Surgical treatment of chronic thromboembolic pulmonary hypertension in combination with a left anterior descending artery myocardial bridge: A case report.

Pulmonary thromboendarterectomy is a potentially curative option for most patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, a special group of patients with CTEPH requires simultaneous cardiac procedures. We report a rare case of successful surgical treatment of a CTEPH patient with a left anterior descending artery myocardial bridge. Despite the complexity of performing pulmonary thromboendarterectomy (PTE), the issue concerning the method of revascularization of the artery in the case of the left anterior descending artery myocardial bridge is controversial. PTE and supracoronary myotomy were performed. In our case, the optimal surgery method for the left anterior descending artery myocardial bridge was chosen intraoperatively based on the depth and length of the myocardial bridge. The patient's significant functional improvement after surgery and hemodynamic normalization were confirmed at the follow-up assessment. This case demonstrates rare but potentially dangerous pathologies that can be treated with minimal adverse effects.

Penetrating Cardiac Injury from Crossbow Successfully Treated With Cardiac Autotransplantation.

A middle-aged male patient presented with self-inflicted penetrating cardiac injury from 2 crossbow bolts causing injury to multiple cardiac structures and surrounding great vessels. He was successfully treated with peripheral cannulation for cardiopulmonary bypass, median sternotomy, hypothermic circulatory arrest, autotransplantation of the heart, and repair of all intracardiac injuries.

Modified technique for coarctation of aorta with hypoplastic distal aortic arch.

BACKGROUND: A combination of coarctation of aorta with various severity of distal arch hypoplasia frequently occurs in newborns. Traditional techniques in the neonatal period such as extended end-to-end anastomosis or inner curve patch are controversial. Arch geometry has a marked role in long-term outcomes. We introduce a modified Amato technique of distal aortic arch enlargement with native tissue-to-tissue reconstruction. METHODS: Neonatal patients with coarctation of aorta and distal aortic arch hypoplasia who underwent surgical reconstruction using this technique between January 2016 and December 2019 in our center were included. Patients with concomitant complex heart defects were excluded. Data were obtained from echo protocols, CT scans before and after repair. The dimensions of the arch were assessed using Z-score, arch geometry was evaluated with height/width ratio. RESULTS: Thirty-two patients (22 males, 10 females) were included. Median age and weight were 7 days (5; 18) and 3.5 kg (3.1; 4.0), respectively. The Z-score of distal part of the arch before and after procedure was significantly different (<0.01). No mortality, recoarctation, or bronchial compression was found during 18 (6-38) months of follow-up. CONCLUSION: Modified technique for coarctation of aorta with hypoplastic distal aortic arch provides favorable geometry of the aorta with a low risk of morbidity. The proper selection and accurate technique could minimize potential risks. This method is relatively safe and might improve long-term outcomes associated with the geometry of aorta.

Mechanical stress alters the expression of calcification-related genes in vascular interstitial and endothelial cells.

OBJECTIVES: Vascular wall calcification is a major pathophysiological component of atherosclerotic disease with many similarities to osteogenesis. Mechanical stress of the vascular wall may theoretically contribute to the proliferative processes by endothelial and interstitial cells. The aim of the study was to investigate the effect of mechanical stress on the expression of some calcification-related genes in primary human endothelial and interstitial cells, and how endothelial cells may stimulate the fibroblast and smooth muscle cells. METHODS: Human umbilical vein endothelial and interstitial cells were subjected to cyclic stretch using a FlexCell® bioreactor, and interstitial cells were also subjected to tensile strain in cultures embedded in 3-dimensional collagen gels. The medium from endothelial cells was used to stimulate the gel-cultured interstitial cells, or the endothelium was sown directly on top. For comparison, human endothelial and smooth muscle cells were isolated from aortic wall fragments of patients with and without the aortic aneurysm. The expression of genes was measured using quantitative PCR. RESULTS: Four hours of cyclic stretch applied to cultured endothelial cells upregulated the mRNA expression of bone morphogenetic protein 2 (BMP-2), a major procalcific growth factor. When applied to a 3-dimensional culture of vascular interstitial cells, the medium from prestretched endothelial cells decreased the expression of BMP-2 and periostin mRNA in the fibroblasts. The static tension in gel-cultured interstitial cells upregulated BMP-2 mRNA expression. The addition of endothelial cells on the top of this culture also reduced mRNA of anticalcific genes, periostin and osteopontin. Similar changes were observed in smooth muscle cells from human aortic aneurysms compared to cells from the healthy aorta. Aortic aneurysm endothelial cells also showed an increased expression of BMP-2 mRNA. CONCLUSIONS: Endothelial cells respond to mechanical stress by upregulation of pro-osteogenic factor BMP-2 mRNA and modulate the expression of other osteogenic factors in vascular interstitial cells. Endothelial cells may, thus, contribute to vascular calcification when exposed to mechanical stress.

Quadricuspid Aortic Valve Combined with Moderate Ascending Aortic Dilatation: A Report of Four Cases.

The quadricuspid aortic valve is a very uncommon malformation associated with aortic insufficiency, aortic stenosis, endocarditis, and ascending aortic dilatation. We report four cases of this aortic valve malformation. One patient with severe aortic regurgitation and moderate aortic dilatation required aortic valve replacement. Three patients had mild or moderate aortic insufficiency combined with moderate ascending aortic dilatation. These patients were referred to follow-up. The presented cases demonstrate that this aortic valve malformation may not be as rare as it appears and that attention must be paid to any quadricuspid findings during computed tomographic angiography and echocardiography.

Correlation of cardiac output and sevoflurane required to maintain anesthetic depth targeted with entropy index.

AIMS AND OBJECTIVES: We investigated the correlation of reduced cardiac output on required sevoflurane to maintain targeted anesthesia depth. MATERIALS AND METHODS: 36 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass were prospectively included in the study. Inspired sevoflurane concentration was adjusted to ensure state entropy index < 40. Analgesia was provided by either boluses of fentanyl 200 µg or continuous infusion of fentanyl 5 µg/kg/h; the total dose of fentanyl administered in the patients was not different (fentanyl boluses 6.5 ± 0.3 µg/kg/h vs. fentanyl infusion 5 µg/kg/h). Cardiac-index (CI), end tidal sevoflurane (ETsev) and entropy index were measured simultaneously at 1-5 min after sternotomy, during internal mammary artery harvesting and during pericardiotomy. 108 sets of variables (entropy index, ETsev, CI) were recorded from 36 subjects at three time points; 13 sets were excluded due to technical drawbacks in measurements. 95 data sets were eligible for analysis. Sixty-five data sets measured in patients with target state entropy index were analyzed to establish the relationship between CI and ETsev. RESULTS: We did not find a linear correlation between ETsev and CI in patients with target entropy index (correlation coefficient = 0.18, P = 0.14). The ETsev necessary to maintain the target level of anesthesia was lower in patients with CI ≤ 2.2 l/min/m2 (1.15% ± 0.28%) than patients with CI > 2.2 l/min/m2 (1.37% ± 0.31%), P = 0.01. CONCLUSION: Relationship between CI and ETsev required for maintaining target level of anesthesia is non-linear. Patients with CI ≤ 2.2 l/min/m2 need lower levels of the ETsev for maintenance of the target anesthesia at an entropy index < 40.