A case report of an ischaemic stroke, caused by a primary cardiac intimal sarcoma.

BACKGROUND: Intimal sarcomas are an extremely rare type of primary cardiac malignancy. They most commonly present with symptoms of cardiac dysfunction. We present a case of intimal sarcoma identified without any cardiac signs or symptoms. Cardiac sarcomas historically carry a very poor prognosis. PRESENTATION: A 57-year-old man presented with a sudden onset of left limb weakness and disorientation. MRI brain identified an acute ischaemic stroke in the right anterior temporal lobe. Four months later, he presented again with transient left arm weakness. The patient had a normal cardiovascular examination and ECG. All other initial investigations for cryptogenic stroke were non-contributory. The patient did not initially get an echocardiogram. When this investigation was performed, after his second presentation, a large pedunculated mass was present in his left atrium. This was resected and identified histologically as a primary intimal sarcoma of his left atrium. The patient was treated with post-operative radiotherapy but declined chemotherapy. He recovered well post-operatively but subsequently passed away 14 months after diagnosis. CONCLUSIONS: It is possible for primary cardiac malignancies to present with only symptoms of systemic emboli. For this reason, echocardiography is a crucial investigation in cases of cryptogenic stroke. Some stroke guidelines do not definitively support routine echocardiography. Primary intimal cardiac sarcoma is a very rare condition with a poor prognosis. The literature is limited to case reports and optimal management is with surgical resection where possible. The role of post operative radiotherapy and chemotherapy is uncertain.

Neuroprotection and Non-Invasive Brain Stimulation: Facts or Fiction?

Non-Invasive Brain Stimulation (NIBS) techniques, such as transcranial Direct Current Stimulation (tDCS) and repetitive Magnetic Transcranial Stimulation (rTMS), are well-known non-pharmacological approaches to improve both motor and non-motor symptoms in patients with neurodegenerative disorders. Their use is of particular interest especially for the treatment of cognitive impairment in Alzheimer's Disease (AD), as well as axial disturbances in Parkinson's (PD), where conventional pharmacological therapies show very mild and short-lasting effects. However, their ability to interfere with disease progression over time is not well understood; recent evidence suggests that NIBS may have a neuroprotective effect, thus slowing disease progression and modulating the aggregation state of pathological proteins. In this narrative review, we gather current knowledge about neuroprotection and NIBS in neurodegenerative diseases (i.e., PD and AD), just mentioning the few results related to stroke. As further matter of debate, we discuss similarities and differences with Deep Brain Stimulation (DBS)-induced neuroprotective effects, and highlight possible future directions for ongoing clinical studies.

Factors influencing left ventricular outflow tract obstruction following a mitral valve-in-valve or valve-in-ring procedure, part 1.

OBJECTIVES: To determine the factors influencing left ventricular outflow tract (LVOT) area reduction after a mitral valve-in-valve (VIV) or a valve-in-ring (VIR) procedure. BACKGROUND: Transcatheter heart valves (THVs) are increasingly used in performing a VIV or a VIR procedure in high-risk patients. Although less invasive, a potential complication is LVOT obstruction. However, the factors predisposing to LVOT obstruction are ill defined. METHODS AND RESULTS: To understand the effects of the various factors, the study was carried out in three parts: To understand the effect of VIV and VIR on reduction in LVOT area with special attention to different surgical heart valve (SHV) orientations and depth of THV implant. This was carried out in porcine and cadaver hearts. To quantify aorto-mitral-annular (AMA) angle in 20 patients with or without mitral disease and to derive a static computational model to predict LVOT obstruction. To study the effect of SHV design on LVOT obstruction after VIV. This was carried out as a bench test. LVOT area reduction was similar after VIV irrespective of orientation of the mitral SHV implantation as it pinned open the SHV leaflets. Similar effect was seen after VIR. The degree of LVOT obstruction was partly determined by AMAangle and was inversely proportional. SHV design, ring design, and depth of SPAIEN XT implantation also had effect on LVOT obstruction. CONCLUSIONS: A possibility of LVOT obstruction should be considered when performing a VIV and VIR procedure. Type of SHV, flexible ring, less obtuse AMA angle, and depth of SAPIEN XT implant can influence the risk.

Cardiac surgery simulation: a low-cost feasible option in an Australasian setting.

