Delirium after transcatheter aortic valve implantation via the femoral or apical route.

We thought that delirium might be less frequent after transcatheter aortic valve implantation via the femoral artery compared with via the cardiac apex. We reviewed 210 patients who underwent transcatheter aortic valve implantation between January 2009 and October 2014. The proportion (95% CI) of patients who suffered delirium in the 3 days after valve implantation were: 10 (3-16%) in 105 patients who had transfemoral implantation; and 35 (25-45%) in 105 patients who had transapical implantation, p = 0.0001. The variables that independently associated with postoperative delirium were age, male sex and the transapical approach. The median (IQR [range]) hospital stay was 7 (5-13 [2-41]) days and 10 (7-15 [2-64]) days, respectively, p = 0.004. Future trials should focus on different peri-operative management strategies to reduce delirium rates after transcatheter aortic valve implantation, particularly in older men having implantations via the cardiac apex.

Atrial masses post cardiac transplantation: diagnostic and treatment dilemmas.

Atrial masses postcardiac transplant are not well reported and their diagnosis and treatment can be challenging. In the asymptomatic patient, differentiating thrombus from cardiac tumor can sometimes be difficult and the use of multiple imaging modalities is recommended. Accurate diagnosis is imperative to inform a treatment plan that balances the benefits and risks of a medical versus surgical approach. We present three cases of atrial masses postcardiac transplant to illustrate this clinical dilemma.

Is atelectasis following aortocoronary bypass related to temperature?

OBJECTIVE: To determine the frequency of acute postoperative atelectasis in patients undergoing aortocoronary bypass with either normothermic (warm) or hypothermic (cold) technique. DESIGN: Prospective, randomized study comparing two groups. SETTING: University-affiliated hospital. PATIENTS: Three hundred thirty-one patients (166 cold and 165 warm) undergoing isolated aortocoronary bypass. MEASUREMENTS: Chest radiographs were obtained preoperatively, on the day of surgery, and subsequently as clinically indicated until discharge from the hospital. Radiologist (blinded to the patient allocation into warm or cold group) scored the atelectasis from 0 to 3 based on its severity. Regression analysis was used to determine if there was any difference in the atelectasis scores between the two groups. RESULTS: Mean daily postoperative atelectasis scores were not different between the cold and warm groups. The number of patients requiring chest radiographs was similar in both groups. The percent of patients with abnormal chest radiographs was similar in both groups. CONCLUSION: The temperature of cardioplegia has no effect on the development of atelectasis following aortocoronary bypass, and therefore temperature-related cold injury is not a major cause of atelectasis following this type of surgery.

Warm heart surgery.

Hypothermia is widely acknowledged to be the fundamental component of myocardial protection during cardiac operations. Although it prolongs the period of ischemic arrest by reducing oxygen demands, hypothermia is associated with a number of major disadvantages, including its detrimental effects on enzymatic function, energy generation, and cellular integrity. We hypothesized that the ideal protected state of the heart would be electromechanically arrested and perfused with blood, that is, aerobic arrest. Under these conditions the fundamental need for hypothermia becomes questionable. We have developed a novel approach to myocardial protection during cardiac operations based on these concepts, in which the chemically arrested heart is perfused continuously with blood and maintained at 37 degrees C. In 121 consecutive coronary bypass procedures we have compared this approach with a historical cohort of 133 consecutive patients treated with hypothermic cardioplegia. Perioperative myocardial infarction was significantly less prevalent (1.7% versus 6.8%; p less than 0.05) in the warm cardioplegic group, as was the use of the intraaortic balloon pump (0.9% versus 9.0%; p less than 0.005) and the prevalence of low output syndrome (13.5% versus 3.3%; p less than 0.005). Cardiac output immediately after bypass was significantly higher than before bypass (3.1 +/- 0.9 versus 4.9 +/- 1.0 L/min; p less than 0.001) only in the warm cardioplegia group. Furthermore, the heartbeat in 99.2% of patients treated with continuous warm cardioplegia converted to normal sinus rhythm spontaneously after removal of the aortic crossclamp compared with only 10.5% of the hypothermic group. The time from removal of the aortic crossclamp to discontinuation of cardiopulmonary bypass (i.e., reperfusion time) was significantly shorter in the warm cardioplegia group (11 +/- 4.3 versus 27 +/- 5.6 minutes; p less than 0.001). Our results suggest that continuous normothermic blood cardioplegia is safe and effective. Conceptually, this represents a new approach to the problem of maintaining excellent myocardial preservation during cardiac operations.

