Post-pneumonectomy patients undergoing cardiac surgery: A case series.

BACKGROUND: Data regarding post-pneumonectomy patient assessment for cardiac surgery is scarce. This retrospective study was conducted to define early and late outcomes in these patients, and to identify risk factors for poor outcomes. METHODS: This study included patients with a previous history of pneumonectomy undergoing on-pump cardiac surgery with median sternotomy. The institutional database was reviewed from 1992 to 2018. RESULTS: Sixteen post-pneumonectomy patients (all lung cancer) were identified. The age range was 53-81 years. The mean FEV1/FVC was 69%. The mean EuroSCORE II was 11.6%. Four patients had heart failure symptoms in the 2 weeks before surgery. Seven patients had isolated coronary artery bypass grafting (CABG) and six patients had CABG + aortic valve replacement (AVR). The major perioperative events affecting the ease and outcomes of the surgical procedures were structural shifts (5), extensive adhesions on heart and vessels (5), and extensive calcification of heart components (5). Important postoperative complications were respiratory (7), infections (5), and acute kidney injury (5). The median hospital length of stay was 7 days. Five patients died in hospital (none with isolated CABG) with a preoperative New York Heart Association classification (NYHA) of III-IV, a cardiopulmonary bypass time of 175.2 min and an aortic cross-clamp time of 104.0 min. The long-term survival data were recorded with a mean follow-up of 7.3 ± 7.1 years (range from 0 to 19). The overall, 5-year survival, was 50% for all cardiac surgeries, 71% for isolated CABG surgeries, and 17% for CABG + AVR surgeries, respectively. CONCLUSION: Post-pneumonectomy patients have acceptable postoperative outcomes and survival. Simple and short surgeries with careful planning can yield favorable outcomes for this high-risk subgroup of patients.

Transitioning to Del Nido cardioplegia for all-comers: the next switching gear?

BACKGROUND: Exclusive use of Del Nido cardioplegia administration in all adult patients undergoing cardiac surgery has been studied for operative, postoperative and myocardial protection outcomes. METHODS: From November 2016 to October 2017, Del Nido cardioplegia was used in 131 consecutive patients (DN group). Using a propensity score, DN group was compared to 251 patients having received intermittent cold blood cardioplegia (CB group). RESULTS: Preoperative characteristics were similar in DN and CB groups. Operative outcomes were statistically different (p < 0.0001): cardiopulmonary bypass (CPB) time (DN 105.9 ± 46.5, CB 131.2 ± 38.8); aortic cross-clamp time (DN 80.8 ± 35.5, CB 102.2 ± 31.3); operative time (DN 203.1 ± 65.0, CB 241.5 ± 54.7); total cardioplegia volume (DN 1328 ± 879, CB 3773 ± 1226); and peak glycemia on CPB (DN 8.2 ± 2.3, CB 9.0 ± 1.8). No statistical differences were noted in intensive care unit stay, hospital stay and hospital death. Myocardial protection outcomes were similar: discharge left ventricular ejection fraction (DN 52 ± 11, CB 51 ± 10); Troponin levels at the end of the surgery (DN 871 ± 1623, CB 1958 ± 854), day 1 (DN 853 ± 1139, CB 993 ± 8234) and day 4 (DN 442 ± 540, CB 463 ± 317). CONCLUSION: Del Nido cardioplegia use in all adult cardiac surgeries is associated with improved surgical efficiency. The design of larger trials including adults combined cardiac procedures and emergencies is needed.

Large Intramural Aortic Hematoma with Intimal Tear.

A 72-year-old man presented with excruciating epigastric pain. A chest computed tomography angiography revealed an aortic intramural hematoma. A filling defect within the distal ascending aorta was noted. Images of an intramular hematoma and surgical details of an ascending aortic replacement under deep hypothermic circulatory arrest are provided.

Caseous Calcification of the Mitral Annulus: A Role for Surgery.

