RESUMO
We report a case of culture-negative aortic valve endocarditis secondary to Tropheryma whipplei infection. Our patient underwent aortic valve replacement after 4 weeks of antibiotic therapy with persistently negative blood culture results. Despite a technically uneventful operation, the patient showed continued sepsis and was unresponsive to a broad-spectrum of antibiotic therapy with subsequent multiorgan failure. He died on the 5th postoperative day, and diagnosis was established at postmortem examination. In this case report, we discuss the diagnosis and treatment of a rare type of endocarditis caused by T. whipplei.
Assuntos
Valva Aórtica/cirurgia , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/cirurgia , Tropheryma , Doença de Whipple , Antibacterianos/administração & dosagem , Endocardite Bacteriana/complicações , Endocardite Bacteriana/tratamento farmacológico , Evolução Fatal , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Doenças RarasRESUMO
INTRODUCTION: Arterial graft physiology influences the long-term outcome of coronary artery bypass grafting (CABG). We studied factors that can affect the overall resistance to flow using internal mammary artery grafting to the left anterior descending artery. METHODS: This was a prospective, nonrandomized observational study of 100 consecutive patients who underwent elective on-pump isolated or combined valve surgery and CABG. Coronary stenoses were assessed using conventional and quantitative coronary angiography assessment. The flow and pulsatility index (PI) of the grafts were assessed by transit-time flowmetry during cardioplegic arrest and at the end of the operation. Fractional polynomials were used to explore linearity, followed by multivariable regression analysis. RESULTS: Univariate analysis demonstrated higher flows at the end of the operation in patients who had higher flows with the cross-clamp on (P < .001), in males (P = .004), in patients with a low PI at the end of the operation (P = .04), and in patients with a larger size of the recipient artery (P = .005). Multivariable regression analysis showed that the graft flow at the end of the operation was significantly associated with the mean flow with the cross-clamp on (P < .001), sex (P = .003), and PI at the end of the operation (P = .003). Concomitant valve surgery did not influence flows. Male patients had 18 mL/min higher flow. CONCLUSIONS: The graft flow at the end of the operation can be determined by the flow with the cross-clamp on, the PI with the cross-clamp off and coronary artery. We reported differences in the graft flows between sexes, and for first the time, we introduced the concepts of "adequate flow" and "resistance-to-forward-flow" for patent coronary grafts.
Assuntos
Ponte de Artéria Coronária/métodos , Artéria Torácica Interna/transplante , Grau de Desobstrução Vascular , Idoso , Velocidade do Fluxo Sanguíneo , Feminino , Humanos , Masculino , Artéria Torácica Interna/fisiologia , Análise Multivariada , Caracteres SexuaisRESUMO
Spontaneous coronary artery dissection is a rare condition usually encountered in young women without risk factors for atherosclerotic disease but with tortuous coronary artery or contemporary presence of fibromuscular dysplasia. Sometimes spontaneous coronary dissection occurs in patients with atherosclerotic disease, although without significant epicardial coronary artery stenosis. We report a case of a patient who underwent minimally invasive mitral valve repair, whose initially uneventful postoperative course was complicated by spontaneous coronary artery dissection of the left main causing a life threatening condition. A subsequent emergency sternotomy was required to perform a coronary artery bypass.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Anomalias dos Vasos Coronários/etiologia , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Complicações Pós-Operatórias , Doenças Vasculares/congênito , Idoso , Ponte de Artéria Coronária , Anomalias dos Vasos Coronários/cirurgia , Feminino , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Doenças Vasculares/etiologia , Doenças Vasculares/cirurgiaRESUMO
Familial hypercholesterolemia is an inherited disorder with incidences of approximately 1:500 and 1:1,000,000 in heterozygous and homozygous form respectively. Affected patients usually show early coronary artery disease and severe aortic root calcification, despite optimization of therapy. We report a case of a 64-year-old woman affected by heterozygous familial hypercholesterolemia which presented dyspnea and anginal symptoms due to a severely calcified aortic root causing valve stenosis and narrowed sinotubular junction. Aortic valve replacement and aortic root enlargement were performed using the Manougian procedure. Even for experiences surgeons, this surgery could prove challenging for this group of patients due to aggressive degenerative tissue calcification of the aortic root, which often presents an extremely calcified aortic valve with a small annulus associated to a narrowed sinotubular junction.
