Single-session double valve replacement: TAVI+tricuspid valve-in-valve procedures.

We describe a 70-year-old lady with rheumatic heart disease and a history of the mitral valve and tricuspid valve replacement, who underwent transcatheter aortic valve implantation and the tricuspid valve-in-valve procedure in a single session.

Mitral valve-in-valve replacement supported by a transapically snared guidewire via septostomy.

We describe a 72-year-old woman, a known case of rheumatic heart disease with a history of mitral and aortic valve replacement 8 years previously, who underwent mitral valve-in-valve replacement supported by a transapically snared guidewire through septostomy.

Smoking and wound complications after coronary artery bypass grafting.

BACKGROUND: The harmful effects of smoking on the postsurgical wound healing disturbances have been widely investigated across various surgical procedures. These effects after coronary artery bypass graft (CABG) surgery have been less explored. We aimed to investigate the association of smoking and the wound healing problems in post-CABG patients. MATERIALS AND METHODS: We compared the incidence of wound complications in 405 smokers and 405 nonsmokers who underwent an elective CABG surgery. The incidence of leg and sternal wound complications was evaluated during the first 7 d as well as at a 6-wk postoperative visit. RESULTS: One hundred fifty-six leg wound complications were noted in 132 patients (16.3%). The overall rate of leg wound healing disturbances was significantly higher in smokers than those in nonsmokers (odds ratio, 1.47; 95% confidence interval, 1.109-4.019; P = 0.010). The incidence rates of leg wound edge necrosis and dehiscence were significantly higher in smokers compared with those in nonsmokers (3.7% versus 0.7%, P = 0.004 and 6.6% versus 0.7%, P < 0.0001, respectively). We found no significant differences between the incidence of postoperative leg wound infection, hematoma, wound edema, and seroma in active smokers and those who never smoked. Thirty-seven postsurgical sternal wound complications (4.6%) were developed in 33 patients (4.1%). The overall rate of sternal wound healing disturbances was similar between smokers and nonsmokers. There was a trend between the sternal wound dehiscence and smoking (P = 0.03); however, the other sternal wound complications were not associated with smoking. CONCLUSIONS: Smoking may contribute to the disturbances of wound healing, especially wound dehiscence, in post-CABG patients.

Aortic root replacement using a modified composite valve graft.

OBJECTIVES: We used a modified technique of a composite graft by moving the valve prosthesis away from the end into the inside of the tube and compared the effectiveness of this surgical method with the standard valved conduits. METHODS: Through a prospective nonrandomized clinical study between March 2011 and June 2012, we performed replacement of the aortic valve and ascending aorta in 30 consecutive patients using a valved composite graft with a mechanical valve prosthesis. A modified self-assembled valved composite graft was employed in 20 patients (Modified group), while the remaining 10 patients received the standard composite graft (Control group). RESULTS: There was significantly less bleeding in the patients with modified grafts (184 vs. 415 mL, p < 0.05). Moreover, the mean transvalvular gradient of the composite graft patients was lower in the modified group than in the control group (9 vs. 14 mmHg, respectively, p < 0.05). CONCLUSIONS: The modified valve composite graft technique results in good hemodynamics and appears to limit blood loss.

Technetium-99m-ubiquicidin scintigraphy in the detection of infective endocarditis.

We present a case of infective endocarditis (IE) diagnosed by the increased (99m)Tc-UBI specific uptake in the tricuspid valve region. In conclusion, our case data may indicate a first pass-like distribution with strong avidity of the tracer to infective endocarditis, facilitating image interpretation.

Efficacy of papillary muscle approximation in preventing functional mitral regurgitation recurrence in high-risk patients with ischaemic cardiomyopathy and mitral regurgitation.

BACKGROUND: Dilated cardiomyopathy (DCM) is often complicated by the appearance of functional mitral regurgitation (FMR). Although mitral ring annuloplasty (MAP) is the most widely used surgical procedure for the surgical treatment of FMR, there are still reports of patients who suffer recurrent FMR at later follow-ups. We sought to investigate the efficacy of papillary muscle approximation (PMA) combined with MAP in preventing the recurrence of FMR in high-risk patients. METHODS: One hundred patients with ischaemic (74%) or non-ischaemic (26%) DCM along with severe (4+/4+) or moderately severe (3+/4+) FMR were enrolled in this prospective, cross-sectional study. According to the interpapillary muscle distance (iPMD) and coaptation depth (CD), the patients were risk stratified as low (iPMD + CD 30 mm, n= 69) and high-risk (iPMD + CD > 30 mm, n= 31) groups. The low-risk patients underwent only MAP, whereas the high-risk patients underwent MAP plus PMA. RESULTS: After a mean +/- SD follow-up of 40.8 +/- 12.5 months, recurrence of 3+ to 4+ MR was observed in 8 (8.7%) and 7 (11.1%) patients in the annuloplasty group (MAP-only) and one (3.4%) patient in the combination group (MAP plus PMA) (P= 0.428). At the final follow-up, the New York Heart Association (NYHA) function class was 1.57 +/- 0.62 in the annuloplasty group and 1.45 +/- 0.57 in the combination group; there was no significant difference in NYHA function class between the first and final follow-ups (P> 0.05). CONCLUSION: iPMD is a valuable index in the riskstratification of the recurrence of post-MAP MR in patients with DCM complicated by FMR.The patients treated with MAP plus PMA had more favourable outcomes and lower recurrence rates than those treated via the traditional route of MAP only.

