Aortic Root Dilation and Testosterone Use: Are They Associated?

Aortic root dilation and thoracic aortic aneurysms are relatively rare in young and healthy patient populations. However, a number of observed incidental cases regarding young males and testosterone use raises suspicion of a potential risk factor for aortic root dilation. The authors' patient, a healthy 40-year-old man with a significant history of testosterone use who developed a massively dilated aortic root, is sufficiently alarming to report. Notwithstanding anecdotal cases, there exists a well-known association between elite strength athletes and aortic root dilation. Nevertheless, very little clinical research exists on the relationship between testosterone use and aortic root dilation and/or thoracic aortic aneurysms. Furthermore, a small number of animal studies showed a relationship between testosterone and vascular dilation, particularly the aorta. Although testosterone may play a role in the development of aortic pathologies, further research is necessary to clarify the possible relationship if cases such as these are to be prevented.

Role of Methadone in Extracorporeal Membrane Oxygenation: Two Case Reports.

Extracorporeal membrane oxygenation (ECMO) affects pharmacokinetics/dynamics of drugs in unpredictable ways. Anecdotally, ECMO patients require high doses of opioids and sedatives, leading to concerns of tolerance. Methadone is a long-acting synthetic opioid with antagonist properties at the n-methyl-d-aspartate (NMDA) receptor. It has been shown to improve spontaneous breathing trials and weaning from mechanical ventilation; however, there is no literature describing its use in ECMO. We describe two patients from the cardiac surgery intensive care unit at Cedars Sinai (Los Angeles, CA) on ECMO for over 30 days maintained on methadone.

Automated Intra-abdominal Pressure Monitoring During Orthotopic Heart Transplant Leads to Early Diagnosis and Treatment of Intraoperative Abdominal Compartment Syndrome-A Case Report.

We describe a case of spontaneous retroperitoneal hematoma leading to abdominal compartment syndrome and organ failure during a complicated orthotopic heart transplantation in a patient previously on mechanical circulatory support. After the patient had been weaned of cardiopulmonary bypass, the patient suddenly became hemodynamically unstable despite good LV and RV function. While the patient was resuscitated, high intra-abdominal pressures were noted on a novel monitor measuring real-time intra-abdominal pressures and urinary output. The early detection of high intra-abdominal pressures led to a swift decompressive laparotomy with the detection of retroperitoneal hematoma and subsequent hemodynamic stabilization.

Successful Outcomes following Repair of a Type A Aortic Dissection during Pregnancy.

Type A aortic dissections during pregnancy are rare but lethal events, with reported mortalities as high as 60%. Unique changes in hemodynamics, hormone-related alterations in aortic tissue, and preexisting risk factors place patients at an elevated risk for dissection. We report a successful repair of a Type A aortic dissection at 32 weeks of gestation, with excellent outcomes in both mother and child. This report highlights the importance of gestational age and multidisciplinary effort.

Hemodynamic Consequences of Laparoscopy for Patients on Mechanical Circulatory Support.

BACKGROUND: Technologic advances and superior survival with mechanical circulatory support (MCS) have led to an expanding population that develops intraabdominal conditions requiring intervention. Whether laparoscopy can be performed without detrimental effects on hemodynamics and device function is not well described. MATERIALS AND METHODS: Effects of laparoscopy performed on MCS were retrospectively assessed. Intraoperative hemodynamics and device function were compared with the same time interval 24 hours prior to surgery using intrapatient paired t tests. Outcomes included survival, transfusion, thromboembolic events, and infection. RESULTS: Twelve patients with ventricular assist devices or total artificial hearts underwent laparoscopy from 2012 to 2014. Median follow-up was 116 days. Operations included cholecystectomy, diagnostic laparoscopy, gastrojejunostomy, and gastrostomy. There were no differences between preoperative and intraoperative mean arterial pressure, heart rate, and inotrope or vasopressor requirements (P > .05). Device fill volume, flow, rate, and power were unchanged (P > .05), whereas pulsatility index decreased by 0.2 (95% confidence interval, 0.03, 0.36) with laparoscopy (P = .03). All intraoperative fluctuations in hemodynamics and device function improved with reduction of pneumoperitoneum, adjusting device speed, or pharmacologic support. There were no operative mortalities. Thirty-day survival and survival to discharge were 75% and 50%, respectively. Despite antiplatelet therapy and preoperative international normalization ratio of 2.2 ± 0.9, there were no re-operations for bleeding, and 50% did not require transfusion. Two patients with recent cardiac surgery had thromboembolic events: one stroke and one device thrombus. None had postoperative bacteremia or driveline infection. CONCLUSIONS: Laparoscopy can be performed on MCS with low morbidity and mortality and minimal perturbations in hemodynamics and device function.