Optimal flow rates for integrated cardioplegia.

BACKGROUND: Antegrade cardioplegic delivery may be impaired by coronary occlusions, whereas retrograde delivery of cardioplegic solution may be inhomogeneous, leading to an accumulation of lactate and hydrogen ions, the products of anaerobic metabolism. Integrated cardioplegia using continuous retrograde cardioplegia and antegrade infusions into completed vein grafts washes out metabolites accumulated in regions inadequately perfused by retrograde cardioplegia alone. To determine the flow rates required to achieve the greatest washout, we compared a high flow rate (200 ml/min) to a low flow rate (100 ml/min). METHODS: Twenty patients scheduled for isolated coronary bypass surgery were prospectively randomized to compare two flow rates for integrated cardioplegic protection using tepid (29 degrees C) blood cardioplegia. Arterial and coronary sinus blood samples were collected to evaluate myocardial metabolism. After antegrade arrest, cardioplegic solution was delivered by coronary sinus perfusion and simultaneous infusions into each completed vein graft at either high or low flow. RESULTS: Increasing from low to high flow increased the washout of lactate and hydrogen ions during the aortic crossclamp period. Two hours after crossclamp removal, ventricular function was better in the high flow groups. CONCLUSIONS: Tepid retrograde cardioplegia resulted in an accumulation of toxic metabolites. The addition of antegrade vein graft infusions at a flow rate of 100 ml/min resulted in a washout of these metabolites. A flow rate of 200 ml/min further improved this washout and resulted in improved ventricular function. An integrated approach to myocardial protection using a flow rate of 200 ml/min may improve the results of coronary bypass surgery.

Autologous porcine heart cell transplantation improved heart function after a myocardial infarction.

OBJECTIVE: Fetal cardiomyocyte transplantation improved heart function after cardiac injury. However, cellular allografts were rejected despite cyclosporine (INN: ciclosporin) therapy. We therefore evaluated autologous heart cell transplantation in an adult swine model of a myocardial infarction. METHODS: In 16 adult swine a myocardial infarction was created by occlusion of the distal left anterior descending coronary artery by an intraluminal coil. Four weeks after infarction, technetium 99m-sestamibi single photon emission tomography showed minimal perfusion and viability in the infarcted region. Porcine heart cells were isolated and cultured from the interventricular septum at the time of infarction and grown in vitro for 4 weeks. Through a left thoracotomy, either cells (N = 8) or culture medium (N = 8) was injected into the infarct zone. RESULTS: Four weeks after cell transplantation, technetium 99m-sestamibi single photon emission tomography demonstrated greater wall motion scores in the pigs receiving transplantation than in control animals (P =.01). Pigs receiving transplantation were more likely to have an improvement in perfusion scores (P =.03). Preload recruitable stroke work (P =.009) and end-systolic elastance (P =. 02) were greater in the pigs receiving transplantation than in control animals. Scar areas were not different, but scar thickness was greater (P =.02) in pigs receiving transplantation. Cells labeled with bromodeoxyuridine in vitro could be identified in the infarct zone 4 weeks after transplantation. Swine receiving transplantation gained more weight than control animals (P =.02). CONCLUSION: Autologous porcine heart cell transplantation improved regional perfusion and global ventricular function after a myocardial infarction.

Technique and pitfalls of retrograde continuous warm blood cardioplegia.

The recent development of normothermic myocardial preservation and systemic perfusion during bypass has questioned the fundamental need for hypothermia during cardiac operations. The antegrade technique of almost continuous perfusion by the aortic root and vein grafts has been supplemented by continuous normothermic blood cardioplegia through the coronary sinus. Recently, great interest has been shown in this technique. It is important to describe the method in detail along with its potential shortcomings and dangers. This communication describes the technical details, pitfalls, and shortcomings of retrograde continuous warm blood cardioplegia.

Myocardial protection in the hypertrophied right ventricle.