Surgical Repair of a Giant Right Atrium Aneurysm That was Incidentally Found in a Boy.

Giant right atrial aneurysms are rare defects with different clinical presentations ranging from lack of symptoms to heart failure. They are diagnosed based on incidental findings. It is commonly found when echocardiography or chest X-ray is performed. Concurrent congenital heart disease and large atrial size are risk factors that may increase the risks of complications such as thromboembolism, fatal arrhythmias, aneurysm rupture, and sudden death. The best treatment has been controversial, with some patients managed surgically and others conservatively. We present a case of a giant right atrium aneurysm that was incidentally detected during a routine examination. The patient underwent successful surgical resection of the right atrial aneurysm.

A Very Rare Case of Isolated Spontaneous Pneumopericardium Secondary to COVID-19.

Coronavirus disease 2019(COVID-19) is currently a pandemic. In addition to respiratory symptoms, involvement of other organs such as the pericardium is also seen. Pneumomediastinum in COVID-19 patients has rarely been reported. Isolated pneumopericardium without pneumomediastinum is even more uncommon. We described a case of COVID-19 in association with pneumopericardium. To the best of our knowledge, no case with isolated pneumopericardium has been reported thus far.

Type B Interrupted Aortic Arch With a Very Large Right Subclavian Artery Aneurysm in an Adult.

Interruption of the aortic arch and right subclavian artery aneurysm is a rare congenital malformation. Survival in adults depends on the formation of collaterals to supply the descending aorta. The interruption of the aortic arch must be taken into account, particularly in patients with hypertension and weak pulses in the lower extremities. We present a case of aortic arch interruption and a right subclavian artery aneurysm in a woman who survived to adulthood.

Incidentally Detected Asymptomatic Cardiac Myxoma in a Patient With COVID-19.

Primary cardiac tumors, such as myxomas, are rare. About 75% of myxomas occur in the left atrium of the heart. Myxomas can have a broad clinical spectrum. The clinical presentation varies from asymptomatic to sudden cardiac death. Sometimes, a diagnosis is difficult. Cardiac myxoma can cause hemodynamic disturbances in the setting of pneumonia and hypercoagulable state in patients with Coronavirus disease 2019(COVID-19) and make treatment decisions difficult. We present a case of unusually huge left atrial mass discovered incidentally in a patient with COVID-19. Upon workup, an echocardiogram revealed an incidental 7 × 5 cm left atrial myxoma. Preoperatively, the patient was monitored closely in the ICU. After stabilization in the ICU, the patient was taken to surgery and the tumor was successfully removed. Pathohistological results after surgical removal of the tumor confirmed the diagnosis of cardiac myxoma. We consider our case extremely rare due to the asymptomatic course despite the large size of the tumor.

A novel mutation in PRKAR1A gene in a patient with Carney complex presenting with pituitary macroadenoma, acromegaly, Cushing's syndrome and recurrent atrial myxoma.

Carney complex (CNC) is a rare syndrome of multiple endocrine and non-endocrine tumors. In this paper we present a 23-year-old Iranian woman with CNC who harbored a novel mutation (c.642dupT) in PRKAR1A gene. This patient presented with pituitary macroadenoma, acromegaly, recurrent atrial myxoma, Cushing's syndrome secondary to primary pigmented nodular adrenocortical disease and pigmented schwanoma of the skin. PRKAR1A gene was PCR amplified using genomic DNA and analyzed for sequence variants which revealed the novel mutation resulting in substitution of amino acid cysteine instead of the naturally occurring valine in the peptide chain and a premature stop codon at position 18 (V215CfsX18). This change leads to development of tumors in different organs due to lack of tumor suppressive activity secondary to failure of synthesis of the related protein.

Aortiopulmonary window: detection with multislice computed tomography.

A young man presented to our center with dyspnea. Echocardiograpy showed a low ejection fraction and a connection between the ascending aorta and the pulmonary artery. Multislice computed tomography confirmed the diagnosis. He underwent successful repair of the connection.

Iatrogenic left main coronary artery obstruction.

A young man with a history of subvalvular aortic valve stenosis repair performed in childhood presented to our center with chest pain. Computed tomography and angiography demonstrated obstruction of the left main coronary artery. The obstruction was believed to result from the cannulation of coronary arteries during antegrade cardioplegia in his previous cardiac surgery.

Huge Mediastinal Thymic Cyst in the Elderly Patient.

Mediastinal thymic cysts are uncommon lesions. Thymic cysts are usually diagnosed incidentally, and their origin could be congenital or acquired. Herein we present the case of a patient who presented with dyspnea. Chest computerized scan showed a large cystic mass. Surgical excision was performed. Pathology findings were consistent with congenital thymic cyst.

