantly, we highlight that near-normal renal recovery may be attained with eculizumab in adults even after a long dependence on dialysis - an observation that has not been reported in the literature so far.

Management of suspected thyroglossal duct cysts.

AIM OF STUDY: The aim of this study was to evaluate management of children with an anterior midline neck swelling by establishing 1) whether a preoperative ultrasound scan (USS) was appropriately requested, performed and reported; 2) whether there was preoperative infection; 3) whether a Sistrunk procedure was performed; 4) the rate of thyroglossal duct cyst (TGDC) recurrence following simple excision vs. Sistrunk procedure. METHODS: A single centre retrospective study of children who underwent surgery for anterior midline neck swelling between April 2000 and May 2015 at our institution was performed. These were identified using a clinical coding system, and data were collected from electronic medical records, radiology, and histopathology reports. Recurrence rates between simple excision and Sistrunk groups were compared using Chi-square test. MAIN RESULTS: 227 patients were identified (115 male, 112 female). 169 (74%) had a preoperative USS. The presence of a thyroid gland was stated in 79% of USS reports. This increased to 92% when the requesting surgeon had specifically asked about this. 48 (21%) patients underwent simple excision, while 175 (77%) had a Sistrunk procedure. Recurrence was significantly more likely following simple excision than a Sistrunk procedure (29% vs 6.9%; P<0.0001). Of 25 TGDC recurrences, 9 (36%) had an inconclusive or alternative histopathological diagnosis at first operation. CONCLUSION: Preoperative USS should be performed in all patients with an anterior midline neck swelling. Appropriate requesting increases likelihood of a report confirming (or otherwise) the presence of a thyroid gland. A Sistrunk procedure is the operation of choice in all children presenting with an anterior midline neck swelling. The surgeon cannot reliably differentiate a TGDC from alternative pathology intraoperatively. LEVEL OF EVIDENCE: Treatment study: level IV.

Delayed Diagnosis of Q Fever: Finally Diagnosed After Elective Cardiac Surgery.

Q fever is a bacterial infection caused by Coxiella burnetti. It can cause both acute and chronic illness. Chronic QF can present as a variety of clinical syndromes. A common and critical manifestation is endocarditis which can present atypically and is easily missed. This case describes a man who, after extensive investigation for splenomegaly and pancytopenia by several specialties, was finally diagnosed with Q fever endocarditis after unexpected aortic valve abnormalities found during elective cardiac surgery. Several factors contributed to diagnostic delay including aspects of clinical assessment and radiologic findings. Vigilance is essential for diagnosis and prompt initiation of effective treatment.