Congenital, acquired, or both? The only two congenitally based, acquired heart diseases.

Discrete subaortic stenosis (DSS) is a type of left ventricular outflow tract obstruction whereas double-chambered right ventricle is a form of right ventricular outflow tract obstruction. Both of these cardiac malformations share lots of similar characteristics which classify them as acquired developmental heart diseases despite their congenital anatomical substrate. Both of them are frequently associated to ventricular septal defects. The initial stimulus in their pathogenetic process is anatomical abnormalities or variations. Subsequently, a hemodynamic process is triggered finally leading to an abnormal subaortic fibroproliferative process with regard to DSS or to hypertrophy of ectopic muscles as far as double-chambered right ventricle is concerned. In many cases, these pathologies are developed secondarily to surgical management of other congenital or acquired heart defects. Moreover, high recurrence rates after initial successful surgical therapy, particularly regarding DSS, have been described. Finally, an interesting coexistence of DSS and double-chambered aortic ventricle has also been reported in some cases.

Surgical Performance Analysis and Classification Based on Video Annotation of Laparoscopic Tasks.

BACKGROUND AND OBJECTIVES: Current approaches in surgical skills assessment employ virtual reality simulators, motion sensors, and task-specific checklists. Although accurate, these methods may be complex in the interpretation of the generated measures of performance. The aim of this study is to propose an alternative methodology for skills assessment and classification, based on video annotation of laparoscopic tasks. METHODS: Two groups of 32 trainees (students and residents) performed two laparoscopic tasks: peg transfer (PT) and knot tying (KT). Each task was annotated via a video analysis software based on a vocabulary of eight surgical gestures (surgemes) that denote the elementary gestures required to perform a task. The extracted metrics included duration/counts of each surgeme, penalty events, and counts of sequential surgemes (transitions). Our analysis focused on trainees' skill level comparison and classification using a nearest neighbor approach. The classification was assessed via accuracy, sensitivity, and specificity. RESULTS: For PT, almost all metrics showed significant performance difference between the two groups (p < 0.001). Residents were able to complete the task with fewer, shorter surgemes and fewer penalty events. Moreover, residents performed significantly fewer transitions (p < 0.05). For KT, residents performed two surgemes in significantly shorter time (p < 0.05). The metrics derived from the video annotations were also able to recognize the trainees' skill level with 0.71 - 0.86 accuracy, 0.80 - 1.00 sensitivity, and 0.60 - 0.80 specificity. CONCLUSION: The proposed technique provides a tool for skills assessment and experience classification of surgical trainees, as well as an intuitive way for describing what and how surgemes are performed.

Surgical Management of an Aspergillus Empyema in a 3-Year-Old Child.

Aspergillus empyema in nonimmunocompromised children is rare. A case of surgical management of invasive aspergillosis in a previously healthy 3-year-old child is presented. The patient was initially admitted to a hospital with severe respiratory deterioration and clinical instability, originally attributed to sepsis. After surgical intervention and the diagnosis of invasive aspergillosis, intravenous therapy with voriconazole was initiated. During postoperative care, the patient's condition remained stable with mild functional respiratory deficits. The diagnosis and treatment of Aspergillus empyema remains challenging, especially in cases that the recognition of aspergillosis is delayed and urgent surgical management of the empyema is required due to rapid clinical deterioration of the patient. The early initiation, prolonged administration, and close monitoring of high-dose antifungal treatment are highly recommended.

Keyframe extraction from laparoscopic videos based on visual saliency detection.

BACKGROUND AND OBJECTIVE: Laparoscopic surgery offers the potential for video recording of the operation, which is important for technique evaluation, cognitive training, patient briefing and documentation. An effective way for video content representation is to extract a limited number of keyframes with semantic information. In this paper we present a novel method for keyframe extraction from individual shots of the operational video. METHODS: The laparoscopic video was first segmented into video shots using an objectness model, which was trained to capture significant changes in the endoscope field of view. Each frame of a shot was then decomposed into three saliency maps in order to model the preference of human vision to regions with higher differentiation with respect to color, motion and texture. The accumulated responses from each map provided a 3D time series of saliency variation across the shot. The time series was modeled as a multivariate autoregressive process with hidden Markov states (HMMAR model). This approach allowed the temporal segmentation of the shot into a predefined number of states. A representative keyframe was extracted from each state based on the highest state-conditional probability of the corresponding saliency vector. RESULTS: Our method was tested on 168 video shots extracted from various laparoscopic cholecystectomy operations from the publicly available Cholec80 dataset. Four state-of-the-art methodologies were used for comparison. The evaluation was based on two assessment metrics: Color Consistency Score (CCS), which measures the color distance between the ground truth (GT) and the closest keyframe, and Temporal Consistency Score (TCS), which considers the temporal proximity between GT and extracted keyframes. About 81% of the extracted keyframes matched the color content of the GT keyframes, compared to 77% yielded by the second-best method. The TCS of the proposed and the second-best method was close to 1.9 and 1.4 respectively. CONCLUSIONS: Our results demonstrated that the proposed method yields superior performance in terms of content and temporal consistency to the ground truth. The extracted keyframes provided highly semantic information that may be used for various applications related to surgical video content representation, such as workflow analysis, video summarization and retrieval.

