Renal cell carcinoma with invasion of the tricuspid valve apparatus.

A right atrial in-growth of renal carcinoma occurs in 1% of cases. A traditional approach to removal of the tumor using cardiopulmonary bypass (CPB) and deep-hypothermic circulatory arrest (DHCA) has been challenged in favor of techniques that allow tumor removal without CPB and DHCA. To the best of the present authors' knowledge, no report has yet been made of an invasion by the tumor of the tricuspid valve leaflets and subvalvular apparatus. The details of such a case are reported herein, where CPB + DHCA was used to completely remove the neoplasm, and to preserve tricuspid valve competence.

Effects of intra-aortic balloon pump on coronary artery bypass grafts blood flow: differences by graft type and coronary target.

The intra-aortic balloon pump (IABP) is used worldwide as an anti-ischemic strategy. However, little is known about the modifications of the graft blood flow during IABP. A retrospective study aimed at analyzing transit-time flow measurements during 1:1 IABP and during its cessation in 401 consecutive patients receiving IABP before coronary artery bypass grafting (n = 880 graft segments) was reported. All normally functioning grafts were considered. Mean diastolic and mean blood flow improved significantly during 1:1 IABP compared with during IABP cessation (P < 0.001), although mean and end-diastolic arterial pressures were significantly lower (P = 0.001). Arterial and sequential saphenous vein (SV) grafts showed greater improvements in mean diastolic and mean flow compared with single venous grafts. Higher flows were also observed in the grafts directed to the circumflex territory. Surplus graft flow (SGF, defined as mean flow during 1:1 IABP/mean flow with IABP off) was recruited (SGF >1) during 1:1 IABP, with higher values in single arterial or sequential SV grafts versus single venous grafts (both P < 0.001). Y-conduit radial artery (RA) grafts showed higher maximum diastolic flow, mean flow, and SGF compared to aortocoronary RA or SV grafts. In this retrospective analysis, IABP was associated with improved diastolic and mean blood flow in bypass grafts. Arterial, sequential, and Y-conduit grafts were associated with greater improvements in blood flow and SGF than aortocoronary SV grafts.

Unusual association of left ventricular diverticulum and hypertrophic cardiomyopathy in an adult.

A 68-year-old female with hypertrophic obstructive cardiomyopathy (HOCM), fibrous subaortic stenosis, mitro-aortic valve insufficiencies, and congenital left ventricular diverticulum (CLVD) at apical level was diagnosed after syncope. Although the association between HOCM and CLVD has been previously reported, no case has ever been disclosed in advanced adulthood.

Combined off-pump minimally invasive coronary artery bypass grafting and mitral valve repair with NeoChord via a left anterolateral small thoracotomy.

Off-pump direct coronary artery bypass grafting through a left anterior small thoracotomy is widely utilized for minimally invasive myocardial revascularization. More recently, a novel technique for transapical off-pump mitral valve repair with the NeoChord device is demonstrating its efficacy. This report describes a case of an 84-year-old male patient with coronary artery disease involving the left anterior descending coronary artery and acute severe mitral regurgitation secondary to posterior leaflet flail who underwent both off-pump coronary artery bypass and mitral valve repair with the transapical implantation of artificial chordae using the NeoChord DS 1000 system through the same anterolateral small thoracotomy.

How should I wean my next intra-aortic balloon pump? Differences between progressive volume weaning and rate weaning.