Assuntos
Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Remoção de Dispositivo/métodos , Próteses Valvulares Cardíacas , Hiperlipoproteinemia Tipo II/diagnóstico , Hiperlipoproteinemia Tipo II/cirurgia , Estenose da Valva Aórtica/etiologia , Feminino , Humanos , Hiperlipoproteinemia Tipo II/complicações , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
INTRODUCTION: Some evidence suggests that surgical minimally invasive (MIDCAB) and hybrid coronary revascularization (HCR) are safe and potentially effective at short-term follow-up. Data on long-term outcomes are more limited and inconclusive. METHODS: Between February 2013 and December 2023, a total of 1997 patients underwent surgical coronary artery revascularization at our institution, of whom, 92 (4.7%) received left anterior mini-thoracotomy access (MIDCAB), either isolated (N = 78) or in combination with percutaneous coronary intervention (N = 14, HCR group). RESULTS: After a median follow-up of 75 months (range 3.1: 149 months), cardiac mortality was 0% while overall mortality was 3%, with one in-hospital mortality and two additional late deaths. Conversion to sternotomy happened in two patients (2.1%), and surgical re-explorations occurred in five patients (4.6%), of whom three for bleeding and two for graft failure. All patients received left internal mammary (LIMA) to left anterior descending artery (LAD) grafting (100%). In the HCR group, 10 patients (72%) showed percutaneous revascularization (PCI) after MIDCAB, showing PCI on a mean of 1.6 ± 0.6 vessels and implanting 2.1 ± 0.9 drug-eluting stents. CONCLUSIONS: MIDCAB, in isolation or in association with hybrid coronary revascularization, is associated with encouraging short- and long-term results in selected patients discussed within a dedicated heart-team.
Assuntos
Injúria Renal Aguda/etiologia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Procedimentos Endovasculares/métodos , Oclusão de Enxerto Vascular/complicações , Stents/efeitos adversos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/cirurgia , Dissecção Aórtica/diagnóstico , Aneurisma da Aorta Torácica/diagnóstico , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Tomografia Computadorizada por Raios XRESUMO
The incidence of bacterial endocarditis (BE) during pregnancy is about 0.01%, while maternal and fetal mortality rates due to BE are 22% and 15%, respectively. Fetal survival is <15% until week 25 of gestation, and cesarean delivery is recommended before cardiopulmonary bypass in the third trimester. The case is described of a 24-year-old woman (a known drug addict), gravida 1, para 0, at week 22 of gestation, with an acute mitral valve endocarditis caused by Staphylococcus aureus. Following urgent mitral valve replacement, the strategy for fetal survival involved reducing the hemodilution and scavenging the cardioplegia solution from the right atrium, avoiding deep hypothermia to minimize rewarming, and maintaining a high pump flow rate (>2.5 l/min/m2) with a mean perfusion pressure of 70 mmHg, using pulsatile perfusion. The patient had an uneventful postoperative course, and at 34 weeks' gestation a normal newborn of 1780 g was delivered by cesarean section. No controlled clinical trials using extracorporeal circulation during pregnancy have been conducted, and reports are limited to single cases. A strategy was proposed to manage the present case of uncontrolled maternal BE at an early gestational age, by addressing several factors that would influence the outcome for both mother and baby.
Assuntos
Endocardite Bacteriana/cirurgia , Implante de Prótese de Valva Cardíaca , Valva Mitral/cirurgia , Complicações Cardiovasculares na Gravidez/cirurgia , Complicações Infecciosas na Gravidez/cirurgia , Abuso de Substâncias por Via Intravenosa/complicações , Antibacterianos/uso terapêutico , Cesárea , Endocardite Bacteriana/microbiologia , Feminino , Idade Gestacional , Parada Cardíaca Induzida , Humanos , Nascido Vivo , Valva Mitral/microbiologia , Gravidez , Complicações Cardiovasculares na Gravidez/microbiologia , Complicações Infecciosas na Gravidez/microbiologia , Staphylococcus aureus/isolamento & purificação , Resultado do Tratamento , Adulto JovemRESUMO