BACKGROUND: Simulation training is a useful adjunct to surgical training and education (SET) in Cardiothoracic Surgery yet training opportunities outside the Royal Australasian College of Surgery or industry-sponsored workshops are rare due to high cost and limited training faculty, time, assessment tools or structured curricula. We describe our experience in establishing a low-cost cardiac simulation programme. METHODS: We created low-cost models using hospital facilities, hardware stores, abattoirs and donations from industry. Three workshops were conducted on coronary anastomoses, aortic and mitral valve replacement. RESULTS: Whole porcine hearts were sourced from local farms. Industry donations of obsolete stock were used for suture and valve material-stations constructed using ironing-board, 2-L buckets and kebab-skewers. Suture ring holders were fashioned from recycled cardboard or donated. All participants were asked to complete pre and post simulation self-assessment forms. Across three workshops, 45 participants (57.8% female) with a median age 27 (interquartile range 24-31) attended. Training level consisted of nurses (8, 17.8%), medical students (17, 37.8%), residents/house officers (6, 13.3%) and registrars (14, 31.1%). There were improvements in knowledge of anatomy (mean difference 18%; 95% confidence interval 12%-24%), imaging (16%; 10%-22%) and procedural components (34%; 28%-42%); and practical ability to describe steps (30%; 24%-38%), partially (32%; 26%-38%) or fully complete (32%; 28%-38%) the procedure. CONCLUSIONS: Simulation-based training in cardiac surgery is feasible in a hospital setting with low overhead costs. It can benefit participants at all training levels and has the potential to be implemented in training hospitals as an adjunct to the SET programme.

Ischemic mitral valve regurgitation: the new challenge for magnetic resonance imaging.

Ischemic mitral valve regurgitation (IMVR) refers to mitral regurgitation in patients with ischemic heart disease (IHD) in the presence of a structurally normal mitral valve. IMVR contributes significantly to morbidity and mortality in patients with IHD. The thresholds for clinical management, surgical intervention, and the choice of surgical procedure continue to evolve and independent determinants for surgical success in the pre- and post-operative evaluation of IMVR are still controversial. Although echocardiography has been valued as the gold standard in the evaluation of IMVR, new technologies such as magnetic resonance imaging (MRI) may be seen as applicable to the investigation of this complex pathology. MRI may allow for detection of parameters that could help clinicians and surgeons to better assess IMVR and eventually guide appropriate treatment whenever necessary. The present article discusses the main parameters that should be routinely investigated while adopting MRI technology to assess patients with IMVR. The review is the result of a multidisciplinary approach to this complex etiopathogenic entity and involves expertise spanning from radiology, cardiology, to cardiac surgery.

Midterm follow-up dynamic echocardiography evaluation after aortic valve repair for aortic valve insufficiency.

We prospectively evaluated 46 patients who underwent aortic valve repair (AVR) for AV regurgitation. Rest/stress echocardiography follow-up was performed. Follow-up duration was 30.7 months, age 56 ± 14 years, ejection fraction% 57.5 ± 10.5%. Preoperative bicuspid AV was present in 14 (30.4%), leaflets calcifications in 8 (17.4%), thickening in 17 (37.0%) and prolapse in 22 (47.8%). Surgical technique included commissuroplasty (22, 47.8%), leaflet remodelling (17, 37.0%), decalcification (7, 15.2%) and raphe removal (14, 30.4%). At follow-up, rest/stress echocardiography median AV regurgitation (rest 1.0 vs. stress 1.0) and mean indexed AV area (IAVA) (rest 2.6 ± 0.74 cm(2)/m(2) vs. stress 2.8 ± 0.4 cm(2)/m(2)) were unchanged (P = ns). Mean (rest 4.7 ± 3.9 mmHg vs. stress 9.7 ± 5.8 mmHg) and peak (rest 9.5 ± 7.2 mmHg vs. stress 19.0 ± 10.5 mmHg) transvalvular gradients were significantly increased (P < 0.0001). At linear regression, there was an independent inverse correlation between commissuroplasty and AV gradients during stress (B = -9.9, P = 0.01, confidence interval= -17.7 to -2.1). Although follow-up haemodynamics of repaired AVs are satisfactory, there was a fixed IAVA and significant increase in AV gradients. We were not able to identify any pre-existing anatomical condition independently related to this non-physiological behaviour under stress. Moreover, commissuroplasty seems to prevent abnormal increase of the AV gradients.