Cardiomyoplasty: ventricular reconstruction after tumor resection.

OBJECTIVE: Although cardiac transplantation has been performed for complete removal of ventricular tumors, complete surgical resection with ventricular reconstruction is desirable. Thus patients with benign tumors would probably be cured, and those with malignant tumors would have a better prognosis. In this study extensive and complete surgical resection of ventricular tumors is followed by anatomic and functional ventricular reconstruction with a dynamic cardiomyoplasty procedure. METHODS: Seven patients (mean age, 32.7 years) underwent complete resection of ventricular tumors. Histologic types were distributed as follows: fibroma in 2 patients and sarcoma, lymphosarcoma, hemangioma, lipoma, and metastatic angiosarcoma, respectively, in the remaining 5 patients. Six of the patients were considered candidates for heart transplantation because of the extent of tumor invasion. Surgery consisted of 4 steps: (1) tumor resection; (2) coronary artery resection (when invaded by the tumor) and coronary artery bypass grafting; (3) valvular reconstruction (when possible) or replacement; and (4) ventricular wall reconstruction with a pericardial patch for closure of the ventricular defect (neoendocardium) covered by the electrostimulated latissimus dorsi muscle flap (neomyocardium). RESULTS: All patients survived surgical intervention, but 2 late postoperative deaths are reported. Among the surviving patients, early complications played a major role in their postoperative course and consisted of arrhythmias, atrioventricular block necessitating a dual-chamber pulse generator, respiratory insufficiency, and heart failure. Two patients were assisted postoperatively with an intra-aortic balloon pump. On postoperative follow-up (mean, 72.4 +/- 8.5 months), an improvement in the patients' functional status was observed. Patients moved from a mean New York Heart Association functional class of 2.8 to a mean functional class of 1.2. CONCLUSIONS: The excellent long-term evolution without recurrence, ventricular dysfunction, and/or thromboembolic complications implies that cardiomyoplasty could be recommended as an alternative to heart transplantation for the therapy of large ventricular tumors.

Chylothorax complicating pulmonary resection.

BACKGROUND: Chylothorax complicating pulmonary resection (CCPR) is infrequent and surgical treatment is for the most part avoided. The purpose of this study is to analyze the clinical and therapeutic characteristics of this complication. METHODS: From March 1981 to June 2001, 26 cases of CCPR (24 men and 2 women; mean age 57 years) were treated in two departments of thoracic surgery. Twenty-five cases complicated lung resection for lung cancer (lobectomy n = 14, bilobectomy n = 3, pneumonectomy n = 8) and 1 case followed lobectomy for a benign lesion. Medical history, location, and characteristics of the chylothorax, lymphography, and clinical evolution after medical or surgical therapy were studied. RESULTS: Medical history was never predictive of CCPR. Chylothorax was right sided in 18 cases and left sided in 8 cases. The total amount of chyle ranged from 1.9 L to 27.9 L per patient with a mean of 7.9 L (pneumonectomy 12.3 L and lobectomy 6.3 L). In 15 patients (pneumonectomy n = 2 and lobectomy n = 13) mean quantity of daily chyle was 0.3 L. All these patients recovered with conservative therapy except for 2 patients who underwent drainage and talc slurry (n = 1) and video-assisted lysis of adhesions (n = 1). In the remaining 11 patients (pneumonectomy n = 6 and lobectomy n = 5) mean quantity of daily chyle was 1 L. The chylous leak was seen at lymphography (n = 4), during reoperation (n = 2), or at lymphography and reoperation (n = 3). The location was clearly identified at the level of thoracic duct tributaries in all cases. In 4 postlobectomy cases (4 of 7), surgery was not performed because of the therapeutic usefulness of lymphography. Reoperation was necessary in 6 cases (postpneumonectomy n = 5, postlobectomy n = 1) and consisted of duct ligation (n = 2), leak/suture (n = 3), and fibrin glue (n = 1). CONCLUSIONS: CCPR is rare and appears to respond well to medical treatment owing to the fact that the thoracic duct is generally patent as the leak is due to injury of its tributaries. When surgery is considered, lymphography may help to select cases in which conservative medical therapy should be continued. However, in a small number of cases, usually after pneumonectomy, surgery remains mandatory.