Objectives: Re-do aortic valve surgery carries a higher mortality and morbidity compared with first time aortic valve replacement (AVR) and often requires concomitant complex procedures. Transcatheter aortic valve replacement (TAVR) is an option for selective patients. The aim of this study is to present our experience with re-do aortic valve procedures and give an insight into the characteristics of these patients and their outcomes. Methods: Retrospective review of 80 consecutive re-do aortic valve procedures. Results: Mean patients' age was 51.80±18.73 years. Aortic regurgitation (AR) was present in 51 (65.4%) patients and aortic stenosis (AS) in 38 (48.7%). Indications for reoperation were: infective endocarditis (IE) (23.8%), bioprosthetic degeneration (12.5%), mechanical valve dysfunction (5%), paravalvular leak (6.2%), patient-prosthesis mismatch (3.8%), native valve disease (25%), aortic aneurysm, pseudoaneurysm and dissection (35%), aortic root/homograft degeneration (27.5%). Forty-one (51.2%) patients underwent re-do AVR, 39 (48.8%) re-do complex aortic valve surgery (28 root, 23 ascending aorta and 6 hemiarch procedures) and 37.5% concomitant procedures. A bioprosthesis was implanted in 43.8%, a mechanical valve in 37.5%, a composite graft in 2.5%, a Biovalsalva graft in 6.2% and a homograft in 10% of patients. In-hospital mortality was 3.8% and incidence of major complications was low. Conclusions: A significant proportion of patients were young (61%<60 y), required complex aortic procedures (49%) or presented with contraindications for TAVR (mechanical valve, AR, IE, proximal aortic disease, need for concomitant surgery). Re-do aortic surgery remains the only treatment for such challenging cases and can be performed with acceptable mortality and morbidity in a specialised aortic centre.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Complicações Pós-Operatórias/cirurgia , Substituição da Valva Aórtica Transcateter , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/mortalidade , Insuficiência da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Bioprótese , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
Objectives: Retrospective review of early results with aortic valve repair (AVr) techniques. Methods: 61 consecutive patients underwent AVr surgery at our institutions between 2008 and 2018. 14 patients had a bicuspid aortic valve and 16 had a connective tissue disorder. In 48 patients, aortic regurgitation (AR) was secondary to an aortic root and/or ascending aneurysms, while in 13 it was due to primary cusp pathologies. 13 patients underwent isolated cusp repair, 19 sinotubular junction remodelling, 25 valve-sparing root replacement (VSRR) and 4 hemiroot replacement. Cusp repair techniques included: 18 free margin plication, 18 commissural re-suspensions, 3 raphe resections and 1 free-edge reinforcement. Subcommissural annuloplasty was performed in 25 patients (42%) with a dilated annulus (>28 mm). Results: 50 patients (82%) left the operating theatre with no AR, 8 with mild central and 3 with mild eccentric AR. In-hospital survival was 100%. Clinical follow-up was complete at 5.08±2.29 years and all patients were alive. Transthoracic echocardiographic follow-up was complete at 2.35±1.92 years and showed the presence of a moderate AR in 10 patients (18%) and severe AR in 2 patients (4%). One of these required re-do aortic valve replacement 6 years after VSRR. Freedom from re-operation at 8 years was 88.15%±1.51%. Conclusion: Good early results are achievable following AVr with acceptable medium-term outcomes. AVr surgery continues to evolve, and concentrating the experience in specialist centres in the UK is recommended.
RESUMO
Pseudoaneurysms of the mitral-aortic intervalvular fibrosa are rare complications that can develop after mitral or aortic valve surgery, endocarditis, or Takayasu arteritis. The optimal timing of surgery to avoid potentially life-threatening complications of pseudoaneurysms has not been established, and watchful waiting has been adopted in specific situations. We describe the case of a 50-year-old man in whom a pseudoaneurysm of the mitral-aortic intervalvular fibrosa developed after aortic root replacement with a homograft. After 13 years of watchful waiting, reoperation was deemed necessary because the pseudoaneurysm had grown to 48 mm and the aortic regurgitation caused by the degenerated homograft had become severe. This case highlights the need for increased awareness of mitral-aortic intervalvular fibrosa pseudoaneurysms and their management.
Assuntos
Falso Aneurisma/cirurgia , Aorta Torácica/cirurgia , Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Aneurisma Cardíaco/cirurgia , Valva Mitral/cirurgia , Falso Aneurisma/diagnóstico , Falso Aneurisma/etiologia , Aorta Torácica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Aneurisma Cardíaco/diagnóstico , Aneurisma Cardíaco/etiologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Imageamento Tridimensional , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Reoperação , Tomografia Computadorizada por Raios XRESUMO
Pseudoaneurysm formation some years after aortic root or ascending aorta surgery, complicated by fistula formation through a branch of the pulmonary artery, is a rare condition described only in case reports. We describe a case of this rare complication in a 58-year-old man, which occurred 13 years after aortic surgery and was characterized by a huge pseudoaneurysm of 70 mm that fistulized into the right pulmonary artery, causing a life-threatening situation.
