Type A intramural hematoma in a patient with acute coronary syndrome mimicking acute Type A aortic dissection.

Intramural hematoma (IMH) of ascending aorta is a rare but potentially lethal form of acute aortic syndrome (AAS). It is characterized by a hematoma within the media layer of the aorta secondary to rupture of the vasa vasorum in the absence of an intimal tear. However, the theory of "micro-tear" which cannot be easily detected has been raised. It may stabilize, regress, or progress to rupture or dissection. Similar to Type A aortic dissection (AD), patients with IMH of ascending aorta, as well as patients with persistent pain, are treated urgent surgery. We report a case of an ascending aorta IMH in a patient admitted to hospital with epigastric and chest pain with ST-elevation myocardial infarction in inferior leads. Coronary angiography (CAG) was performed and contrast injection from the right coronary artery (RCA) ostium showed marked contrast enhancement of the aortic wall. The CAG was terminated with a suspicion of Type A AD. The diagnosis of IMH starting just above RCA ostium with a thickness of 18 mm was made with computed tomographic angiography. An emergent surgical repair of the aorta and one-vessel coronary artery bypass graft surgery was performed successfully in our patient.

Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction.

BACKGROUND: The deep hypothermic circulatory arrest (DHCA) technique has been used in aortic arch and isthmus hypoplasia for many years. However, with the demonstration of the deleterious effects of prolonged DHCA, selective cerebral perfusion (SCP) has started to be used in aortic arch repair. For SCP, perfusion via the innominate artery route is generally preferred (either direct innominate artery cannulation or re-routing of the cannula in the aorta is used). Herein, we describe our technique and the result of arch reconstruction in combination with selective cerebral and myocardial perfusion (SCMP) and short-term total circulatory arrest (TCA) (5-10 min) through ascending aortic cannulation. METHODS: Thirty-seven cases with aortic arch and isthmus hypoplasia accompanying cardiac defects were operated on with SCMP and short TCA in Baskent University Istanbul Research and Training Hospital between January 2007 and Sep 2012. There were 17 cases with ventricular septal defect (VSD)-coarctation with aortic arch hypoplasia (CoAAH), 4 cases of transposition of the great arteries-VSD-CoAAH, 4 cases of Taussing Bing Anomaly-CoAAH, 2 cases complete atrioventricular canal defect-CoAAH, 3 cases single ventricle-CoAAH, 3 cases of type A interruption-VSD, 2 subvalvular aortic stenosis-CoAAH and 2 cases of isolated CoAAH. The aorta was cannulated in the middle of the ascending aorta in all cases. The cross-clamp was applied to the aortic arch distal to either the innominate artery or the left carotid artery. In addition, a side-biting clamp was applied to the descending aorta. The aorta between these two clamps was reconstructed with gluteraldehyde-treated autogeneous pericardium, using SCMP. The proximal arch and distal ascending aorta reconstructions were carried out under short TCA. RESULTS: The mean age of the patients was 2.5 ± 2 months. The mean cardiopulmonary bypass and cross-clamp times were 144 ± 58 and 43 ± 27 minutes, respectively. The mean SCMP and descending aorta ischemia times were 22.6 ± 4.8 and 27 ± 6.3 minutes, respectively. Mean TCA time was 7.6 ± 2.1 minutes (min: 4, max 10 min). The mean in-hospital stay time was 8.6 ± 1.9 days. None of the cases operated with this technique had neurological defects. The mortality rate was 2.7% (1 patient). CONCLUSION: SCMP with aortic cannulation and short TCA (under 10 minutes) in aortic reconstruction is safe and practical in this high-risk patient group.

Total correction in tetralogy of Fallot with anomalous major coronary artery: an alternative method to conduit use.

INTRODUCTION: A coronary artery anomaly precludes the use of a trans-annular patch in right ventricular outflow tract (RVOT) reconstruction. Herein we present three patients with coronary artery anomalies who underwent total corrective operations without using a conduit. METHODS: Between 2007 and 2010, 84 patients with tetralogy of Fallot (TOF) were operated on. Nine (9.4%) of them had a coronary artery anomaly. Three (3.1%) of the patients were operated on using the double-outflow technique and two had a Blalock-Taussig shunt before the total corrective operation. In two patients, the left anterior descending artery (LAD) and in one, the right coronary artery (RCA) crossed the RVOT. RESULTS: Postoperatively, the right-to-left ventricular pressure ratios were 0.45, 0.59 and 0.60 after cardiopulmonary bypass. No gradient was detected in the RVOT in postoperative echocardiographical measurements (< 15 mmHg gradient). In all three patients, there were moderate pulmonary insufficiencies. All were discharged home on the sixth day postoperatively. Mean follow-up duration was 9.8 ± 8 months. In the follow up of all three patients, there were moderate pulmonary insufficienciencies but no right ventricular dysfunction. CONCLUSION: The 'double-outflow' technique is appropriate for TOF patients with a major coronary artery anomaly since it can easily be performed without the need of a conduit.

Giant right atrial myxoma leading to cardiac arrest in an infant.

We present the case of a three-month-old infant with a giant right atrial myxoma obstructing the tricuspid valve, who following haemodynamic deterioration and cardiac arrest, was operated upon as an emergency. On echocardiogram, there was a mass attached to the tricuspid annulus, in close proximity to the septal leaflet, with dimensions of 16.6 × 12.5 mm. The mass was prolapsing through the tricuspid valve into the right ventricle and obstructing the inflow. While preparing for surgery, cardiac arrest occurred, so the patient underwent an emergency operation under cardiopulmonary resuscitation. The mass was excised without damaging the tricuspid valve and the conduction system. Histologically, the mass consisted of a myxoid matrix with scatted globoid and star-shaped myxoma cells. The patient stayed 15 days in the intensive care unit and was discharged home on the 20th day postoperatively. Although accepted as a benign tumour, a myxoma can display an aggressive clinical course in infants. In centres where cardiac operations cannot be performed, these patients need to be transferred to cardiac centres as soon as possible. Whatever the clinical presentation, we advocate immediate surgical extirpation of the tumour in order to avoid any unpredictable consequences in its clinical course.

Redo sternotomy for extra-anatomical correction of aortic coarctation and mitral repair in an adult after failed endovascular treatment.

Recently, extra-anatomical bypass surgery has been widely used in complicated adult aortic coarctation cases with concomitant intracardiac repair. Stent implantation has been widely used for primary aortic coarctation as well. The procedure has been shown to be effective with long term follow ups. However, failed stent implantations like stent fracture and dislodgement may complicate the clinical status and subsequent surgical procedure. Extra-anatomic bypass can provide effective results and lower morbidity in cases with concomitant intracardiac problems and stent failure. Here we present an adult aortic coarctation patient who had undergone a Bentall operation and two unsuccessful stent implantations for recurrent aortic coarctation. The patient then got an extra-anatomic bypass for aortic coarctation and concomitant mitral valve commissurotomy through median sternotomy.