Right ventricular cardiomyoplasty: 10-year follow-up.

BACKGROUND: Chronically depressed right ventricular (RV) function presents an unsolved therapeutic challenge in cardiac surgery. Despite recent advances in medical and surgical therapies, prognosis remains poor and patient's quality of life and mortality are frequently unacceptable. The aim of this study is to present the first clinical report and long-term results of RV dynamic cardiomyoplasty applied in patients with RV failure caused by isolated RV cardiomyopathies. METHODS: Seven consecutive patients (5 males, 2 females; mean age, 40 +/- 9 years; range, 15 to 63 years) from a series of 113 cardiomyoplasty procedures performed at Broussais and Pompidou Hospitals were evaluated. The mean duration of follow-up was 10 +/- 3.5 years. All patients had predominant RV dysfunction, associated with tricuspid regurgitation in 6 patients. The cause of RV failure was arrhythmogenic cardiomyopathy (4 patients), ischemic (2 patients), and Uhl's disease (1 patient), and endomyocardial fibrosis (1 patient). Six patients were in preoperative New York Heart Association functional class III and 1 was in intermittent class III/IV. The mean preoperative ejection fraction (measured by isotopic technique) was 18% +/- 5.7% for the right ventricle and 40% +/- 13% for the left ventricle. Right ventricular dynamic cardiomyoplasty consists of wrapping the RV free walls with the left latissimus dorsi muscle flap. The distal part of the latissimus dorsi muscle is fixed to the diaphragm and then electrostimulated. Six patients required associated tricuspid valve surgery. RESULTS: There were no perioperative deaths. The mean duration of follow-up was 10 +/- 3.5 years. Six patients are alive with a remarkable quality of life, 4 are in New York Heart Association functional class I and 2 are in class II. One patient who was in New York Heart Association functional class II died in postoperative year 7 caused by stroke. At last follow-up, mean RV ejection fraction was 33% +/- 11.8% and left ventricular ejection fraction was 52% +/- 12.6%. CONCLUSIONS: The results of this long-term study demonstrate hemodynamic and functional improvements after RV cardiomyoplasty without perioperative mortality, no long-term malignant arrhythmias, and RV dysfunction related deaths. We believe that RV cardiomyoplasty, associated with tricuspid valve surgery when required, could be an effective treatment for severe RV failure.

Cellular cardiomyoplasty: clinical application.

Myocardial regeneration can be induced with the implantation of a variety of myogenic and angiogenic cell types. More than 150 patients have been treated with cellular cardiomyoplasty worldwide, 18 patients have been treated by our group. Cellular cardiomyoplasty seems to reduce the size and fibrosis of infarct scars, limit postischemic remodelling, and restore regional myocardial contractility. Techniques for skeletal myoblasts culture and ex vivo expansion using autologous patient serum (obtained from plasmapheresis) have been developed by our group. In this article we propose (1) a total autologous cell culture technique and procedures for cell delivery and (2) a clinical trial with appropriate endpoints structured to determine the efficacy of cellular cardiomyoplasty.

Fulminant myocarditis in adults and children: bi-ventricular assist device for recovery.

