Double papillary fibroelastoma: beautiful, innocent flowers in the left heart.

Papillary fibroelastoma is a rare, benign tumor, and multiple papillary fibroelastomas are even more uncommon. In an asymptomatic patient scheduled for carotid endarterectomy, transthoracic echocardiography discovered a fibroelastoma on the mitral valve. Then, transesophageal echocardiography showed another fibroelastoma on the aortic valve. Because he also needed a right coronary artery bypass, the patient underwent surgical excision of both masses. Fibroelastomas are not always as innocent as they seem, and surgical excision is necessary because of their potential for systemic or coronary embolization. Transoesophageal echocardiography may improve the diagnosis of multiple papillary fibroelastomas.

Continuous cold blood cardioplegia improves myocardial protection: a prospective randomized study.

BACKGROUND: To assess the influence on myocardial protection of the rate of infusion (continuous vs intermittent) of cold blood cardioplegia administered retrogradely during prolonged aortic cross-clamping. The end-points were ventricular performance and biochemical markers of ischemia. METHODS: Seventy patients undergoing myocardial revascularization for three-vessel disease were prospectively randomized to receive intermittent or continuous retrograde cold blood cardioplegia. Hemodynamic measurements were obtained using a rapid-response thermodilution catheter and included right ventricular ejection fraction, cardiac output, left and right ventricular stroke work index, and systemic and pulmonary vascular resistance. Blood samples were obtained from the coronary sinus before cross-clamp application and immediately after cross-clamp removal for determinations of lactate and hypoxanthine. RESULTS: The left ventricular stroke work index trend was significantly superior (p = 0.038) by repeated-measures analysis in continuous cardioplegia. Other hemodynamic measurements revealed a similar trend. The need for postoperative inotropic drugs support was reduced in continuous cardioplegia. The release of lactate in the coronary sinus after unclamping was 2.30 +/- 0.12 mmol/L after intermittent cardioplegia and 1.97 +/- 0.09 mmol/L after continuous cardioplegia (p = 0.036). The release of hypoxanthine was 20.47 +/- 2.74 micromol/L in intermittent cardioplegia and 11.77 +/- 0.69 micromol/L in continuous cardioplegia (p = 0.002). CONCLUSIONS: Continuous cold blood cardioplegia results in improved ventricular performance and reduced myocardial ischemia in comparison with intermittent administration.

Off-pump coronary artery bypass grafting: a case-matched comparison of hemodynamic outcome.

OBJECTIVE: The objective of this study was to assess improved myocardial protection by performing coronary artery bypass grafting (CABG) on the beating heart. A case-matched study was conducted among patients who underwent CABG either on-pump (group 1), or off-pump (group 2). METHODS: Forty-five pairs of patients, having a similar clinical profile, were selected on the basis of five variables: age, gender, body surface area, ejection fraction, extent of coronary disease. Operative risk predicted by the The Society of Thoracic Surgeons national database was 1.80+/-0.35% in group 1, and 1.89+/-0.37% in group 2 (NS). Cold blood cardioplegia and 28 degrees C cardiopulmonary bypass were used in group 1. In group 2, beating heart coronary grafting was achieved with the Octopus 1 and 2 stabilizers. The average number of distal anastomoses was 2.8+/-0.1 in group 1 and 2.3+/-0.1 in group 2 (P=0.015). RESULTS: There was no significant difference among the groups regarding the trend in cardiac index, left and right ventricular stroke work indexes, and systemic and pulmonary vascular resistance indexes. However, heart rate trend was slower in group 2 (P=0.05). Pharmacological support was required in 65% of the patients in group 1, and in 33% in group 2 (P<0.001). The total amount of Dobutamine and/or Dopamine administered during the first 48 h was 3914+/-1306 gamma/kg in group 1 and 1645+/-697 gamma/kg in group 2 (P=0.049). Release of creatine kinase MB mass isoenzyme (CK-MB mass) was markedly reduced in group 2 (P<10(-4)). CONCLUSIONS: Hemodynamic outcome following off-pump CABG is similar to on-pump CABG but the need for inotropic support is significantly reduced and CPK-MB mass release is markedly lower.

Reoperation for ascending aorta false aneurysm using deep hypothermia and circulatory arrest.