OBJECTIVE: Although the intra-aortic balloon pump is the most used ventricular assist device, no study has ever evaluated the best weaning method. We compared 2 different intra-aortic balloon pump weaning methods. METHODS: Thirty consecutive patients needing an intra-aortic balloon pump because of perioperative low-output cardiac syndrome were randomized to be weaned by ratio (4 consecutive hours of a 1:2 assisting ratio followed by 1 hour of a 1:3 ratio; group R) or by progressive volume deflation (10% of total volume every hour for 5 consecutive hours; 15 patients, group V). A duration of 5 hours was set a priori as the weaning duration. The weaning protocol was started when the cardiac index was greater than 2.5 L/min/m(2), the central venous pressure was 12 mm Hg or less, the blood lactate was less than 2.5 mmol/L, the mean arterial pressure was greater than 65 mm Hg, and the preserved urine output (≥1 mL/kg/hr) lasted for at least 5 consecutive hours before weaning. The cardiac index, indexed systemic vascular resistance, cardiac cycle efficiency, and central venous pressure were registered at 9 points (T0, start; T1 to T5, the first 5 weaning hours; T6, 2 hours after withdrawal; T7, 12 hours after withdrawal; and T8, at intensive care unit discharge) using the pressure recording analytical method. The interval from intra-aortic balloon pump withdrawal to intensive care unit discharge, weaning failure, perioperative troponin I, and lactate (same points) were compared. RESULTS: All patients, except for 1 belonging to group R (P = 1.0), were successfully weaned. Group V had better preserved cardiac index, indexed systemic vascular resistance, cardiac cycle efficiency, and central venous pressure (group*time P = .0001). Group R had worse cardiac index from T5 to T8 (P ≤ .0001), indexed systemic vascular resistance from T2 to T8 (P ≤ .004), cardiac cycle efficiency from T3 to T8 (P ≤ .001), central venous pressure from T4 to T8 (P ≤ .0001), and a longer interval from intra-aortic balloon pump withdrawal to intensive care unit discharge (P = .0001). The lactate level was lower in group V from T5 to T8 (P ≤ .027; group*time P = .001). CONCLUSIONS: Intra-aortic balloon pump weaning by volume deflation allowed better hemodynamic and metabolic parameters.

Leukocyte filtration of blood cardioplegia attenuates myocardial damage and inflammation.

OBJECTIVES: Leukocyte filtration of blood cardioplegia (cLkF) is postulated to reduce ischaemia-reperfusion myocardial injury. Contradictory results have been published and few studies have addressed perioperative cytokine leakage and haemodynamic status after LkF. METHODS: Thirty patients undergoing isolated aortic valve replacement were randomized to cLkF (cLkF-Group) or to standard cold blood cardioplegia (S-Group). Troponin I (TnI) and lactate were sampled from the coronary sinus at reperfusion. Peripheral TnI and lactate were collected preoperatively at admission, and in the intensive care unit (ICU) at 8, 12, 36 and 60 h postoperatively. Cardiac index (CI), indexed systemic vascular resistances, cardiac cycle efficiency (CCE) and central venous pressure (CVP) were registered preoperatively, at admission to the ICU and at the 6th, 12th, 18th, 24th and 36th postoperative hour. IL-6, IL-8, TNF-alpha and IL-10 were sampled preoperatively, at reperfusion, on admission to the ICU and the 6th, 18th and 24th postoperative hours. RESULTS: The cLkF group showed lower TnI (2.4 ± 0.4 vs. 5.1 ± 0.8 µg/l, P = 0.0001) and lactate (0.9 ± 0.1 vs. 1.6 ± 0.2 mmol/l, P = 0.0001) from the coronary sinus at reperfusion. TnI levels (group-P = 0.0001, group time-P < 0.0001) and lactate (group time-P = 0.001) remained lower postoperatively after cLkF. Ventricular defibrillation at aortic declamping was less common in the cLkF-Group (33.3% vs. S-Group: 93.3%; P = 0.002). Cytokines demonstrated significant postoperative leakage (time-P = 0.0001 in both groups for IL-6, IL-8, TNF-alpha, IL-10), with lower pro-inflammatory (IL-6 group-P = 0.0001, group time-P = 0.0001; IL-8 group-P = 0.0001, group time-P = 0.007; TNF-alpha group-P = 0.0001; group time-P = 0.012) and higher anti-inflammatory cytokine secretion after cLkF (IL-10 group-P = 0.005). Perioperative haemodynamic indices proved to be similar between the two groups (group-P = NS for CI, SVRI, CCE and CVP). CONCLUSIONS: cLkF during blood cardioplegia attenuates myocardial ischaemia/reperfusion injury and reduces perioperative leakage of TnI, lactate and pro-inflammatory cytokines. These data did not result in a better haemodynamic status.