OBJECTIVE: Fulminant myocarditis (FM) is uncommon and may be followed by a rapidly intractable cardiogenic shock. We report five consecutive patients with FM successfully bridged to recovery with a mechanical paracorporel biventricular assist device (BiVAD). METHODS: Five patients, four adults and one child (mean age 27+/-6 years, range, 5-36 years) underwent implantation from November 1999 to May 2003, for FM. Prior to implantation, all patients required maximal inotropic support, three of them had an intra-aortic balloon pump, the child had an extra-corporel membrane oxygenation (ECMO) support previously inserted in another institution. Cardiac catheterisation showed a mean CPW of 37+/-1 mmHg, mean CVP 18+/-2 mmHg, and mean CI 1.7+/-0.1l/min. Echocardiogram showed a severe biventricular hypokinesia, without any ventricular dilatation and a mean LVEF at 12.5%. Two patients were implanted in cardiac arrest under external cardiac resuscitation. All patients underwent BiVAD implantation (MEDOS HIA-VAD). A 72 ml right paracorporel ventricle (a 23 ml in the child) was instituted between the double stage venous canula used during CPB and a pulmonary artery outflow canula. A 80 ml left paracorporel ventricle (a 25 ml in the child) was instituted between a left ventricle apical canula and an aorta outflow canula. RESULTS: There was no death. The mean duration support time was 11+/-6 days (from 7 to 21 days). Two patients experienced transitory deficiency due to a stroke. Four patients showed signs of FM on histological findings. Despite serologic examination and viral genome research on myocardial biopsies, pathogenic agents were not identified. At mean follow-up of 31+/-15 months, all the patients fully recovered with a mean LVEF=60% and no left ventricular dilatation. CONCLUSIONS: In FM with intractable cardiogenic shock, the use of a BiVAD as a bridge to recovery is a life saving approach and should be considered before multi-end organ failure.

Triple valve repair for young rheumatic patients.

BACKGROUND: Facing young foreign polyvalvular rheumatic patients, for which long-term anticoagulation is not available, we have chosen to attempt triple valve repair procedures in order to avoid prosthetic implantation in this particular population suffering from triple valve disease. METHODS: Twenty-one young rheumatic patients (mean age:11+/-4 years) underwent triple valve repair procedures including cusp extension on the aortic valve aortic between September, 1992 and December, 2000. Valvular pathology characteristics according to Carpentier's classification included mitral insufficiency type III post+II ant (n=10), type III post (n=4), type II ant (n=2), mitral stenosis (n=5), type III aortic insufficiency (n=21), type I (n=13) and type III (n=8) tricuspid insufficiency. RESULTS: Firstly, the mitral valve disease were corrected using Carpentier's techniques of repair: prosthetic ring annuloplasty (n=16), commissurotomy (n=12), chord transposition (n=11) or shortening (n=4), papillary muscle sliding plasty (n=4) and pericardial patch leaflet enlargement (n=6). Secondly, aortic lesions were corrected using glutaraldehyde stabilized autologous pericardium triple cusps extension technique (n=21). Lastly, tricuspid repairs were always performed on beating hearts using commissurotomy (n=8), prosthetic ring (n=12) or other techniques (n=9) of annuloplasty. The operative mortality was 4.7% (one patient died). Echocardiograms before discharge showed grade I mitral insufficiency in seven patients and grade I aortic insufficiency in five patients. There was no late death during a mean follow-up of 51+/-31 months. Two patients underwent valvular redo surgery because of aortic and mitral plasty deterioration due to rheumatic disease progress. After 5 years, 90% of the patients were free from redo valvular surgery. CONCLUSIONS: In rheumatic patients, autologous pericardial patch extension of the aortic valve permitted widespread use of reconstructive surgery even in patients suffering from triple valve disease. Triple valve repair, in this particular challenging setting of patients, has provided satisfactory initial and mid-term results and could be considered as an interesting palliative surgical approach.

Cryopreserved aortic viable homograft for active aortic endocarditis.