Hypertrophied right ventricle presents a sensitive state that may not be adequately protected by modern cardioplegic methods. Cardiac metabolism, performance, and ultrastructure were measured in response to 1 hour of cardioplegic arrest in 15 pigs with right ventricular hypertrophy using intermittent hypothermic crystalloid, blood, and Flusol DA 20%-based cardioplegia. Reperfusion time was 1 hour. One hour after a 60-minute cross-clamp period, there were no differences in light microscopy. Total energy stores increased in 4 of 5 animals given blood cardioplegia compared with 1 of 5 for each of the other groups. Cardiac performance data also showed better results for animals treated with blood cardioplegia. After 30 minutes of reperfusion, animals receiving blood cardioplegia recovered 131% +/- 42% of preoperative systolic performance compared with 106% +/- 49% for Fluosol-treated animals and only 82% +/- 27% recovery for the crystalloid-treated group. After 60 minutes of reperfusion, the blood group showed 119% +/- 20% recovery compared with 89% +/- 23% and 85 +/- 50% recovery for Fluosol- and crystalloid-treated hearts, respectively. In conclusion, blood cardioplegia provided better protection than did crystalloid or Fluosol DA 20% cardioplegia when animals with right ventricular hypertrophy underwent 1 hour of cardioplegic arrest. It may have repaired damaged myocardium, leaving better hearts after cross-clamping than before.

Coronary artery disease following repair of tetralogy of Fallot: implications and management.

A 62-year-old man underwent successful coronary artery bypass for unstable angina 34 years after a complete repair of tetralogy of Fallot. Coronary risk factors were hypertension and a positive family history. While coronary disease was the presenting complaint, he had evidence of widespread atherosclerosis. He is the first patient reported to undergo coronary artery bypass following repair of tetralogy of Fallot. Coronary artery disease complicating tetralogy of Fallot has been mentioned five times in the literature. As the population of patients who have undergone tetralogy of Fallot ages, the number showing signs of coronary disease will likely rise. Thus, vigilance regarding risk factor modification must encompass these patients as they age.

Cardiac transplantation for Fabry's disease.

Fabry's disease is a rare cause of cardiomyopathy. There are no previous reported cases of cardiac transplantation for end-stage cardiomyopathy secondary to Fabry's disease. Recurrence of disease in allografts following renal transplantation has been documented, but the course following heart transplantation is not known. A 53-year-old female presented with congestive heart failure and was found to have end-stage restrictive cardiomyopathy secondary to Fabry's disease, as diagnosed by endomyocardial biopsy. She underwent cardiac transplantation. Eight weeks post-transplantation, electron microscopy of an endomyocardial biopsy specimen showed concentric lamellar inclusions within myocytes similar to inclusions seen in the preoperative biopsy and the explanted heart. However, subsequent biopsies up to one year after heart transplantation did not show any such inclusions. There has been no clinical evidence of Fabry's cardiomyopathy. Heart transplantation is a viable option for end-stage Fabry's cardiomyopathy. However, long term follow-up is required to determine clinical outcome.

Primary cardiac sarcoma involving the pulmonary artery and valve.

Primary pulmonary artery neoplasms are rare and lethal. Those involving the pulmonary valve are even rarer with only a few reported cases in the literature. The poor prognosis of these neoplasms, despite attempted multimodal therapy, is largely related to delay and difficulty in diagnosis. The case of a 53-year-old woman is described who within one month of suddenly developing shortness of breath was found to have a mass arising from the pulmonary valve and extending through the pulmonary vasculature, requiring extensive surgical resection. She died two weeks postoperatively. The morphological findings of this primary pulmonary artery sarcoma are presented. Diagnosis, treatment, prognosis and literature are reviewed, and consideration of this tumour in the differential diagnosis of other pulmonary diseases is emphasized.

Spontaneous dissection of the left main coronary artery.

Spontaneous coronary artery dissection remains a rare but important cause of acute coronary syndromes. Presentation depends on the extent of the dissection, the vessels involved and the rate of its development, and can encompass the entire spectrum of coronary syndromes, with some patients being asymptomatic and others presenting with angina, non-ST segment elevation myocardial infarction, ST-elevation myocardial infarction and sudden cardiac death. The authors describe a 33-year-old pregnant woman who presented with a non-ST segment elevation myocardial infarction secondary to a spontaneous dissection of the left main coronary artery.

An intracardiac mass presenting as atrial fibrillation in a patient with testicular carcinoma.

A 20-year-old male with known testicular carcinoma presented with atrial fibrillation. Investigations, which revealed a pulmonary metastasis with invasion of the left atrium, are presented along with a review of the current literature.

Effect of a single bolus of intracoronary basic fibroblast growth factor on perfusion in an ischemic porcine model.

