A rare complication: Right ventricular lead perforation abutting the left anterior descending artery through the left ventricle and the septum.

BACKGROUND: Cardiac perforation is an uncommon complication of transvenous pacemaker implantation typically occurring through the apex. CASE SUMMARY: We report a case of patient, in whom ventricular lead perforation was confirmed 6 days after implantation of a dual chamber pacemaker. The ventricular lead was perforating the ventricular septum, near the left anterior descending artery, exiting the left ventricle. The patient underwent cardiac surgery due to the lead perforation as also as aortic valve replacement due to concomitant severe aortic valve stenosis. DISCUSSION: The presented case report is a rare case of lead perforation through the LV and illustrates that lead perforation can still occur even after placement of the RV lead in septal position and even through the thick ventricular wall.

Ascending Aorta Dissection Before 5.5 cm Diameter; "It Wasn't Raining When Noah Built the Ark".

INTRODUCTION: The aim of this study was to compare mean maximum ascending aortic diameter at the time of acute aortic dissection with the current surgical threshold for elective ascending aortic operations on non-syndromic thoracic aortic aneurysms. MATERIAL AND METHODS: All consecutive non-syndromic adult patients admitted for acute type A aortic dissection in a single tertiary centre were prospectively enrolled from April 2020 to March 2021. The primary endpoint was the difference between mean maximum aortic diameter at the time of dissection and the 5.5 cm threshold for elective repair. Secondary endpoints included 30-day/in-hospital mortality, aortic length and comparison with normal controls, length/height ratio index, "actual" preoperative Euroscore II and "predicted" Euroscore II if electively operated. RESULTS: Among 31 patients ageing 67.3±12.03 years on average, mean maximum aortic diameter at the time of dissection was 5.13±0.66 cm, significantly lower than the guidelines-derived surgical threshold of 5.5 cm (p=0.004). Mean aortic length was 11±1.47 cm, also significantly longer compared normal controls reported in the literature (p<0.001). The 30-day/in-hospital mortality was 35.5%. Mean length/height ratio index was 6.18±0.76 cm/m. Finally, mean "actual" preoperative Euroscore II was 10.43±4.07 which was significantly higher than the 1.47±0.57 "predicted" Euroscore II (p<0.05). CONCLUSIONS: The maximum aortic diameter at the time of acute type A aortic dissection of non-syndromic cases was significantly lower than the current recommendation for elective repair. Lowering of the current diameter-based surgical threshold of 5.5 cm may be profitable in terms of prevention, but further investigations should be undertaken. Length-based thresholds could also add to timely aortic dissection prevention.

Wearable cardioverter defibrillator: bridging for implantable defibrillators in left ventricular assist device patients.

There is currently conflicting data available regarding the use of implantable cardioverter-defibrillators (ICD) in left ventricular assist device (LVAD) patients. While the benefit of an ICD in heart failure patients is well demonstrated, such benefit has failed to reach the LVAD population. In lack of randomized control trial data on the topic of ICD use in LVAD recipients, major societal guidelines are in disagreement when comes to the topic of routine implantation of a permanent defibrillator in prospective ventricular assist device patients. Alternative permanent defibrillator strategies have been suggested for the LVAD population such as subcutaneous implantable cardioverter defibrillators (S-ICDs) but eligibility of patients for such practice remains disappointing. Although most of the heart failure patients undergoing LVAD implantation already bear an ICD, clinicians are left with the decision of de novo implanting an ICD in an important number of patients. Wearable cardioverter defibrillators could prove beneficial in LVAD recipients by utilizing them as a bridge to decision towards the implantation of a permanent defibrillator.

Ectopic hepatocellular carcinoma in the adrenal gland with inferior vena cava thrombosis and right atrial extension.

Intravascular tumor extension in the inferior vena cava (IVC) is known to occur with abdominal tumors, such as renal cell, hepatocellular, adrenal cell carcinoma, and Wilm's tumor. We encountered a 53-year-old male patient presenting with pulmonary embolism and a right atrial mass with imaging evidence of an adrenal tumor extending into the IVC, up to the right atrium. The patient underwent surgery for the resection of the tumor using cardiopulmonary bypass by a team of cardiothoracic surgeons and urologists. Histology identified the tumor as hepatocellular carcinoma, which developed as ectopic hepatic tissue in the right adrenal gland.