OBJECTIVES: Ascending aorta false aneurysms after cardiac surgery are uncommon. Resternotomy is hazardous and may result in massive and uncontrollable hemorrhage if the false aneurysm is entered. Here we report our experience with the use of deep hypothermia and circulatory arrest to avoid this risk. METHODS: From March 2000 to December 2007, seven patients (mean age 50 years) were reoperated for an ascending aorta false aneurysm. Three patients had undergone an aortic valve replacement (n=2) or an aortic valve repair (n=1). Three had undergone an ascending aorta replacement with a valved conduit (n=2) or an aortic valve repair (n=1) for type A dissection. One had undergone a coronary artery bypass grafting. Mean delay to reoperation was 133 months (range 22-324 months). Two patients had positive blood cultures (Staphylococcus species). Cardiopulmonary bypass was established by extramediastinal access. Patients were cooled to 18 °C. RESULTS: Resternotomy was performed uneventfully under total circulatory arrest in all patients. Four patients underwent an ascending aorta replacement with a valved conduit (n=2) or a dacron conduit (n=2) associated with a mitral valve replacement in one patient. Direct suture was performed in two patients and in one patient the aorta was repaired using a saphenous vein patch. There was one hospital death. Mean follow-up was 53 months (range 14-90 months). CONCLUSION: Resternotomy under circulatory arrest and deep hypothermia is a safe technique well-adapted to patients with an ascending aorta false aneurysm.

Prostatic abscess associated with Bacteroides fragilis mediastinitis after heart surgery.

Anaerobic mediastinitis after cardiac surgery is a rare and poorly understood condition. We observed a patient with diabetes and myelodysplastic syndrome who developed Bacteroides fragilis mediastinitis in conjunction with a prostatic abscess, several days after coronary artery bypass surgery; this hitherto unpublished observation suggests that suppurative infection of the genito-urinary tract may constitute a portal of entry for postoperative anaerobic mediastinitis in predisposed patients.

Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone.

BACKGROUND: The benefit of the Cox Maze procedure combined with heart surgery was evaluated at long-term follow-up. METHODS: The outcome for 37 patients who underwent a Cox Maze III procedure combined with heart surgery (Maze group) was compared with that of 66 patients who had heart surgery alone (control group). All patients were in persistent atrial fibrillation preoperatively. The two groups had similar preoperative characteristics and were operated upon during the same era (1996 to 2004). RESULTS: Five-year survival, including hospital deaths, was 89% +/- 5% in the Maze group and 60% +/- 7% in the control group (log rank p = 0.008). Causes of death were predominantly related to heart failure (1 of 37 in the Maze group and 12 of 66 in the control group; p = 0.02) and to sudden death (0 of 37 in the Maze group and 9 of 66 in the control group; p = 0.02). After correction for preoperative variables, Cox regression analysis showed that the Maze procedure improved survival independently (p = 0.019). In a subgroup of patients with left atrial diameter of more than 60 mm preoperatively, the 5-year survival estimate was 92% +/- 6% in the Maze group versus 59% +/- 9% in the control group (log rank p = 0.012). The 5-year estimate of conversion to sinus rhythm was 91% +/- 7% in the Maze group and 33% +/- 7% in the control group (log rank p < 0.001). CONCLUSIONS: The restoration of sinus rhythm by a Maze procedure combined with heart surgery markedly improved long-term survival in this series.

Do coronary bypass graft flows differ between on-pump and off-pump operations?

BACKGROUND: The aim of this study is to compare hemodynamic factors in coronary bypass grafts on-pump and off-pump. METHODS: Two propensity score-matched groups of 89 patients each including 408 dual beam Doppler flow measurements were compared. The study included only patent and single terminolateral bypass grafts. RESULTS: Flow was 64.9 +/- 37.3 mL/min in the on-pump group versus 58.6 +/- 35.0 mL/min in the off-pump group (p = 0.063); velocity was 23.8 +/- 10.5 versus 20.5 +/- 10.4 cm/s (p = 0.004); resistance measured as mm Hg/(mL/min(-1)) was 1.50 +/- 1.09 versus 1.76 +/- 1.14 (p = 0.020); pulsatility index was 1.98 +/- 1.52 versus 2.44 +/- 1.62 (p = 0.004). The hematocrit was 23.5 +/- 3.8% in the on-pump and 32.9 +/- 4.1% in the off-pump groups (p < 0 0.001). Multivariate analysis showed that hematocrit was the most significant factor influencing flow (p < 0.001) and velocity (p < 0.001), along with resistance (p = 0.004) and pulsatility index (p < 0.001). In a subset of 50 hemodynamic measurements made on left internal thoracic arteries implanted onto left anterior descending arteries and matched for hematocrit, there were no differences between on-pump and off-pump groups regarding flow, velocity, resistance, or pulsatility index. CONCLUSIONS: Off-pump compared with on-pump bypass surgery is associated with lower velocity and higher resistance in the grafts, mainly caused by changes in hematocrit and viscosity related to hemodilution.

Radiofrequency ablation of atrial flutter combined with closure of atrial septal defect.

Radiofrequency ablation of atrial flutter combined with patch closure of an atrial septal defect is described. Radiofrequency energy was delivered in the cavo-tricuspid isthmus and from the inferior margin of the atriotomy down to the septal defect using a temperature-controlled multipolar radiofrequency catheter. In addition, cryolesions were applied to the junction of the ablation scar with the tricuspid annulus and with the ostium of the inferior vena cava. Sinus rhythm was restored and an electrophysiologic study conducted 2 months later confirmed the bidirectional conduction block of the cavo-tricuspid isthmus.