BACKGROUND: To evaluate the short and long-term results of cryopreserved aortic viable homograft (CAVH) in the treatment of active aortic endocarditis. METHODS: From January 1992 to December 2002, 104 patients (23 females, 81 males) with a mean age 51 +/- 13 years (from 14 to 77) underwent CAVH replacement for active aortic valve endocarditis. Seventy-six patients (73%) had endocarditis of the native aortic valve, 28 (27%) had endocarditis of prosthetic aortic valve; among them, eight had a recurrent infection. Eighty-three patients (80%) had isolated aortic endocarditis. Plurivalvular endocarditis was observed in 21 (20%) patients, (aortic and mitral in 16 patients, aortic and tricuspid in 5). Intraoperative transesophageal echocardiography was systematically used. Anatomical lesions included perforations in 89 (86%) patients, vegetations in 79 (77%) patients and periannular extensions in 60 (58%) patients. Precise bacteriologic diagnosis was available in 82 (80%) patients. RESULTS: Cryopreserved aortic viable homografts were inserted using the aortic root replacement technique in 93 (89%) patients and the subcoronary technique in 11 (11%) patients. Associated procedures were performed in 38 (37%) patients: mitral (n = 23) and tricuspid (n = 3) valve repair, partial homograft mitral valve replacement (n = 3), partial homograft tricuspid valve replacement (n = 3), coronary bypass graft (n = 3), and ascending aorta replacement (n = 3). Hospital mortality was 5 (5%) patients. Causes of death included: myocardial infarction (n = 2), myocardial failure (n = 2), and multiorgan failure (n = 1). During follow-up (61 +/- 36 months, from 6 months to 136 months), 9 secondary deaths occurred (2 were cardiac related), 14 aortic valvular redo surgeries were performed (2 for nonstructural failure, 6 for structural failure, and 6 for endocarditis). Actuarial survival at ten years was 83%, with 93% of the patients free from cardiac death. At ten years, actuarial rate for freedom from reoperation was 76% and freedom from recurrent endocarditis was 93%. No thromboembolic complications were observed. CONCLUSIONS: The CAVH has proven its effectiveness in treating the destructive lesions of active aortic endocarditis. It has provided satisfactory immediate and long-term results. Allowing the possibility to avoid a prosthetic material, CAVH could represent an option for surgically treating active aortic endocarditis more rapidly.

A rare inferior middle mediastinal tumor resection under extra-corporeal circulation.

An inferior middle mediastinal mass was observed in a 51-year-old woman initially presenting as pericardial effusion and mimicking lymph node disease. Thoracotomy demonstrated a tumor invading the posterior atrial wall. Complete resection was possible under the extracorporeal circulation. The tumor proved to be a soft tissue myoepithelioma in an exceptional location. Despite the difficult surgical resection due to location, prognosis of this absolutely rare tumor without cytologic features of malignancy should be good.

Chylothorax and re-expansion pulmonary edema following myocardial re-vascularization: role of lymph vessel insufficiency.

Chylothorax is a rare complication following coronary artery bypass graft surgery. In the following case, we report a chylothorax complicating left internal mammary artery harvesting due to injury of the left anterior mediastinal lymph node chain (LAMLNC) at the level of the proximal pedicle of the mammary artery. Re-expansion pulmonary edema occurred during re-operation for chylothorax following suturing of this lymph node chain. This observation demonstrates the role of the LAMLNC in both complications when injured or interrupted.

Prediction of arterial oxygen tension during one-lung ventilation: analysis of preoperative and intraoperative variables.

OBJECTIVE: To determine whether currently available preoperative and intraoperative variables related to arterial oxygen tension (PaO(2)) can be used as predictors for low PaO(2) during one-lung ventilation (OLV). DESIGN: A prospective cohort study. SETTING: Primary university hospital. PARTICIPANTS: Adult patients (n = 92) undergoing thoracic surgery requiring OLV. INTERVENTIONS: Preoperative and intraoperative data, including past medical history, physical examination, and usual preoperative and intraoperative tests, were collected and used as explanatory variables for PaO(2) during OLV by univariate and multivariate analysis. A stepwise logistic regression including the same independent variables was used to identify patients who should be expected to develop arterial hypoxemia (PaO(2) <70 mmHg). Arterial blood gas samples were analyzed 15 minutes after the onset of OLV and after thoracotomy to determine the lowest PaO(2) value during OLV. MEASUREMENTS AND MAIN RESULTS: Preoperative (age, hematocrit, relative perfusion of the nondependent lung) and intraoperative (PaO(2) during 2-lung ventilation and mean arterial pressure at the lowest PaO(2)) variables were identified as independent factors affecting PaO(2) in OLV. PaO(2) during 2-lung ventilation was the only independent variable accounting for arterial hypoxemia when multivariate logistic regression was performed. CONCLUSION: The PaO(2) during OLV can be predicted using routinely available preoperative and intraoperative data. From a clinical point of view, this study failed to identify patients at risk of arterial hypoxemia when OLV is instituted because mainly intraoperative independent variables are involved in the decrease of PaO(2) in this situation.