Pulmonary artery dissection.

Pulmonary artery dissection is a rare and life-threatening event, usually a complication of chronic pulmonary hypertension leading to pulmonary artery aneurysm. We review the literature on this subject.

Combined thoracic endovascular aortic repair and neurosurgical intervention for injury due to posterior spine surgery.

Aortic injuries represent a rare but life-threatening complication of spinal surgery. Perforation of the aorta due to pedicle screw penetration or misplacement can lead to immediate bleeding with hemodynamic instability or to pseudoaneurysm development with delayed risk of rupture, which can occur weeks to months later. Recently, thoracic endovascular aortic repair (TEVAR) in aortic trauma has contributed to a reduction of both mortality and morbidity. The literature on this subject is reviewed.

Case Report: Right atrial organized thrombus three years after tricuspid annuloplasty.

Background: Occurrence of right atrial masses, especially in patients with history of cardiac surgery, is rare. Differential diagnosis between malignant and non-malignant aetiologies might be cumbersome, and surgery is often required to prevent complications or disease evolution. Case: We report the case of a 16-year-old girl from a rural area of Sudan, who underwent surgery for a modified De Vega's tricuspid annuloplasty, and mitral and aortic valve replacement with mechanical prostheses. The patient was on regular follow-up but demonstrated a poor compliance to anticoagulation therapy with a time in therapeutic range between 52% and 20%. She remained asymptomatic, but a right atrial mass was diagnosed by transthoracic echocardiography during a follow-up visit 41 months after the first operation. Surgical removal of the mass revealed an organized thrombus arising from the point where the Prolene stitches for the tricuspid annuloplasty were previously passed. The patient recovered from surgery, was discharged home on post-operative day 10 and the first follow-up visit at 30 days after discharge confirmed a good clinical status and a normal transthoracic echocardiography (TTE). Conclusions: This case report describes the diagnostic and therapeutic work-out of a thrombus formation on the suture lines of a tricuspid annuloplasty. Moreover, it highlights the importance of a strict and long follow-up after valvular surgery and of the adherence to anticoagulation therapy, especially for patients living in rural areas of developing countries.

Ministernotomy with subclavian extension for the management of a large intrathoracic pseudoaneurysm.

We report on the management of a large intrathoracic subclavian pseudoaneurysm treated using an upper J ministernotomy with subclavian extension. This approach allows exposure of the supraaortic vessels and upper portion of the thoracic cavity and may be of help in selected cases.

Simple open-heart surgery protocol for sickle-cell disease patients: a retrospective cohort study comparing patients undergoing mitral valve surgery.

OBJECTIVES: Sickle-cell disease (SCD) patients are considered to be at high risk from open-heart surgery. This study assessed the role of a simple sickling-prevention protocol. METHODS: Perioperative non-specific and SCD-specific morbidity and 30-day mortality are investigated in a retrospective cohort study on patients undergoing isolated mitral valve surgery. Patients with and without SCD were compared. In the SCD cohort, a bundle of interventions was applied to limit the risk of sickling: 'on-demand' transfusions to keep haemoglobin levels of around 7-8 g/dl, cardiopulmonary bypass (CPB) with higher blood flow and perfusion temperature, close monitoring of acid-base balance and oxygenation. RESULTS: Twenty patients with and 40 patients without SCD were included. At baseline, only preoperative haemoglobin levels differed between cohorts (8.1 vs 11.8 g/dl, P < 0.001). Solely SCD patients received preoperative transfusions (45.0%). Intraoperative transfusions were significantly larger in SCD patients during CPB (priming: 300 vs 200 ml; entire length: 600 vs 300 ml and 20 vs 10 ml/kg). SCD patients had higher perfusion temperatures during CPB (34.7 vs 33.0°C, P = 0.01) with consequently higher pharyngeal temperature, both during cooling (34.1 vs 32.3°C, P = 0.02) and rewarming (36.5 vs 36.2°C, P = 0.02). No mortality occurred, and non-SCD-specific complications were comparable between groups, but one SCD patient suffered from perioperative cerebrovascular accident with seizures, and another had evident haemolysis. CONCLUSIONS: SCD patients may undergo open-heart surgery for mitral valve procedures with an acceptable risk profile. Simple but thoughtful perioperative management, embracing 'on-demand' transfusions and less-aggressive CPB cooling is feasible and probably efficacious.