Situs Inversus Totalis: Single-Stage Anatomic Repair of Complex Congenital Heart Disease.

Transposition of the great arteries occurs rarely in patients with mirror image dextrocardia and situs inversus, while the combination with severe coarctation of the descending aorta (CoA) makes the anatomy even more unusual. Therefore, it is not surprising that a case with such unusual and complicated anatomy presents unique problems when a primary definitive correction is attempted. We report a patient with situs inversus totalis and complex congenital heart disease including transposition of the great arteries and severe CoA who underwent successful complete, single-stage, anatomic correction.

Sterile Necrosis of the Sternum: A Rare Complication Following Coronary Artery Bypass Surgery.

We herein present the unique case of a 68-year-old male diabetic patient who developed sterile necrosis of the sternum 1 month after myocardial revascularization with the use of bilateral internal thoracic artery grafts. The sternum had been closed by the bilateral Robicsek wiring technique. The sternum was removed, and bilateral pectoralis major flaps were used to cover the defect. The patient had an uneventful recovery.

Epididymo-Orchitis in Bechet's Disease: A Review of the Wide Spectrum of the Disease.

 Behçet's disease is a chronic, recurrent, inflammatory disorder characterized by orogenital ulcers and skin lesions; serious manifestations also include ocular, large vessel, gastrointestinal and neurological involvement. Genetic and unknown environmental factors modify the wide clinical spectrum of the disease. During the long clinical course of the disease, testicular and epididymal involvement has been reported, with scrotal pain and swelling being the most common symptoms. In this review, we discuss the various aspects of epididymo-orchitis in Behcet's disease patients, and we evaluate the diagnostic approaches as well as the empirical therapeutic modalities of this entity.

Pulmonary valve replacement in patients with corrected tetralogy of Fallot.

Introduction: Development of pulmonary insufficiency in patients with surgically corrected tetralogy of Fallot (TOF) may lead to severe right heart failure with serious consequences. We herein present our experience with pulmonary valve replacement (PVR) in these patients. Methods: From 2005-2013, 99 consecutive patients (71 males/28 females, mean age 38±8 years), underwent PVR after 7 to 40 (mean 29 ± 8) years from the initial correction. Seventy nine of the symptomatic patients presented in NYHA II, 14 in III and 2 in IV. All underwent PVR with a stented bioprosthetic valve, employing a beating heart technique with normothermic extracorporeal circulation support. Concomitant procedures included resection of aneurysmal outflow tract patches (n = 37), tricuspid valve annuloplasty (n = 36), augmentation of stenotic pulmonary arteries (n = 9), maze procedure (n = 2) and pulmonary artery stenting (n = 4). Results: There were 2 perioperative deaths (2%). One patient developed sternal dehiscence requiring rewiring. Median ICU and hospital stay was 1 and 7 days respectively. Postoperative echocardiography at 6 and 12 months showed excellent bioprosthetic valve performance, significant decrease in size of the right cardiac chambers and reduction of tricuspid regurgitation (TR) in the majority of the patients. At mean follow-up of 3.6 ± 2 years, all surviving patients remain in excellent clinical condition. Conclusion: Probability of reoperation for pulmonary insufficiency in patients with surgically corrected TOF increases with time and timely PVR by preventing the development of right heart failure is crucial for long-term survival. Current bioprosthetic valve technology in combination with the beating heart technique provides excellent immediate and short-term results. Further follow-up is necessary to evaluate long-term outcome.

Cardiac arrest reveals a mobile large left atrial myxoma.

Left atrial myxoma could be a rare cause of cardiac arrest as this mass could impinge on the mitral orifice causing left ventricular inflow tract obstruction.

Rare multiple bronchial abnormalities in a patient with congenital heart disease.

