Right Ventricular Perforation by Fractured Sternal Wires: A Narrative Review.

INTRODUCTION: Migration of a fragmented sternal wire is an unusual and rare phenomenon following cardiovascular surgery. It can present with variable clinical presentations, ranging from incidental findings to hemodynamic instability. Here, we described two cases of fragmented sternal wire migration to the right ventricle. METHODS: Retrospective review of the clinical course of two patients presenting with a fragmented sternal wire embedded in the right ventricle after sternotomy for cardiovascular surgery. We also conducted a literature review to identify similar cases, compared them based on reported clinical variables, and discussed the role of diagnostic imaging and management. RESULTS: We identified 13 patients (11 from the literature), of which 85% were men, and the median age was 64 years; 46% presented with hemorrhagic shock, another 46% had other cardiovascular symptoms, and 8% were asymptomatic. The presentation was bimodal, 54% presented within three weeks of the original sternotomy, while 46% had sternotomy more than a year before. Sternal dehiscence/instability was observed in 61% of cases. Computed tomography scan was the most common diagnostic modality (54%). Two patients did not undergo surgery, and two others died after surgery, while others had a successful surgical repair. CONCLUSION: Migration of a fragmented sternal wire is a phenomenon presented on a dehisced and unstable sternum that can occur days or years after sternotomy. These findings and the associated cardiac injury can be easily missed on computed tomography scan reporting if one is not looking for it. After diagnosis, treatment should be individualized according to the patient's needs.

Multimodal Imaging in Mycobacterium Chimaera Cardiovascular Infections: The Mayo Clinic Experience.

Objective: To review the salient features of multimodality cardiovascular imaging in patients with disseminated Mycobacterium chimaera (MC) infections after exposure to contaminated heater-cooler units during cardiopulmonary bypass. Patients and Methods: Twelve patients with confirmed MC infection were retrospectively identified after a review from January 1, 2010, to April 30, 2021. The electronic medical records were examined with a focus on transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography (CT), cardiac magnetic resonance imaging, and positron emission tomography-CT. Results: Three (27.3%) patients had diagnostic findings of endocarditis on transthoracic echocardiography, with most patients having nonspecific abnormalities including elevated prosthetic valve gradients or prosthetic leaflet thickening. Transesophageal echocardiography identified 4 (36.7%) patients with vegetations and 3 (27.3%) with aortic root abscess or pseudoaneurysm, with more common findings such as mild aortic root or prosthetic leaflet thickening. Six (50%) patients underwent cardiac CT imaging, which found aortic root pseudoaneurysms or abscesses, prosthetic ring dehiscence, and leaflet thickening. Three (25%) patients underwent cardiac magnetic resonance imaging demonstrating prosthetic valve vegetations, leaflet thickening, and abnormal myocardial delayed enhancement in a noncoronary distribution, suggesting myocarditis. Ten (83%) patients underwent positron emission tomography-CT, 4 (40%) had an abnormal fluorodeoxyglucose uptake around the cardiac prosthetic material, and 7 (70%) had a fluorodeoxyglucose uptake in other organs, suggesting concomitant multiorgan involvement. Conclusion: Multimodality cardiovascular imaging is central to the management of patients with disseminated MC and can help establish a preliminary diagnosis while awaiting confirmatory microbiological data, potentially reducing the time to diagnosis. Imaging findings are subtle and atypical, not always meeting classically modified Duke's criteria for infectious endocarditis. Clinicians should have a high index of suspicion for the disease and a low threshold for repeat imaging when initial testing is equivocal.

Percutaneous Vacuum-Assisted Aspiration of Mobile Caseous Mitral Annulus Calcification.

A 68-year-old woman presented with an incidentally found intracardiac mass. Transesophageal echocardiography (TEE) showed a 26 × 8 mm mobile mass attached to a calcified posterolateral mitral annulus. The mass was removed with a commercially available percutaneous catheter system using cerebral embolic protection and TEE guidance. The pathologic examination showed caseous mitral annular calcification.

Resisting arrest: Perioperative confirmation and management of an iatrogenic aortocoronary arteriovenous fistula after coronary artery bypass grafting for redo cardiac surgery.

Although rare, iatrogenic aortocoronary arteriovenous fistulae (ACAVF) occur when a coronary graft is mistakenly anastomosed to an epicardial vein rather than its intended arterial target. Patients may be asymptomatic, demonstrate angina, dyspnea, arrhythmias, syncope, or diminished exercise capacity, and may have wide pulse pressures with evidence of coronary steal. A thorough insight into the disordered anatomy is critical to safely manage a patient for redo cardiac surgery, especially when attempting to arrest the heart. We present a case for redo cardiac surgery of an iatrogenic ACAVF confirmed perioperatively with multiple modalities and its intraoperative management.

Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure: A Novel Risk Factor for Early Bioprosthetic Failure.

OBJECTIVES: The clinical implications of finding immobile leaflet(s) at the time of bioprosthetic valve implantation but with acceptable prosthetic haemodynamics are uncertain. We sought to determine the characteristics of such patients and their impact on outcome. METHODS: Patients with immobile leaflet at the time of surgical bioprosthetic valve implantation were identified retrospectively by a systematic search of an institutional echocardiography database (2010-2020). Intraoperative echocardiograms were reviewed de-novo to confirm immobile leaflet(s) at the time of implantation. Cases were matched 1:2 to controls with normal bioprosthetic leaflets motion for age, sex, prosthesis position, prosthesis model, size, year of implantation, and pre-implantation left ventricular ejection fraction. Proportional hazards method was used to analyse the composite endpoint of stroke, valve thrombosis or re-intervention. RESULTS: Immobile leaflet at the time of bioprosthetic valve implantation were found in 26 patients (median age 71 ys 39% males) following tricuspid (n=13), mitral (n=11) and aortic (n=2) valve replacements; 96% received porcine prostheses; prosthesis size was 27 mm or larger in 92%. Immobile leaflet were recorded on intraoperative reports in 16 (62%) cases. It resulted in elevated gradient or mild-moderate prosthetic regurgitation in three (12%), but none led to immediate corrective action intraoperatively. At median follow-up of 21 (4-50) months, presence of immobile leaflet was associated with composite clinical endpoint of stroke, valve thrombosis or re-intervention (hazard ratio 6.8, 95% CI 1.8-25.2, p<0.01) compared to controls. CONCLUSION: Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised intraoperatively and appears to be associated with early bioprosthetic dysfunction and worse clinical outcome.

Overview of Optimal Techniques for Pericardiocentesis in Contemporary Practice.

PURPOSE OF REVIEW: This review summarizes the optimal techniques for the performance of pericardiocentesis in contemporary practice, highlighting the indications, contraindications, and techniques used. Routine pericardial catheter management and the diagnostic role of pericardial fluid analysis are described. RECENT FINDINGS: Echocardiographic-guided pericardiocentesis should be considered the therapy of choice in current clinical practice and may be performed safely despite the presence of coagulopathy and thrombocytopenia in the hands of expert operators. Computed tomography (CT)-guided techniques may provide a useful adjunctive tool in patients with poor acoustic windows or complex loculated effusions. Conservative management utilizing pericardiocentesis may be considered in select patients with device lead and interventional-related pericardial effusions. Echocardiographic-guided pericardiocentesis with extended pericardial drainage (goal output < 50 mL/24 h) should be considered the standard of care in contemporary practice. Pericardial fluid analysis should be tailored based on the clinical history and appearances of the pericardial fluid.

End-of-Therapy Echocardiography May Not Be Needed in All in Patients With Endocarditis.

BACKGROUND: The American Heart Association (AHA) guidelines for infective endocarditis (IE) management recommend end-of-therapy (EOT) echocardiography (ETE) to "establish a new baseline" and based on "expert opinion." METHODS: Medical records of IE patients treated between January 2005 and December 2011 were reviewed. Utilization of ETE and cumulative incidence of re-treatment with antimicrobials or cardiovascular surgery (re-Rx/CVS) within 1 year after EOT were evaluated. RESULTS: A total of 243 patients completed clinical follow-up at EOT and 170 at 1 year after EOT. One hundred seventy-seven of 243 (72.8%) underwent ETE, the majority (51.4%) transthoracic echocardiography. One hundred thirty-three of 177 (75.1%) were without new/worsened signs or symptoms (new/w-SSx). One hundred forty-one of 177 (79.7%) overall and 117/133 (87.9%) patients without new/w-SSx had no new ETE findings as compared with initial echocardiography. Among 36/177 (20.3%) with new ETE findings, 20/36 (55.6%) had new/w-SSx; ETE findings were more likely in patients with new/w-SSx (39.2% vs 8.3%; P < 0.001) at EOT. Patients were at increased risk of re-Rx/CVS with either new ETE findings (hazard ratio [HR], 25.86; 95% confidence interval [CI], 7.64-87.56; P < .001) or new/w-SSx (HR, 5.35; 95% CI, 2.87-9.95; P < .001). The highest risk of re-Rx/CVS was in patients with both new/w-SSx and new ETE findings (HR, 45.94; 95% CI, 19.07-110.71). Conversely, only 7/187 (3.4%) patients without new/w-SSx who had an ETE required re-Rx/CVS. CONCLUSIONS: The majority of patients without new/w-SSx at EOT will not have new ETE findings or need re-Rx/CVS within 1 year after EOT. EOT new/w-SSx is associated with new ETE findings and predicts the need for re-Rx/CVS. Further study is needed to determine whether patients without new/w-SSx need ETE.