Oral anticoagulant management of patients with mechanical heart valves at the Salam Centre of Khartoum: Observations on quality of anticoagulation and thrombotic risk.

INTRODUCTION: Rheumatic heart disease with mechanical heart valve (MHV) replacement is common in Africa. However, MHV requires long-life anticoagulation and managing this can be challenging. METHODS AND RESULTS: We report data of a prospective observational study conducted between August 2018 and September 2019 in MHV patients in the Salam Centre for Cardiac Surgery built in Khartoum, by Emergency, an Italian Non-Governmental Organization, to evaluate the quality of anticoagulation control and the risk of thrombotic complications. RESULTS: We studied 3647 patients (median age 25.1 years; 53.9 % female). Median Time in Therapeutic Range (TTR) was 53 % (interquartile range 37 % to 67 %) and 70 thrombotic events (rate 1.8 × 100 pt-years [95 % CI 1.38-2.23]) were recorded. Among patients in the first quartile of TTR (≤37 %), we recorded 34/70 (48.6 %) of all thrombotic events (rate 3.7 × 100 pt-years [95 % CI 2.5-5.1]), with a high mortality rate (2.2 × 100 pt-years [95 % CI 1.3-3.3]). In patients with guideline-recommended TTR (≥65 %) the event rate was 0.8 × 100 pt-years for thrombotic events [95 % CI 0.3-1.5] and 0.4 × 100 pt-years for mortality [95 % CI 0.1-0.9]. Multivariable analysis showed that having a TTR in the lowest quartile (≤37 %) and being noncompliant are significantly associated with increased thrombotic risk. Aspirin use or different valve type did not influence the thrombotic risk. Almost 40 % of all thromboembolic complications could have been potentially prevented by further improving VKA management to obtain a TTR > 37 %. CONCLUSION: The thrombotic risk of MHV patients on VKAs living in a low-income country like Sudan is associated with low quality of anticoagulation control. Efforts should be made to decrease the number of non-compliant patients and to reach a guideline-recommended TTR of ≥65 %.

Incidence of neoplastic disease in cardiac allograft recipients.

Incidence of neoplastic disease represents a serious complication after heart transplantation. In this review, the authors discuss the incidence, causes, and types of tumors in cardiac allograft recipients. Prevention and tumor monitoring for early treatment are highlighted.

Immunology insights into cardiac allograft rejection.

Despite long-term complications from chronic immunosuppressive therapy, the phenomenon of chronic rejection is still a limitation in cardiac allograft recipients. In this review, starting from basic immunologic concepts, we analyze the mechanisms involved in rejection following heart transplantation, with particular emphasis on chronic rejection manifested as cardiac allograft vasculopathy (CAV). Etiopathogenesis of CAV and diagnostic imaging studies are also discussed.

Open aortic arch surgery: how to reduce air embolism risk during antegrade cerebral perfusion.

Antegrade cerebral perfusion (ACP) is used widely, with the aim of obtaining cerebral protection during open aortic arch surgery. ACP is considered by many to be the reason for improvements in the clinical outcome of this type of surgery. However, perioperative cerebral complications may still occur. Cerebral complications during ACP are considered to be due mainly to embolic events rather than hypoperfusion. We believe that many of the embolic events during ACP may be due to air embolism rather than to vessel manipulation only. To reduce the risk of air embolism during ACP, we propose an easy technique, with the suggested steps to be followed in an exact sequence.

Treating Children With Advanced Rheumatic Heart Disease in Sub-Saharan Africa: The NGO EMERGENCY's Project at the Salam Centre for Cardiac Surgery in Sudan.

Rheumatic heart disease is endemic in Sub-Saharan Africa and while efforts are under way to boost prophylaxis and early diagnosis, access to cardiac surgery is rarely affordable. In this article, we report on a humanitarian project by the NGO EMERGENCY, to build and run the Salam Centre for Cardiac Surgery in Sudan. This hospital is a center of excellence offering free-of-charge, high-quality treatment to patients needing open-heart surgery for advanced rheumatic and congenital heart disease. Since it opened in 2007, more than 8,000 patients have undergone surgery there; most of them Sudanese, but ~20% were admitted from other countries, an example of inter-African cooperation. The program is not limited to surgical procedures. It guarantees long-term follow-up and anticoagulant treatment, where necessary. By way of example, we report clinical features and outcome data for the pediatric cohort: 1,318 children under the age of 15, operated on for advanced rheumatic heart disease between 2007 and 2019. The overall 5-year survival rate was 85.0% (95% CI 82.7-87.3). The outcomes for patients with mitral valves repaired and with mitral valves replaced are not statistically different. Nevertheless, observing the trend of patients undergoing valve repair, a better outcome for this category might be assumed. RHD in children is an indicator of poor socio-economic conditions and an inadequate health system, which clearly will not be cured by cardiac surgery alone. Nevertheless, the results achieved by EMERGENCY, with the crucial involvement and participation of the Sudanese government over the years, show that building a hospital, introducing free cardiac surgery, and offering long-term post-operative care may help spread belief in positive change in the future.

