Choice of valve substitutes.

Infective endocarditis often necessitates surgical intervention, and the choice of valve substitute remains a topic of controversy and highly debatable due to the wide range of available options and recent technical advancements. This manuscript reviews the different valve substitutes in the context of infective endocarditis, including mechanical and bioprosthetic valves, homografts, xenografts, and tissue-engineered valves. The patient's age, sex, demographic location, intellectual quotient, comorbidities, available options, and the experience of the surgeon should all be taken into consideration while choosing the best valve substitute for that individual. While valve repair and reconstruction are preferred whenever feasible, valve replacement may be the only option in certain cases. The choice between mechanical and bioprosthetic valves should be guided by standard criteria such as age, sex, expected lifespan, associated comorbidities, and anticipated adherence to anticoagulation therapy and accessibility of medical facilities for follow-up. For patients with severe chronic illness or a history of intracranial bleeding or associated hematological disorders, the use of mechanical prostheses may be avoided. Homografts and bioprosthetic valves provide an alternative to mechanical valves, thereby decreasing the necessity for lifelong anticoagulation after surgery and diminishing the likelihood of bleeding complications. The manuscript also discusses specific valve substitutes for different heart valves (aortic, mitral, pulmonary, tricuspid positions) and highlights emerging techniques such as the aortic valve neocuspidization (Ozaki procedure) and tissue-engineered valves. Ultimately, the ideal valve substitute in IE should be evidence based on a comprehensive elucidation of clinical condition of the patient and available options.

Ruptured sinus of Valsalva aneurysm in a case of Ebstein anomaly: a clinical masquerade of two perfectly balanced lesions.

A combination of a ruptured sinus of Valsalva (RSOV) with Ebstein anomaly is a rare and clinically challenging entity. We describe a case of a 29-year-old female who presented with progressive dyspnoea and epigastric discomfort with symptoms and clinical findings not consistent with any single definitive diagnosis. In the primary echocardiography assessment, she was diagnosed with Ebstein anomaly. On the grounds of several unexplained clinical features and routine review echocardiography by the cardiology team, she was found to have a rare combination of Ebstein anomaly associated with RSOV. A cath study was performed to study the interplay of the hemodynamics of the two lesions, not described before in the literature, and also explain the clinical features not consistent with any one entity. We emphasize the significance of meticulous history-taking and sound clinical evaluation followed by corroboration with the diagnostic modalities for precise diagnosis and timely planned intervention in such rare associations. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01622-4.

A rare case of Kawasaki disease with giant coronary artery aneurysm.

Kawasaki disease (KD) is an acute, self-limiting vasculitis that occurs in children of all ages. This was first described by Kawasaki in 1967. Spontaneous regression is observed; however, 25% of patients develop coronary artery aneurysm (CAA). These may result in ischaemic heart disease causing myocardial infarction, rupture leading to pericardial tamponade and distal embolization which culminate in sudden cardiac death. Diagnosis of KD relies on clinical suspicion with no gold standard diagnostic test. A case of KD with giant CAA in a 14-year-old female is described with emphasis on challenges pre- and peri-operatively. The review provided post description of the case emphasizes on pathophysiology with clinical course of CAA in association with KD and justification of our approach with an insight into newer treatment modalities.

Successful surgical correction of tetralogy of fallot associated with anomalous left coronary artery connection to pulmonary artery.

Tetralogy of fallot is rarely associated with anomalous left coronary artery connection to main pulmonary artery. High index of suspicion is needed preoperatively to diagnose this association and treat successfully. We present a case of 9-year-old boy with the rare association of tetralogy of fallot and anomalous left coronary artery connection to pulmonary artery with a giant steal intercoronary collateral crossing right ventricular outflow tract who was treated successfully by single-stage surgical correction.

Global Unmet Needs in Cardiac Surgery.

More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.

Results of mitral valve repair in rheumatic mitral regurgitation.

Between January 1988 and December 2003, 898 patients with rheumatic heart disease (mean age 22.4+/-10.1 years) underwent mitral valve (MV) repair. Five hundred and sixty-five patients (63%) had pre-operative atrial fibrillation. Six hundred and ten (68%) patients were in NYHA class III or IV. Four hundred and twelve (45.9%) had pure mitral regurgitation (MR) and 486 (54.1%) had mixed mitral stenosis and MR. The pathology was leaflet prolapse (n=270, 30%), annular dilatation (n=717, 79.8%) and calcification (n=39, 4.3%). Reparative procedures included annuloplasty (n=793, 88%), commissurotomy (n=530, 59%), chordal shortening (n=225, 25%), cusp excision/plication (n=41, 4.5%), cuspal thinning (n=325, 36%), cleft suture (n=142, 16%), decalcification (n=30, 3.3%), chordal transfer (n=13, 1.4%), and neo chordae construction (n=3, 0.3%). Early mortality was 32 (3.6%). Follow-up ranged from 6 to 180 months (mean 62.7+/-31.8 months) and was 96% complete. Six hundred and twenty-one patients (69%) had no, or trivial, or mild MV. Two hundred and seventy-seven of the 866 survivors had MR which was moderate in 153 (18%) and severe in 124 (14%) patients. Thirty-five patients underwent re-operation. There were 21 late deaths (2.4%). Actuarial and re-operation-free survival at 10 years were 92+/-1.1% and 81+/-5.2%, respectively. Freedom from moderate or severe MR was 32+/-3.9%. MV repair in the rheumatic population is feasible with acceptable long-term results.

Anticoagulation protocol and early prosthetic valve thrombosis.

BACKGROUND: [corrected] Prosthetic valve thrombosis is a major cause of morbidity and mortality following heart valve replacement with a mechanical valve. METHODS AND RESULTS: 538 patients who underwent mechanical valve replacement between April 1999 and June 2003 were included in the study. They were divided into two groups. Group A (n=245) consisted of patients who underwent mechanical valve replacement between April 1999 and June 2001. Anticoagulation was started on the first post-operative day and consisted of only oral nicoumalone. Group B (n=293) consisted of patients who underwent mechanical valve replacement between July 2001 and June 2003; enoxaparin was started six hours following surgery in addition to oral nicoumalone which was started on first post-operative day. Fifteen (6.1%) patients in group A developed early prosthetic valve thrombosis at an interval of 4.33+/-0.97 months (range 3-6 months) following surgery. Ten had prosthetic valve thrombosis in the mitral position and five had prosthetic valve thrombosis in the aortic position. In group B, six (2.1%) patients developed early prosthetic valve thrombosis at a median interval of 4.58+/-0.9 months (range 3.5-6 months) in the mitral position (p=0.01). CONCLUSIONS: Addition of enoxaparin to the anticoagulation regime in the immediate post-operative period significantly reduces early prosthetic valve thrombosis.