Left atrial appendage aneurysm with paroxysmal atrial fibrillation.

Aneurysm of the left atrial appendage is extremely rare, and afflicted patients most commonly present with atrial tachyarrhythmia or thromboembolism. For these patients, resection of the aneurysm is the recommended and preferred therapy. We present the case of a 57-year-old woman who was found incidentally to have a large aneurysm of the left atrial appendage presenting as atrial fibrillation. After surgical intervention with resection of the aneurysm and a Cox maze III procedure, the patient recovered and was discharged in sinus rhythm.

Enhanced intracellular heat shock protein 70 expression of leukocytes and serum interleukins release: comparison of on-pump and off-pump coronary artery surgery.

BACKGROUND: Coronary artery bypass grafting (CABG) employing cardiopulmonary bypass (CPB; "on-pump" technique) is known to induce a systemic inflammatory response and heat-shock protein 70 kDa (HSP70) expression. The objective of the present study was to investigate the perioperative intracellular HSP70 expression of leukocytes and serum interleukin (IL) release in CABG conducted with both on-pump and off-pump techniques. METHODS: Thirty-seven patients referred for elective CABG were enrolled in this study. These patients were categorized into the following three groups: on-pump cardioplegic arrest (n = 12); on-pump beating heart (n = 13); and off-pump (n = 12). Blood samples were collected at four time points during the perioperative period. Enzyme-linked immunosorbent assay (ELISA) was used to determine the serum level of IL-8, IL-10, IL-12, and HSP70. Flow cytometric analysis of intracellular HSP70 was performed in populations of lymphocytes, monocytes, and granulocytes. RESULTS: The clinical outcomes were comparable among the three groups. Elevated serum IL-8, IL-10, IL-12 were found in all three groups during the perioperative period. Serum HSP70 was elevated in all three groups and was significantly lower in the off-pump group than in the on-pump cardioplegic arrest and on-pump beating-heart groups. Heat shock protein-70 expression was found in leukocytes and showed a faster response in monocytes and granulocytes than in lymphocytes. The inflammatory response in the off-pump group was less than in either of the on-pump groups. CONCLUSIONS: During the perioperative period, activation of inflammatory response was associated with enhanced expression of HSP70 within leukocytes in CABG patients.

Coronary artery fistula detected by 64-slice multidetector computed tomography: case report.

Coronary artery fistula (CAF), a rare anomaly of a coronary artery, is defined as an anomalous communication between a coronary artery and a cardiac chamber or vessels. Coronary angiography remains the main modality for diagnosing CAF. We present a case of fistulous communication between the left anterior descending coronary artery and the main pulmonary artery. The exact anatomy of the fistula was demonstrated by 64-slice multidetector computed tomography (MDCT). Surgical ligation on a beating heart was carried out. Intraoperative Doppler flow detection was used to evaluate the shunt of the CAF. We prefer MDCT as a new diagnostic modality to provide the detailed anatomy of a CAF.

Monotherapy with anti-CD20 monoclonal antibody in a heart transplant recipient with sick sinus syndrome and posttransplantation lymphoproliferative disorder: a case report.

Posttransplantation lymphoproliferative disorder (PTLD) is a serious complication of organ transplantation, with an incidence of 0.8% to 20% in heart transplant (HTx) recipients, and standard treatment may be too toxic in some cases. Rituximab is an anti-CD20 monoclonal antibody that has demonstrated efficacy in patients with various lymphoid malignancies and has been demonstrated effective in combination with chemotherapy regimens such as CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone). Cardiotoxicity with CHOP remains a major concern for treating HTx recipients with PTLD, however. We present a case of an HTx recipient with sick sinus syndrome and PTLD who was successfully treated with rituximab alone, avoiding the cardiotoxicity of CHOP. The cardiotoxicity induced by CHOP should be kept in mind in HTx recipients with PTLD, especially when there is an existing heart problem in such recipients. Monotherapy with rituximab can be considered a safe choice.

Coronary artery spasm after off-pump coronary artery bypass grafting.

BACKGROUND: Coronary artery spasm (CAS) in the immediate postoperative period has been recognized as a possible cause for perioperative myocardial ischaemia after off-pump coronary artery bypass grafting (CABG). It varies in severity and can be associated with circulatory collapse and death. The purpose of this study was to present our experiences on CAS after off-pump CABG and detail its management. METHODS: The case reports of three patients with similar clinical presentations of ischaemic heart disease who underwent CABG using an off-pump technique are reviewed. Severe manifestations of CAS in the immediate postoperative period with documented angiographic findings are presented. RESULTS: Three patients (two men and one woman) with angina pectoris were diagnosed with coronary artery disease using coronary angiography. The elective off-pump CABG was uneventful; however, severe manifestation of myocardial ischaemia with abrupt onset developed at the intensive care unit. All three patients underwent immediate coronary angiography to verify the diagnosis of CAS. Apart from intracoronary nitroglycerine infusion and medical support with inotropic agents, extracorporeal membranous oxygenation was carried out because of severe haemodynamic deterioration in one case, while support was required with intraaortic balloon pumping in another. All three patients made a full recovery. CONCLUSION: Coronary artery spasm can severely complicate the postoperative course for patients undergoing off-pump CABG, leading to myocardial ischaemia or infarction, life-threatening arrhythmias, persistent hypotension and even cardiac arrest. Early awareness and diagnosis of CAS with the establishment of appropriate management strategies may prevent its potentially lethal consequences.

Successful treatment of Salmonella mycotic aneurysm of the descending thoracic aorta.

Salmonella mycotic aneurysms of the descending thoracic aorta are exceedingly rare. There are few case reports and even fewer reports of long term survival. The case of a 68-year-old female presenting with a mycotic aneurysm of the descending thoracic aorta caused by Salmonella species is described, which involved successful surgical intervention.