Surgery for acute aortic dissection: an easy and cheap method to reinforce the anastomosis.

Bleeding from the anastomotic site is a frequent complication of surgery for acute aortic dissection. Many methods have been devised in order to avoid this problem. We report a simple, easy technique to reinforce the anastomotic sites. One small 4-mm-high ring is cut from the same prosthesis and placed circumferentially inside the aorta edge. Another ring of the same width is opened in a "C" shape, and placed outside the aorta. The conduit was eventually sutured to the aorta in a standard fashion using a running 3-0 polypropylene suture. The final result appeared good with no bleeding, and the rim lines appear clearer and the edges easier to suture because the Dacron is thinner than other used materials (that is, Teflon). In our opinion, this technique is a simple method to reinforce the anastomosis for both proximal and distal aorta.

Transposition of the left carotid artery to the ascending aorta to repair aortic arch injury.

We present a case where we repaired the aortic arch, by the transposition of the left carotid artery to the ascending aorta. A 52-year-old man presented to our department with a penetrating chest wound by a gunshot in the attempt of suicide. The aortic arch and the insertion of the left carotid artery were involved in the lesion. Through sternotomic approach, the aortic arch was repaired in extracorporeal circulation. Left carotid artery was transected to allow easier repair of the arch posterior wall involved in the lesion, and to reduce the danger of residual stenosis. Then, it was translocated to the ascending aorta by interposing a 7-mm Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ, USA) conduit. The patient complicated renal failure and pneumonia in the postoperative period, but eventually he was discharged in good general conditions.

Treatment of malperfusion during surgery for type A aortic dissection.

During surgery for acute type A aortic dissection, malperfusion may occur during cardiopulmonary bypass. Retrograde perfusion trough femoral cannulation is considered a predisposing factor. However, this may occur even with antegrade perfusion, because of the presence of multiple flaps or compression of the true lumen by the false lumen. In this particular setting, the aim is to reach a perfusion of the true lumen of the dissected aorta. A technique of epicardial ultrasound-guided direct cannulation of the dissected aorta's true lumen by a Seldinger technique may help in those cases. We describe the technique with particular interest to the epicardial ultrasound control and the type of arterial cannula to be inserted by the Seldinger technique.

[Cardiac tamponade: a modified video-assisted thoracoscopic approach]. / Tamponamento cardiaco: approccio modificato in videotoracoscopia.

Pericardial effusion may lead to cardiac tamponade sometimes requiring surgical treatment. The aim of the study was to retrospectively analyse a group of patients with cardiac tamponade treated with a modified video-assisted thoracoscopy technique. We treated 15 patients (8 males and 7 females; mean age 63 years; range 24-80 years) with cardiac tamponade. All patients were treated by a modified video-assisted thorascopic approach on the right hemithorax, with the use of two trocars: a 15-mm trocar on the 4th right intercostal space on the anterior axillary, and a 10-mm trocar on the 7th right intercostal space on the median axillary line. We used a 5-mm optic, the size of which permitted the simultaneous use of two instruments through a single trocar (both for the optic and the endoscopic forceps), leaving the second trocar for the dissecting scissors. In all patients we obtained a pericardial resection equivalent to the one obtainable in an anterolateral thoracotomy. There was no intraoperative mortality or perioperative morbidity. Drainage of the pericardial effusion was effective in all cases. The modified video-assisted thoracoscopic technique on the right chest using two trocars seems a feasible surgical technique for patients suffering from cardiac tamponade.

Surgical management of severe damage of the aortic annulus.

Aortic annular erosion and abscess are serious complications of prosthetic aortic valve endocarditis and can be treated with aortic valve translocation and left ventricle outflow tract reconstruction. These two surgical techniques seem to have similar early postoperative outcomes, and their use can be considered an option after the failure of conventional surgical methods.