Assuntos
Falso Aneurisma/etiologia , Aorta/cirurgia , Aneurisma Aórtico/etiologia , Fístula Artério-Arterial/etiologia , Implante de Prótese Vascular/efeitos adversos , Artéria Pulmonar , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/cirurgia , Aorta/diagnóstico por imagem , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/cirurgia , Aortografia/métodos , Fístula Artério-Arterial/diagnóstico por imagem , Fístula Artério-Arterial/cirurgia , Angiografia por Tomografia Computadorizada , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/cirurgia , Reoperação , Resultado do TratamentoRESUMO
Pectus excavatum can be associated with coronary artery diseases that can become difficult to manage in urgent situations. We describe the use of an off-pump minimally invasive direct coronary artery bypass (MIDCAB) through the fourth intercostal space incision in a patient with pectus excavatum and acute coronary syndrome who previously underwent a cosmetic prosthesis implantation. The patient refused any surgical procedure that could compromise the integrity of his cosmetic prosthesis and a left mini-thoracotomy was a good option to avoid the removal of the prosthesis. The preservation of the integrity of the thoracic cage enhanced chest wall stability and pulmonary function and permitted avoidance of inadvertent cardiac structure iatrogenic injuries. MIDCAB was optimal for the exposure of the left internal thoracic artery and the left anterior descending artery. The deformity of the chest should not be considered as an absolute contraindication to off-pump MIDCAB when other surgical options are not viable, even in emergency situations.
Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Tórax em Funil/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Próteses e Implantes , Toracotomia/métodos , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Tórax em Funil/complicações , Tórax em Funil/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
Bronchial artery embolization is a well-known treatment for hemoptysis. Adverse events of this procedure include multiple systemic embolism and infarction. Myocardial infarction has been recently reported during bronchial artery embolization, owing to the presence of a coronary-to-bronchial artery fistula. We report the management of an ischemic left ventricular free wall rupture caused by bronchial artery embolization in a patient with massive hemoptysis, bronchiectasis, and undetected coronary-to-bronchial artery anomalous connection.
Assuntos
Artérias Brônquicas , Embolização Terapêutica/efeitos adversos , Ruptura Cardíaca/etiologia , Infarto do Miocárdio/etiologia , Idoso , Feminino , HumanosAssuntos
Dor nas Costas/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Valva Mitral/cirurgia , Osteófito/complicações , Dor Pós-Operatória/etiologia , Osteofitose Vertebral/complicações , Espondilartrite/complicações , Vértebras Torácicas , Idoso , Anti-Inflamatórios não Esteroides/uso terapêutico , Dor nas Costas/diagnóstico , Átrios do Coração/diagnóstico por imagem , Humanos , Masculino , Tomografia Computadorizada Multidetectores , Osteófito/diagnóstico por imagem , Osteófito/tratamento farmacológico , Medição da Dor , Dor Pós-Operatória/diagnóstico , Fatores de Risco , Índice de Gravidade de Doença , Osteofitose Vertebral/diagnóstico por imagem , Osteofitose Vertebral/tratamento farmacológico , Espondilartrite/diagnóstico por imagem , Espondilartrite/tratamento farmacológico , Esternotomia/efeitos adversos , Vértebras Torácicas/diagnóstico por imagem , Resultado do TratamentoAssuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Ecocardiografia Transesofagiana , Fibroma/diagnóstico por imagem , Fibroma/cirurgia , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Cirurgia Torácica Vídeoassistida , Tomografia Computadorizada por Raios X , Adulto , Ponte Cardiopulmonar , Humanos , Masculino , Valor Preditivo dos Testes , Resultado do TratamentoRESUMO
BACKGROUND AND AIM OF THE STUDY: To review our experience with reoperation for aortic false aneurysms (FA) and to present an analysis of the relevant surgical approaches and risks. METHODS: From May 1999 to June 2006, 11 patients underwent a total of 13 reoperations due to aortic false aneurysms, with an incidence of 3% of all thoracic aortic cases. Cardiopulmonary bypass (CPB) and cooling were started before sternotomy in all cases. Three different strategies were adopted for patients depending on the position of the FA in the mediastinum as indicated by a preoperative CT scan. These included: deep hypothermic circulatory arrest (18 degrees C), moderate hypothermia (28 degrees C), and mild hypothermia (32 degrees C). In two patients, the sternotomy ruptured the FA causing profuse hemorrhaging. In all the other cases sternotomy was performed without complication. The repair consisted in simple repair by direct suture (10 cases) or extensive repair by refashioning the anastomosis (three cases). RESULTS: Two hospital deaths occurred with a hospital mortality rate of 16.7%. Permanent neurological deficit developed in one patient. Transient neurological deficit in the form of left lower limb weakness was observed in one patient. False aneurysm recurrence developed in two cases. Among patients present at follow-up (nine survivors), four are in NYHA class I and five in class II. CONCLUSIONS: Aortic false aneurysms carry a high mortality and morbidity rate. Nevertheless, we believe that selecting the right strategy according to the position of the FA in the chest can reduce surgical risk, thus permitting relatively safe resternotomy.