Although many variations regarding lobar or segmental bronchial subdivisions have been described, abnormal bronchi originating from the trachea or main bronchi are relatively rare. These abnormalities can remain undetectable as they usually do not present with symptoms; however, they may pose major obstacles during surgery especially when accompanied by bronchial wall abnormalities.

An alternative technique to safely close the chest after placing a child on central venoarterial extracorporeal membrane oxygenation.

Central venoarterial (VA) placement of extracorporeal membrane oxygenation (ECMO) is performed surgically, and in the majority of cases, the patient remains with an open sternum. Herein, a case of a 3-year-old patient who underwent insertion of a central VA ECMO for heart failure due to acute myocarditis is described. An alternative technique for ECMO placement providing sternal closure and minimizing infection risk for the safe patient transport is described.

Operating the blues.

A 63-year-old man bearing most signs and symptoms (facial pigmentation, degenerative arthritis, and dark urine) pertinent to his known history of alkaptonuria underwent aortic valve replacement for critical aortic stenosis. Although rare, aortic stenosis is the most common cardiac manifestation of alkaptonuric ochronosis.

Aorto-Right Ventricular Tunnel: An Uncommon Problem with a Common Solution.

Aorto-ventricular tunnel is a rare congenital malformation, and aorto-right ventricular tunnel (ARVT) is an even less common entity. Here, we report the case of a 3-month-old female who underwent successful surgical closure of ARVT. The origin of the right coronary artery was proximal to the ostium of the tunnel.

Thymic Cyst Popping Up in a Patient With Congenital Heart Disease.

The unusual case of a thymic cyst emerging and rapidly expanding, mimicking hence a right atrial aneurysm in an asymptomatic patient with congenital heart disease is presented.

T-Bar Utilization for Concomitant Coronary Artery Bypass Graft Operation and Left Upper Lobectomy.

Management in patients with coexisting coronary artery disease and lung carcinoma is usually a two-stage operation, with the cardiac surgery procedure followed by pulmonary resection at a later time. Delayed tumor resection on the other hand may be detrimental. Off-pump coronary artery bypass grafting could facilitate concomitant lung resection at one stage via median sternotomy. T-bar retractor may be a useful tool in the surgical approach of this combined operation.

Juvenile Adamantiades-Behçet Disease.

Adamantiades-Behçet disease (ABD) is a chronic, multisystemic, recurrent, inflammatory vascular disorder of unknown etiology. Patients with symptoms initially appearing at the age of 16 or less are considered as cases of juvenile-onset ABD (JABD). JABD is relatively rare compared to ABD of adults, and only case reports and case studies have been published regarding this subtype of the disease. Epidemiology, clinical features, diagnosis and treatment of JABD are discussed in this review.

One-Stage Repair of an Interrupted Aortic Arch with an Aortopulmonary Window in a Premature Neonate.

Interrupted aortic arch with an aortopulmonary window is a rare congenital entity that is associated with high morbidity and mortality, especially in premature low-birth-weight infants, and the proper timing of surgical correction remains a matter of debate. We present the case of a premature infant weighing 1.6 kg who successfully underwent one stage surgical repair to treat interrupted aortic arch with an aortopulmonary window. The therapeutic management of this patient is described below, and a review of the literature is presented.

Diffuse Calcifications of the Spleen in a Woman with Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, which affects a wide variety of organs including the spleen. Splenic involvement in SLE includes conditions such as splenomegaly, hyposplenism, infarction, and spontaneous rupture. However, only a few cases of splenic calcifications in patients with SLE have been reported. Herein, we present a case of a 24-year-old female diagnosed with SLE, in which we found diffuse splenic calcifications. The unique pattern of splenic calcifications in SLE contributes to the differential diagnosis from other conditions such as infections and other connective tissue diseases, which also cause calcifications in the spleen.

Benign emptying of the post-pneumonectomy space: recognizing this rare complication retrospectively.

Patients presenting with a sudden drop in the pleural fluid level after a pneumonectomy in the absence of a recognizable bronchopleural fistula (BPF) have been classified as cases of benign emptying of the post-pneumonectomy space (BEPS). A retrospective study of 1378 pneumonectomies identified 4 cases of BEPS (0.29%). The patients were men; median age 64 years and all had undergone a right pneumonectomy. The median time at diagnosis was 31 days postoperatively and the median follow-up time was 31 months. None of the patients experienced a documented BPF or empyema. Although BEPS is an extremely rare complication, early recognition and close patient monitoring will prevent unnecessary interventional strategies.