Off-pump technique in coronary artery bypass grafting in elderly patients.

BACKGROUND: The use of cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG) is associated with substantial morbidity and mortality, especially in the elderly. The purpose of this study was to evaluate the feasibility of beating heart coronary artery revascularization in patients aged at least 80 years. METHODS: A retrospective chart review was carried out for 17 patients aged over 80 years who underwent isolated off-pump CABG at the Tri-Service General Hospital, Taiwan, during the period July 1999 to December 2000. The demographic characteristics, operative data, postoperative results and short-term outcomes of patients were compared with those of 12 patients who underwent conventional CABG using CPB during the same time period. RESULTS: The off-pump group consisted of 13 men and four women with a mean age of 82.2 +/- 0.9 years and an ejection fraction of 53.4 +/- 4.1%. The on-pump group consisted of eight men and four women with a mean age of 83.5 +/- 0.5 and an ejection fraction of 42.0 +/- 4.8%. The mean number of anastomoses performed per patient was 3.1 +/- 0.3 in the off-pump group and 3.0 +/- 0.14 in the on-pump group. There was no occurrence of stroke, myocardial infarction, re-entry for bleeding or renal failure among patients in the off-pump group. Intubation time (10.6 vs 48.4 h), intensive care unit stay (2.9 vs 4.2 days) and postoperative stay (12.7 vs 18.1 days) were significantly shorter in the off-pump group than in the on-pump group. No patient died in the off-pump group, whereas one patient died in the on-pump group. CONCLUSIONS: The results of this study suggest that the off-pump technique is a safe and efficacious method for myocardial revascularization in elderly patients and that the short-term outcome obtained with this technique are promising. Our data suggest that the off-pump technique is preferable in these patients.

Congenital coronary artery fistulas: clinical considerations and surgical treatment.

BACKGROUND: Coronary artery fistulas are uncommon abnormalities that can cause significant cardiac morbidity. Indications for operation vary, particularly, for asymptomatic patients. Early surgical correction is indicated because of the high incidence of late symptoms and complications. METHODS: From January 1981 to December 2001, all 15 patients who underwent surgical management of congenital coronary artery fistulas at the Tri-Service General Hospital, Taipei, Taiwan, China were included in the present retrospective study. RESULTS: Twelve patients were symptomatic at the time of the diagnosis. Coronary artery fistulas involved the right coronary artery in five patients, left coronary artery in nine, and both the right and the left coronary arteries in one. Coronary artery fistula drained into the right ventricle in seven patients, right atrium in three, pulmonary artery in two, left ventricle in one, left atrium in two, and coronary venous sinus in one. The value of pulmonary blood flow/systemic blood flow ranged from 0.98 to 2.1. Six patients had associated cardiac anomalies. All patients received surgical correction. Nine patients received cardiopulmonary bypass during operation. There was zero operative mortality and operative morbidity was low. All patients had a stable condition and were asymptomatic during a mean postoperative follow-up of 13.3 years. CONCLUSIONS: Early surgical treatment for coronary artery fistulas is safe and effective. The risk of operative correction appears to be considerably less than the potential for development of serious and potentially fatal complications, even in asymptomatic patients.

Infective endocarditis from Streptococcus viridans associated with colonic carcinoma: a case report.

Streptococcal bacteremia is an uncommon presentation for colorectal malignancy, yet most physicians would probably be aware of the association between Streptococcus bovis infection and such malignancy; however, many physicians may be unaware that other streptococcal species are also associated with colon and rectal cancers. We describe a 62-year-old male with adenocarcinoma of the sigmoid colon with the presentation of infective endocarditis due to infection by Streptococcus viridans, and we also report on the condition's successful treatment.

Perforated periaortic valve abscess presents as acute pericarditis and patient died in transesophageal echocardiographic study.

Rupture of infective endocarditis-associated perivalvular abscess of left ventricular outlet leading to death is a rare complication of transesophageal echocardiography. We report a case of impending rupture periaortic valve abscess of left ventricular outlet that was initially diagnosed as acute pericarditis at the emergency department in which the patient suddenly collapsed during the ongoing procedure of transesophageal echocardiography. Emergency surgical intervention was performed, but in vain. Destructive aortic valve and rupture of the periaortic valve abscess were found.

Ruptured congenital sinus of valsalva aneurysms.

BACKGROUND AND AIM OF THE STUDY: Rupture of the sinus of Valsalva is rare, and there is a higher incidence of such rupture in Oriental countries than elsewhere. The objective of this study is to present the pathologic features and the clinical outcome after surgery in such patients. METHODS: Between 1980 and 2001, a total of 17 patients (15 males and 2 females) with ruptured aneurysm of sinus of Valsalva underwent surgical intervention at the Tri-Service General Hospital, Taiwan. Their age ranged from 22 to 59 years with a mean of 33.5 years. These surgical operations made up 0.51% of the total cardiac operations (3305) performed during this period. The medical records were retrospectively reviewed. RESULTS: The origin of the ruptured aneurysm of the sinus of Valsalva was the right coronary sinus in 12 patients, the noncoronary sinus in 4, and the left coronary sinus in one patient. The aneurysms ruptured into the right ventricle in 12 patients, into the right atrium in 3 patients, and into the left ventricle in 2 patients. Associated cardiac anomalies were aortic regurgitation in eight patients, ventricular septal defect in seven, and coronary artery fistula in one patient. There was no early postoperative death and one patient underwent a second operation after aneurysm of the sinus of Valsalva (ASV) relapse. CONCLUSIONS: The operation for a ruptured aneurysm of sinus of Valsalva carries a low operative risk and results in excellent long-term survival after surgical treatment.