An 80-year-old man followed for aortic stenosis was found to have an intracardiac mass. Multiple imaging modalities were inconclusive in characterizing the mass but raised concerns about the potential malignancy of the mass. Fear of operating on an elderly patient with a potential for cardiac neoplasia led to a percutaneous transseptal biopsy that failed to provide a clear diagnosis. Cardiac valvular surgery was performed in addition to excisional biopsy of the mass that turned out to be caseous necrosis of mitral annular calcifications.

Concurrent Epicardial Cardiac Resynchronization at Time of Complicated Biventricular Device Extraction: A Potentially Life-Saving Option.

A 60-year-old man with cardiac resynchronization therapy defibrillator (CRT-D) lead endocarditis underwent transvenous lead extraction that was complicated by coronary sinus laceration and tamponade. Severe left ventricular dysfunction and unstable hemodynamic parameters persisted after emergent sternotomy, drainage, and repair. Reinstitution of cardiac resynchronization therapy with an epicardial device resulted in immediate hemodynamic improvement. Our case illustrates the potentially life-saving nature of single-stage extraction and reimplantation in resynchronization responders.

Neonatal Cardiac Arrest From Left Ventricular Cardiac Hemangioma: A Surprising Presentation.

Cardiac hemangioma is rare, even more when leading to a cardiovascular collapse in a seemingly healthy newborn. A 6-day-old neonate had a tamponade caused by a basolateral hemangioma of the left ventricle. Partial surgical resection was performed. A congenital lobular capillary hemangioma was diagnosed upon histologic examination. The patient recovered completely and shows normal development at the 12-month follow-up.

Early diaphragmatic plication after cardiac surgery: a case report in an obese patient.

BACKGROUND: Diaphragmatic plication to help ventilation weaning of an adult obese patient after cardiac surgery is very uncommon. Diaphragm paralysis is usually treated with conservative measures and ventilator support, after which surgical management is considered after months of medical monitoring. CASE PRESENTATION: We report the case of a morbidly obese patient to whom ventilation weaning was unsuccessful following coronary artery bypass graft operation with mitral valve replacement. A de novo right hemidiaphragm elevation was seen on the chest X-ray. Diaphragmatic plication was performed promptly to treat severe respiratory insufficiency and generated favorable outcomes. CONCLUSIONS: Early diaphragmatic plication could be considered in the postoperative period of cardiothoracic surgery to facilitate management and ventilation weaning in the context of de novo diaphragm paralysis.

Post esophagectomy diaphragmatic hernia: a case report of a rare cause of acute respiratory distress.

BACKGROUND: Diaphragmatic hernia is frequent among the elderly and is usually associated with mild chronic digestive and respiratory symptoms. CASE PRESENTATION: An elderly post-esophagectomy male patient, in the early postoperative period of cardiac surgery, presented with acute respiratory distress. An emergent surgery was performed to reduce a giant diaphragmatic herniation. CONCLUSIONS: An acute transhiatal herniation can cause serious respiratory impairment; surgical repair should be considered in select patients of cardiac surgery.

Mitral Annular Calcification and Mitral Valve Replacement: A New Approach.

Mitral valve replacement is technically challenging in the context of mitral annular calcification. A new surgical strategy is described that was used in a 71-year-old obese patient, where intraatrial prosthesis insertion and valve fixation into native uncalcified structures were performed without calcium debridement.

Anomalous Left Coronary Artery From the Pulmonary Artery: Masquerading as Peripartum Cardiomyopathy.

Diagnosed with peripartum cardiomyopathy 8 years earlier, a 45-year-old woman had sudden cardiac death. After resuscitation, the patient was diagnosed with an anomalous origin of the left coronary artery from the pulmonary artery and underwent a successful coronary repair. The management of a patient with clinical features of cardiomyopathy is reviewed.

Buttocks Hard as Rocks: Not Wanted after Aortic Dissection Repair.

The authors report the case of a patient developing a gluteal compartment syndrome after DeBakey type I dissection repair. Prompt recognition and treatment led to successful results. The surgical approach to the gluteal compartment is described.