Cardiac tumors: a retrospective multicenter institutional study.

PURPOSE: Primary cardiac tumors are uncommon but not extremely rare. Cardiac tumors, mostly intracavitary, include benign and malignant tumors that arise from the endocardium, heart valves or myocardium. This retrospective study summarizes the experience of the Cardiac Surgery Departments of three tertiary Hospitals in this field, and particularly in cardiac myxomas, over the last 29 years. Herein, we present the results of cardiac tumors excision in relation to postoperative morbidity and mortality. METHODS: Between 1985 and 2014, 117 patients, aged from 16 to 82 years, underwent resection of a cardiac tumor. RESULTS: Ninety one of the tumors (77.78%) were myxomas, 15 of them (12.82%) were other primary cardiac tumors, 7 of them (5.98%) were infra-diaphragmatic tumors and the remaining 4 tumors (3.42%) were benign intracavitary masses (thrombi). Patients operated on for a cardiac tumor had a 30-day mortality rate of 3.29%. Atrial fibrillation appeared in 21 out of 91 patients (23.07%) operated on for cardiac myxoma, while neurological complications were observed in 3 patients (3.29%). Re-exploration for bleeding was performed in 5 out of 91 cases (5.49%) and recurrence occurred in 4.39% of myxomas. CONCLUSIONS: Despite being rare, primary cardiac tumors require open heart intervention soon after their diagnosis in order to prevent complications and achieve low mortality rates.

Effect of an E-Prescription Intervention on the Adherence to Surgical Chemoprophylaxis Duration in Cardiac Surgery: A Single Centre Experience.

In our hospital, adherence to the guidelines for peri-operative antimicrobial prophylaxis (PAP) is suboptimal, with overly long courses being common. This practice does not offer any incremental benefit, and it only adds to the burden of antimicrobial consumption, promotes the emergence of antimicrobial resistance, and it is associated with adverse events. Our objective was to study the effect of an electronic reminder on the adherence to each element of PAP after cardiac surgery. We conducted a single center, before and after intervention, prospective cohort study from 1 June 2014 to 30 September 2017. The intervention consisted of a reminder of the hospital guidelines when ordering PAP through the hospital information system. The primary outcome was adherence to the suggested duration of PAP, while secondary outcomes included adherence to the other elements of PAP and incidence of surgical site infections (SSI). We have studied 1080 operations (400 pre-intervention and 680 post-intervention). Adherence to the appropriate duration of PAP increased significantly after the intervention [PRE 4.0% (16/399) vs. POST 15.4% (105/680), chi-square p < 0.001]; however, it remained inappropriately low. Factors associated with inappropriate duration of PAP were pre-operative hospitalization for <3 days, and duration of operation >4 h, while there were significant differences between the chief surgeons. Unexpectedly, the rate of SSIs increased significantly during the study (PRE 2.8% (11/400) vs. POST 5.9% (40/680), chi-square p < 0.019). The implemented intervention achieved a relative increase in adherence to the guideline-recommended PAP duration; however, adherence was still unacceptably low and further efforts to improve adherence are needed.

Creating arteriovenous fistula using an automatic anastomotic device.

We describe the use of the Cardica C-Port xA Distal Anastomosis System for performing an automated, arteriovenous fistula in patients on hemodialysis with end stage renal failure.

Mechanical assistance by intra-aortic balloon pump counterpulsation during reperfusion increases coronary blood flow and mitigates the no-reflow phenomenon: an experimental study.

The effects of the intra-aortic balloon pump (IABP) counterpulsation on the extent of myocardial infarction (MI), the no-reflow phenomenon (NRP), and coronary blood flow (CBF) during reperfusion in an ischemia-reperfusion experimental model have not been clarified. Eleven pigs underwent occlusion of the mid left anterior descending coronary artery for 1 h, followed by reperfusion for 2 h. CBF, distal to the occlusion site, was measured. In six experiments, IABP support began 10 min before, and continued throughout reperfusion (IABP Group). Five pigs without IABP support served as controls. At the end of each experiment, the myocardial area at risk (MAR) of infarction and the extent of MI and NRP were measured. Hemodynamic measurements at baseline and during coronary occlusion were similar in both groups. During reperfusion, systolic aortic blood pressure was significantly lower in the IABP Group than in controls. In the IABP Group, CBF reached a peak at 5 min of reperfusion, gradually decreased, but remained higher than at baseline, and significantly higher than in controls throughout the 2 h of reperfusion. In controls, CBF increased significantly above baseline immediately after the onset of reperfusion, then returned to baseline within 90 min. The extent of NRP (37 ± 25% vs. 68 ± 17%, P = 0.047) and MI (39 ± 23% vs. 67 ± 13%, P = 0.036), both expressed as percentage of MAR, was significantly less in the IABP group than in controls. After prolonged myocardial ischemia, IABP assistance started just 10 min before and throughout reperfusion increased CBF and limited infarct size and extent of NRP.