Massive acute aortic regurgitation after infected pacemaker lead removal: a word of caution.

We report a case of massive acute aortic valve regurgitation in a 54-year-old man secondary to a percutaneous extraction of infected permanent pacemaker leads. This case emphasizes how carefully patients should be monitored during and after the procedure, regardless of their hemodynamic status. The patient successfully underwent urgent surgical intervention.

Iatrogenic hypoglycemia secondary to tight glucose control is an independent determinant for mortality and cardiac morbidity.

OBJECTIVE: Evaluation of the effects of tight glycemia control in critically ill patients should include temporal as well as punctual glycemia data. METHODS: Insulin drip was used to target intensive care unit (ICU) glucose levels between 80 and 126 mg dl⁻¹ in a consecutive series of adult cardiac surgery patients. ICU hourly glycemia was prospectively recorded. Glycemia standard deviation, hyperglycemia index (area under the curve for glycemia>126 mg dl⁻¹ divided by total hours in ICU), and hypoglycemic episodes were recorded and analyzed, together with outcomes. RESULTS: A total of 596 patients were included. Hypoglycemia occurred in 21% of the patients. In-hospital mortality was 2.6%. There was a univariate correlation between mortality and glycemia standard deviation, and hypoglycemia occurrence. At multivariate analysis, hypoglycemia was a determinant for mortality (p=0.002; odds ratio (OR)=20.0), respiratory failure (p=0.0001; OR=1.4), requirement of a tracheostomy (p=0.0001; OR=21.6), and hemodynamic instability requiring intra-aortic balloon pump (IABP) (p=0.01; OR=1.5). To clarify the determinants of hypoglycemia, a second multivariate model was built. Diabetes (p=0.0001; OR=23) and chronic renal failure (p=0.01; OR=25) were the sole determinants for hypoglycemia occurrence. CONCLUSION: Iatrogenic hypoglycemia secondary to ICU tight glycemia control correlates with hospital mortality, respiratory, and cardiac morbidity in patients undergoing cardiac surgery. ICU hyperglycemia index and glycemia temporal variability have no independent correlation with outcomes. Higher glycemia targets should be advised in the perioperative management of patients with diabetes and renal failure, as both conditions independently increase the risk of hypoglycemia occurrence.

Intraoperative validation of a new system for invasive continuous cardiac output measurement.

OBJECTIVE: Although bolus thermodilution technique for cardiac output (CO) measurement has widespread acceptance, new systems are currently available. We evaluated a continuous CO system (TruCCOMS, Aortech International Inc.) that operates on the thermal conservation principle and we compared it with the reference standard transit time flow measurement (TTFM). MATERIALS AND METHODS: Nine consecutive cardiac surgery patients were evaluated. After general anesthesia and intubation, a TruCCOMS catheter was percutaneously placed in the pulmonary artery (PA). After median sternotomy and pericardiotomy, a TTFM probe was placed around the main PA. Right ventricular (RV) CO measurements were recorded with both TruCCOMS and TTFM at different times: before cardiopulmonary bypass (CPB) (T0), during weaning from CPB (T1), and prior to sternal closure (T2). Data analysis included paired student t test, Pearson correlation test, and Bland-Altman plotting. RESULTS: TruCCOMS CO values were significantly lower at T0 (TruCCOMS 4.0 +/- 1.0 vs. TTFM 4.5 +/- 1.0 L/min; P < 0.0001) and T1 (TruCCOMS 3.6 +/- 0.5 vs. TTFM 4.2 +/- 0.7 L/min; P < 0.0001), and comparable at T2 (TruCCOMS 4.5 +/- 0.7 vs. TTFM 4.6 +/- 0.8 L/min; P = 0.4). Pearson test showed a significant correlation between TruCCOMS and TTFM CO measurements (RT0 = 0.9, RT1 = 0.8, RT2 = 0.6; P < 0.0001). Bland-Altmann plotting showed a bias of -0.53 +/- 0.43 L (-12%) at T0, -0.64 +/- 0.43 L (-14.5%) at T1, and -0.1 +/- 0.66 L (-0.8%) at T2. CONCLUSION: Although TruCCOMS may significantly underestimate CO, measurement trends correlate with TTFM. For this reason, a negative trend in RV output should trigger more specific diagnostic procedures.