Changes in comorbidities, diagnoses, therapies and outcomes in a contemporary cardiac intensive care unit population.

Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years. METHODS: We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression. RESULTS: We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94-0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85-0.96, P = .002) a critical care discharge diagnosis. CONCLUSIONS: We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time.

Echocardiographic mimicker of thrombus on a mechanical aortic valve prosthesis due to cavitation: A paradoxical phenomenon of pressure recovery.

We describe a case of a mass-like echocardiographic density on a mechanical prosthetic aortic valve. We initially suspected a thrombus vs vegetation on transthoracic echocardiography, but after transesophageal echocardiography, the density was subsequently determined to be cavitation by reviewing the initial images in slow motion.

Pre- and post-pericardiocentesis echo-Doppler features of effusive-constrictive pericarditis compared with cardiac tamponade and constrictive pericarditis.

AIMS: To review 2D and Doppler findings in patients diagnosed with effusive-constrictive pericarditis (ECP) and compare these to patients with cardiac tamponade and patients with surgically-proven constrictive pericarditis (CP). METHODS AND RESULTS: We identified 22 patients diagnosed with ECP at Mayo Clinic, MN, USA between 2002 and 2016 who had persistent elevation of jugular venous pressure post-pericardiocentesis. We compared them to 30 patients with CP and 30 patients with cardiac tamponade who had normalization of venous pressure post-pericardiocentesis. All patients were in sinus rhythm. Mean age was 57 ± 18 years in the ECP group; 36% were females. Most ECP and cardiac tamponade cases were idiopathic (41% and 33%, respectively). Prior to pericardiocentesis, medial and lateral e' velocities were higher in ECP compared with tamponade; both ECP and tamponade patients had markedly decreased hepatic vein diastolic forward flow velocities. Inspiratory and expiratory mitral E/A ratios were higher in ECP compared with tamponade, but lower than those observed in CP. Post-pericardiocentesis, hepatic vein diastolic forward flow velocities increased in both ECP and tamponade. Hepatic vein diastolic reversal velocities decreased in tamponade but were unchanged in ECP. During median follow-up of 481 days, three patients required pericardiectomy for CP; they were all in the ECP group (14% of ECP cases). CONCLUSION: ECP may have unique echo-Doppler features that distinguish it from both CP and tamponade. Our findings suggest that ECP could be diagnosed by echocardiography even prior to pericardiocentesis. ECP appears to have a good prognosis, particularly in patients presenting acutely.

Left ventricular non-compaction cardiomyopathy: Incidental diagnosis after ST-elevation myocardial infarction.

Left ventricular non-compaction cardiomyopathy is a rare congenital cardiomyopathy, which usually presents early in life but may also manifest into adulthood. We present the case of an elderly woman with left ventricular non-compaction cardiomyopathy, which was discovered incidentally following an ST-elevation myocardial infarction.

Cardiac implantable electronic device lead-based masses and atrial fibrillation ablation: a case-based illustration of periprocedural anticoagulation management strategies.

INTRODUCTION: Cardiac implantable electronic device (CIED) leads frequently develop echogenic masses. However, the nature of these masses is not well understood. In patients in whom atrial fibrillation (AF) catheter ablation is planned, there is concern that transseptal puncture may result in cerebrovascular embolism of these masses. The optimal therapeutic strategy in this setting remains undefined. METHODS: We describe six patients identified over a 6-year period (2008-2014) with device lead-based masses prior to or at the time of AF ablation. We examined the anticoagulation strategy and periprocedural management based on mass identification. RESULTS: In all six patients (age 39-73; four males), the device lead mass was found in the right atrium. The average mass size was 11 ± 1.3 mm. The majority of patients were already on anticoagulation (5/6; 83 %), and an intensified anticoagulation regimen was initiated (INR goal 3.0). In all six patients, the size of the device lead mass decreased on repeat imaging. In two sixths (33 %) patients, the lead-based mass completely resolved within 2 months. The remaining four patients had persistent lead-based masses (average follow-up of 10.9 ± 9.6 months). DISCUSSION: We describe a series of patients with CIED lead-based masses found at the time of ablation. These cases illustrate that lead-based masses can disappear while patients are on high-intensity anticoagulation, most compatible with a thrombotic origin. These early data will need to be assessed in larger cohorts for further validation and evaluation of safety.