Risk factors for prolonged stay in cardiac surgery intensive care units.

AIMS AND OBJECTIVES: To identify the factors that might affect the length of stay in the intensive care unit (ICU-LOS) among cardiac surgery patients. BACKGROUND: ICU-LOS forms an important factor for assessing the effectiveness of the provided nursing care. A number of factors can be accused for increasing patient hospitalization. The nursing workload (NWL), among others, was found to play a significant role as it is closely associated with the quality of care. DESIGN: An observational cohort study among 313 consecutive patients who were admitted to the cardiac surgery intensive care unit of a general, tertiary hospital of Athens, Greece from November 2008 to November 2009. METHODS: Data collection was performed by using a short questionnaire (for basic demographic information) and two instruments, the Nursing Activities Score (NAS) and the logistic EuroSCORE, for assessing the NWL and the perioperative risk for each patient respectively. RESULTS: ICU-LOS of more than 2 days increased with age and was more common among females (p < 0.001 and p = 0.02, respectively). Multivariate logistic regression analysis revealed a positive association between increased perioperative risk and the increased ICU-LOS [odd ratio (OR) 1.9, 95% confidence interval (CI) 1.0-3.5, p = 0.04], while patients with a first day NAS of more than 61.6% had an almost 5.2 times greater probability to stay in the cardiac surgery unit for more than 2 days (OR 5.2, 95% CI 3.0-8.8, p < 0.001). CONCLUSIONS: Increased level of NWL and patient perioperative risk are closely associated with increased ICU-LOS. RELEVANCE TO CLINICAL PRACTICE: The correlation between patient perioperative risk and ICU-LOS encourages the early identification of high-risk patients for prolonged hospitalization. Furthermore, the relationship between NWL and ICU-LOS allows the early identification of these patients with the use of an independent nursing tool.

Implantable cardioverter defibrillators in left ventricular assist device patients: Α systematic review and meta-analysis.

Implantable cardioverter-defibrillators (ICDs) remain the standard of care in advanced heart failure with reduced ejection fraction patients for the prevention of sudden cardiac death. However, current guidelines remain conflicting with respect to the use of ICDs in patients supported with a continuous flow left ventricular assist device (CF-LVAD). The current review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing the use of ICD in patients with CF-LVADs were included. The 2 primary outcomes studied were all-cause mortality, and a successful bridge to heart transplantation. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs). We also compared baseline characteristics between US and European studies, for CF-LVAD patients with an ICD. Among all studies, the use of an ICD was not associated with all-cause mortality in patients with CF-LVADs (OR: 0.85, 95% CIs: 0.64-1.12, p = 0.24). The presence of an ICD was associated with a trend towards increased likelihood of successful bridge to heart transplantation (OR: 1.12, 95% CI: 1.0-1.3, p = 0.06). A subgroup analysis of studies published by European centers revealed a significant decrease in pooled mortality (OR: 0.58, 95% CI: 0.4-0.83, p = 0.003) with the use of ICD, contrary to an increase in pooled mortality among studies published by US centers (OR: 1.2, 95% CI 1.02-1.33, p = 0.025). Moreover, we identified significant differences in baseline characteristics such as bridge to transplantation rate, Interagency Registry for Mechanically Assisted Circulatory Support profiles, and use of an intra-aortic balloon pump or extracorporeal membrane oxygenation preoperatively, between the US and European populations. While this meta-analysis did not show an overall survival benefit with the use of an ICD in CF-LVAD patients, it revealed significant differences in the derived benefit, in distinct patient populations. This might reflect differences in baseline patient characteristics and warrants further investigation.

High Flow Oxygen Therapy at Two Initial Flow Settings versus Conventional Oxygen Therapy in Cardiac Surgery Patients with Postextubation Hypoxemia: A Single-Center, Unblinded, Randomized, Controlled Trial.