Donor pharmacological hemodynamic support is associated with primary graft failure in human heart transplantation.

The aim of this study was to test the impact of donor and recipient characteristics on the development of primary graft failure (PGF) after heart transplantation (HT) by focusing on the donor's inotropic support. Heart donors and matched recipients data were prospectively collected. Univariate and multivariate analyses were used to determine independent predictors for PGF and peri-operative mortality. The donor's high inotrope requirement was defined as sustained need for dopamine exceeding 10 microg/kg/min and/or alpha agonists exceeding 0.06 microg/kg/min. PGF instead was defined as need for immediate post-HT mechanical circulatory support. Since 2006, we have performed 37 HTs. PGF occurred in six patients (16.2%). Although four patients (66.6%) were weaned off circulatory support, two of them (33.3%) died on mechanical assistance. Total in-hospital mortality was 10.8% (4/37). Upon multivariate analysis, pre-harvesting donor high inotrope dosage was the major determinant for PGF (P=0.03, OR=10.8). Given the organ shortage, many centers accepted marginal hearts assuming the donor's pre-harvest hemodynamic managing has a reduced impact on PGF development. As PGF remains the most lethal postoperative complication, the hazards should be carefully considered when using pre-harvesting high inotrope infusion rates.

Ischemic mitral valve regurgitation in patients with depressed ventricular function: cardiac geometrical and myocardial perfusion evaluation with magnetic resonance imaging.

OBJECTIVE: To investigate geometrical and functional changes involving the left ventricle (LV) and mitral valve (MV) apparatus in patients with depressed LV ejection fraction (LVEF) and ischemic MV regurgitation (IMVR). METHODS: A series of patients with three vessels coronary artery disease (CAD) and depressed LVEF underwent cardiac magnetic resonance imaging to investigate MV/LV geometry and function, and myocardial perfusion/vitality. Geometrical data were indexed by anterior MV leaflet length. Two groups were identified: CAD without IMVR (group CAD), and with IMVR (group IMV). RESULTS: Eleven patients were enrolled in the CAD group and 13 in the IMV group. IMVR volume was significantly higher in the IMV group (24.0+/-12.0 vs 4.5+/-5.2; p<0.0001). LVEF% was comparable (IMV 34.6+/-13.0 vs CAD 31.5+/-13.0; p=ns). Indexed MV/LV geometrical variables were comparable in the two groups. Perfusion/vitality study showed inferior myocardial necrosis occurred more often in the IMV group (p=0.01). At Pearson test, MV regurgitation occurrence correlated with inferior myocardial necrosis (r=0.5; p=0.006), non-indexed systolic/diastolic annular inter-commissural diameters (r=0.4; p=0.04) and MV annular areas (r=0.4; p=0.04). Papillary muscles distance (PMD) and LV volumes inversely correlated with LVEF% (r=-0.6; p<0.05 and r=-0.8; p<0.001). At multivariable analysis, no independent determinants for IMVR were identified and LV volumes were the sole determinants for LVEF% (p<0.05). CONCLUSION: In patients with depressed LVEF%, IMV cannot be explained by LV geometrical modifications alone. Although PMD, LV volumes, and LVEF% are correlated, they have no direct impact in the development of IMVR. In contrast, inferior myocardial necrosis and increased inter-commissural MV diameters may lead to deformity of MV complex and subsequent IMV.

Protruding left intercostal mass after left ventricular aneurysmectomy.

In this report we summarize a case of myocardial infarction that developed an apical ventricular aneurysm, which was surgically removed to re-expand and reappear as a pulsating chest wall mass 16 years later.

Left anterior descending coronary artery bridge: contraindication to cardiac transplantation?

We report two cases of cardiac transplantation of donor hearts with left anterior descending (LAD) myocardial bridging (MB). In the first case, the diagnosis was done only days after transplant. In the second case, a pre-operative angiography showed evidence of LAD myocardial bridging and the organ was used for a marginal recipient. Both patients tolerated the procedure very well and did not have peri-operative cardiac complications. In this study, MB is discussed and its relationship to rejection of donor hearts is evaluated. In light of the growing demand for donated hearts, and in consideration of the relatively high and often undiagnosed occurrence of MB, a liberalized approach to acceptance of this anatomic variant could be adopted in the selection of donor hearts. Identification of MB in the prospective donor heart should not be an absolute contraindication for transplantation.