Basic fibroblast growth factor (bFGF) has been shown to induce angiogenesis in various animal models, but the methods of administration used experimentally are not clinically feasible. The objective of this study was to determine whether a single intracoronary bolus injection of bFGF would improve coronary perfusion in a porcine ischemic model that mimics clinical chronic ischemia. A copper coil studded with gold was delivered into the proximal right coronary artery of juvenile Yorkshire pigs and deployed by interventional techniques. After a four-week interval for stenosis maturation, bFGF (100 micrograms) was administered by bolus injection into the left coronary artery in five animals, and vehicle alone was administered in four animals. Angiogenesis and change in right coronary perfusion area were assessed two weeks later by angiography, myocardial contrast echocardiography and immunohistochemistry. The right coronary perfusion area increased significantly after treatment in all but one of the animals that received bFGF but not in any of the controls. Intimal hyperplasia was not induced by bFGF. Capillary density determined histochemically was not different in the two groups. In conclusion, in a porcine ischemic model, bFGF administered by a single bolus intracoronary injection into the contralateral artery improved antegrade perfusion into the ischemic territory although without histological evidence of angiogenesis. This preliminary work merits further investigation.

A simple model of right ventricular hypertrophy.

Previous models of right ventricular hypertrophy (RVH) created by pulmonary artery (PA) banding in adult large animals have been associated with an unpredictable response of the right ventricle to the band and a high mortality due to the variable degree of acute stenosis. We studied the efficacy of PA banding in young pigs to produce RVH by progressive gradual stenosis during growth. Sixteen Yorkshire pigs at 6 weeks of age had nonconstricting 5-mm wide Dacron strips placed around the PA via a left minithoracotomy. The animals were returned for study in 2-3 months. There were no deaths during the growth period. Five sham-operated pigs acted as controls. Right ventricular free wall (RVFW) to total heart weight ratio was greater in the banded group (0.38 +/- 0.05 vs. 0.28 +/- 0.01, P less than .005) as was the RVFW to left ventricular free wall (LVFW) weight (1.09 +/- 0.25 versus 0.66 +/- 0.03, P less than .005). While the LVFW to total heart weight ratio decreased (0.36 +/- 0.04 vs 0.45 +/- 0.05, P less than .005), the septal ratio did not change (0.26 +/- 0.04 vs. 0.29 +/- 0.02, NS), indicating concomitant septal hypertrophy. This technique is simple, reliable, and reproducible in creating right ventricular and septal hypertrophy in the young pig with no mortality during maturation.

Coronary bypass after ascending aorta to femoral graft placement running head: CABG after ascending aorta-bifemoral graft.

A 73-year-old woman had undergone ascending aorta-bifemoral bypass 9 years previously and now required coronary artery bypass for unstable angina. The technical considerations for the operation had never been described. We successfully completed the operation by mobilization of the pre-existent graft as it exited the thorax and by intermittent aortic root perfusion of the graft. Postoperatively she had no lower extremity complications, despite what was likely a graft dependent circulation. The same technique for coronary bypass can likely be used for all extra-anatomic bypass grafts originating from the ascending aorta. An alternate theoretical method is also discussed.

Primary intimal (spindle cell) sarcoma of the heart: a case report and review of the literature.

Intimal (spindle cell) sarcomas of the left atrium are extremely rare primary cardiac tumours with three cases reported (Li et al. (2013), Cho et al. (2006), and Modi et al. (2009)). We present a 69-year-old man who first came to medical attention after experiencing abdominal discomfort. He had a 30 lb weight loss apparently due to dieting. He denied any other constitutional symptoms. His symptoms persisted despite a course of antibiotics for presumed diverticulitis. Laboratory values were within normal limits, though the haemoglobin was 131 g/L (normal: 140-180). Subsequent abdominal computed tomography (CT) scan revealed an abdominal wall mass and intracardiac lesion; the cardiac mass was further characterized by transesophageal echo (TEE), magnetic resonance imaging (MRI), and dedicated cardiac CT. TEE revealed a mass attached to the posterolateral wall of the left atrium above the mitral annulus, and the cardiac CT and MRI confirmed the TEE findings. The patient underwent extensive surgical resection and repair of the left side of the heart. Postoperatively, he developed acute renal failure requiring dialysis and reintubation for volume overload. He became acutely hypotensive, developed multiorgan failure, and succumbed to his illness. Histopathologic examination of the left atrial mass showed an intimal sarcoma.