In cardiac surgery patients with pre-extubation PaO2/inspired oxygen fraction (FiO2) < 200 mmHg, the possible benefits and optimal level of high-flow nasal cannula (HFNC) support are still unclear; therefore, we compared HFNC support with an initial gas flow of 60 or 40 L/min and conventional oxygen therapy. Ninety nine patients were randomly allocated (respective ratio: 1:1:1) to I = intervention group 1 (HFNC initial flow = 60 L/min, FiO2 = 0.6), intervention group 2 (HFNC initial flow = 40 L/min, FiO2 = 0.6), or control group (Venturi mask, FiO2 = 0.6). The primary outcome was occurrence of treatment failure. The baseline characteristics were similar. The hazard for treatment failure was lower in intervention group 1 vs. control (hazard ratio (HR): 0.11, 95% CI: 0.03-0.34) and intervention group 2 vs. control (HR: 0.30, 95% CI: 0.12-0.77). During follow-up, the probability of peripheral oxygen saturation (SpO2) > 92% and respiratory rate within 12-20 breaths/min was 2.4-3.9 times higher in intervention group 1 vs. the other 2 groups. There was no difference in PaO2/FiO2, patient comfort, intensive care unit or hospital stay, or clinical course complications or adverse events. In hypoxemic cardiac surgery patients, postextubation HFNC with an initial gas flow of 60 or 40 L/min resulted in less frequent treatment failure vs. conventional therapy. The results in terms of SpO2/respiratory rate targets favored an initial HFNC flow of 60 L/min.

Autopsy of 54 cases of surgically excised cardiac myxomas. Investigation of their impact on immune response.

INTRODUCTION: The impact of cardiac myxomas on the immune response is still indefinite, although laboratory tests and histological findings suggest that there is a correlation between myxomas and inflammatory reaction. OBJECTIVES: Our study speculates that cardiac myxomas are associated with inflammatory response and investigates potential elements of inflammation in the histopathological examination and biomarkers from laboratory tests. METHODS: It is a retrospective study and data were collected from a single center between May 2010 to May 2018. Autopsies and laboratory tests of 54 cases were analyzed. RESULTS: In 20,4% of the autopsies, inflammatory elements were identified. The neutrophil/lymphocyte ratio (NLR) preoperatively is elevated in patients suffering from cardiac myxoma while its value is correlated to the tumor size. CONCLUSIONS: Cardiac myxoma is an entity that affects the immune response of patients. The biomarker NLR could be utilized as a prognostic factor regarding enlarged cardiac myxomas. Future studies still need to be conducted in order to confirm the usefulness of this biomarker on cardiac myxomas.

Hyperpyrexia in a patient with a left ventricular assist device: a diagnosis beyond the obvious.

As the number of patients receiving a left ventricular assist device increases, physicians must always keep in mind that several conditions can present with non-specific symptoms, such as fever, tachypnoea and confusion. We herein report the case of a left ventricular assist device patient who developed a life-threatening condition with acute hyperthermia, confusion and extremities' clonus and muscle spasms. The patient was diagnosed with serotonin syndrome, attributed to the coadministration of 2 commonly prescribed medications (citalopram and omeprazole). This case highlights that a significant proportion of left ventricular assist device patients is treated with serotonergic agents that may predispose them to the appearance of serotonin syndrome, a potentially life-threatening condition.

Perioperative predictors of delirium and incidence factors in adult patients post cardiac surgery.

BACKGROUND: Delirium is a quite common complication in adult patients post-cardiac surgery. The purpose of our study was to identify perioperative characteristics and also focus on incidence factors that could predict delirium in the cardiac surgery intensive care unit (CICU) postoperatively. METHODS: We conducted a prospective study of 179 consecutive patients, who underwent open-heart surgical operation and were admitted to the CICU of a general tertiary hospital in Athens, Greece. The patients were screened for delirium by using the diagnostic tools of Rich-mond Agitation Sedation Scale (RASS score) and the Confusion Assessment Method - ICU (CAM-ICU). The delirium assessment was carried out on the 1st and the 2nd postoperative day, and was conducted twice every nursing shift. A short questionnaire on sociodemographics and clinical patient characteristics was used for data collection purposes. RESULTS: A total of 179 patients who underwent open-heart surgical operation with cardiopulmonary bypass (CPB) were enrolled in our study. The 2-day incidence of postoperative delirium in ICU was 11.2% (n=20/179). The main independent predictors of delirium on the 2nd postoperative day were neutrophil-to-lymphocyte ratio (p=0.001) and urea levels (p=0.016). Additionally, increased perioperative creatinine (p=0.006) and sodium (p=0.039) levels were significantly associated with delirium occurrence. Furthermore, elevated EuroSCORE (p=0.001), extended length of stay (LOS) in ICU (p<0.001), and extended LOS with endotracheal tube (p=0.001) were also statistically significant indicators. CONCLUSION: Patients with extended LOS with endotracheal tube and prolonged stay in ICU in accordance with peaked urea, neutrophil-to-lymphocyte ratio, creatinine, and sodium levels seem to have a significantly greater probability of developing delirium in the ICU. Further research is needed in the field of postoperative cardiac patients in order to determine the causality and etiology of certain risk factors for delirium.

Coronary artery bypass grafting and paraparesis; is there a correlation?

Adult cardiac surgery is associated with significant perioperative morbidity and mortality rates, mainly in elderly patients with co-morbidities. A series of postoperative complications may arise and delay the recovery of patients undergoing cardiac surgery. Such complications also increase the burden of resource use and may affect late survival rates. Neurological complications appear mainly as stroke of varying degrees, with impairment of mobility and ability of the patient. We describe a rare case of progressive paraparesis after on-pump coronary artery bypass grafting, and review its aetiology, diagnosis and management.

Antegrade cardioplegia as a possible cause of acute saphenous vein endothelial damage in patients undergoing on pump coronary artery bypass surgery.

BACKGROUND: The administration of antegrade cardioplegia through vein grafts after the completion of each distal anastomosis is a common practice. However, the cardioplegic solution may disrupt the vein endothelium and contribute to late vein graft atherosclerotic disease. This study aimed at evaluating the possible impact of the cardioplegic solution on vein graft endothelium. METHODS: Total of 52 patients (16 women and 36 men) aged 68±8.5 years old that underwent on pump coronary revascularization with at least one vein graft were enrolled. Sections of grafts from the greater saphenous vein were obtained prior to and after delivery of potassium antegrade cardioplegic solution through them. These sections were then examined histologically with immunochemical stain and CD34 index. The endothelial damage and length of vein specimens of both graft sections were evaluated. RESULTS: The endothelial damage of vein specimens appeared to be increased significantly with exposure to antegrade cardioplegia in male and female patients (P from Wilcoxon tests <0.001, for both genders). The increase in the length of vein specimens was significant too (P from Wilcoxon test <0.001 for men and P=0.001 for women). CONCLUSIONS: Antegrade cardioplegia delivered through vein grafts causes substantial damage on vein endothelium. This may have an adverse effect on long-term graft patency.

Development and validation of a hydrophilic interaction liquid chromatography method for the quantitation of impurities in fixed-dose combination tablets containing rosuvastatin and metformin.

A hydrophilic interaction liquid chromatography method with diode array detection (HILIC-DAD) was developed and validated for the simultaneous determination of impurities in extended-release fixed-dose combination tablets containing rosuvastatin and metformin in a ratio 1:100. The analytes were separated by hydrophilic interaction liquid chromatography using an XBridge®-HILIC analytical column under isocratic elution. The mobile phase was composed of ammonium formate at 150 mM containing 0.05% diethylamine (pH 8.5)/acetonitrile, 4/96 (v/v) and pumped at a flow rate of 0.5 mL min-1. Method validation was performed according to ICH guidelines. The calibration curves for rosuvastatin, metformin and their seven impurities showed good linearity (r > 0.994) within the calibration ranges tested. The intra- and inter-day R.S.D. values were less than 4.5%, while the relative percentage error Er was less than 2.7% for all compounds. Accelerated stability studies performed under various stress conditions including hydrolysis, oxidation and heat proved the selectivity of the procedure. A run time of less than 25 min for each sample made it possible to analyze a large number of samples per day. The method is the first reported application of HILIC for the analysis of impurities in fixed-dose combination tablets containing rosuvastatin and metformin and it can be used for the quality control of these drugs.

A "tilt" toward cinefluoroscopy.

Fluoroscopy permits rapid and straightforward assessment of mechanical valve function and allows a distinction between normal and malfunctional prostheses, acting as a complementary diagnostic step.