The 64-multislice computed tomogram averts misdiagnosis of an anomalous origin of the left main coronary artery.

A 38-year-old woman was discovered to have a systolic murmur for an unrelated complaint. Transesophageal echocardiography showed no atrial or ventricular septal defects, but multiple large collateral vessels in inter-ventricular septum. The origin of left coronary artery was not seen at the expected site on the aortic root. The 64-multislice computed tomography confirmed the diagnosis of an anomalous origin of the left coronary artery from the pulmonary artery. Left coronary artery was revascularized with a saphenous vein graft with an uneventful recovery.

The association between Chlamydia pneumoniae DNA in arherosclerotic plaque and major risk factors in patients undergoing coronary artery bypass grafting.

BACKGROUND AND AIM: This study was conducted to investigate the prevalence of Chlamydia pneumoniae pathogen inside the atherosclerotic plaque of patients undergoing CABG by using PCR assay and to determine whether there is any association between the presence of bacteria in atherosclerotic lesions and classical coronary risk factors. METHODS: In a cross-sectional study, 102 patients (20 to 79 years old; 73.5% male) undergoing CABG were evaluated in terms of major coronary risk factors and the presence of Chlamydia pneumoniae. RESULTS: Chlamydia pneumoniae was found in 23.4% of coronary plaque specimens. Of these, two patients had no risk factor and the rest of the patients had 1 to 3 risk factors. Patients with positive PCR were more likely to have hypercholesterolaemia (p = 0.009) and low HDL levels (p = 0.000) in comparison with the PCR-negative group. There were no statistical differences for other risk factors. CONCLUSION: Our results imply the synergic contribution of Chlamydia pneumoniae DNA and known dyslipidaemia to the development of atherosclerotic lesions in patients undergoing CABG.

Heart transplantation in iran; a comprehensive single-center review of 15-year performance.

BACKGROUND: Heart transplantation in Iran was first performed in July 1993. Since then, Shariati Hospital, affiliated to Tehran University of Medical Sciences, has been representing the most active center of cardiac transplantation in Iran and one of the major sites in the Middle East. This is a comprehensive review of our 15-year practice registry to make a scheme of our record and achievements. METHODS: Clinical data on all consecutive transplanted patients from the Department of Cardiac Surgery, Shariati Hospital, Tehran, Iran over the last 15 years were reviewed. Descriptive and analytical statistics were extracted in regard to recipients, donors, surgical characteristics, and current status of the patients on follow-up. RESULTS: Totally, 90 patients were transplanted since 1993; 11, 32, and 47 in three five-year periods, respectively. The mean age of the recipients was 29.30+/-13.17 years. Motor-vehicle accident was the main cause of brain death of donors (48.8%). The most common indication for surgery was idiopathic dilated cardiomyopathy (75.5%).The mean survival rate has been 6.66+/-0.87 years. One-year and five-year survivals had a rising trend through the five-year periods. Acute allograft rejection and infection were the two major events complicating our transplants. CONCLUSION: This study shows that despite a vast variety of obstacles, we have passed the primitive milestones. The number of transplants is increasing at a higher rate in recent years, and patients' survival rates and outcomes seem to be improving.

Prediction of atrial fibrillation via atrial electromechanical interval after coronary artery bypass grafting.

BACKGROUND: We assessed the validity of the atrial electromechanical interval, measured by transthoracic tissue Doppler echocardiography, in determining patients at risk of post-coronary artery bypass graft atrial fibrillation (AF). METHODS AND RESULTS: This prospective study recruited 355 patients in sinus rhythm who were candidates for coronary artery bypass grafting. The patients underwent a preoperative transthoracic echocardiography with a tissue Doppler evaluation and were monitored with continuous ECG telemetry during their hospital stay. Sixty-eight patients had postoperative AF (19.2%), with the incident occurring 2.3+/-0.7 days after surgery. The median length of hospitalization was 7.0 days for the AF patients and 6.0 days for the non-AF patients (P<0.0001). The subjects with postoperative AF differed from the sinus rhythm patients in that the former had a lower ejection fraction (40.4+/-8.5% versus 48.4+/-9.4%), a reduced maximal A-wave transmitral Doppler flow velocity (44.3+/-4.6 versus 53.3+/-10.9 cm/s), an increased total atrial volume (68.7+/-12.6 versus 55.3+/-11.8 mL), and a prolonged atrial electromechanical interval (141.9+/-13.4 versus 100.3+/-10.3 ms, respectively; P<0.0001 for all). In addition, the AF patients were older than the sinus rhythm group (66.0+/-8.0 versus 59.8+/-8.5 years). The atrial electromechanical interval was the best independent discriminator of the history of AF. We defined a cutoff point for the atrial electromechanical interval and chose 120 milliseconds for categorization, which yielded 100% sensitivity and 94.8% specificity for the prediction of AF. CONCLUSIONS: The atrial electromechanical interval by transthoracic tissue Doppler echocardiography could be a valuable method for identifying patients vulnerable to post-coronary artery bypass graft AF.

Complicated course consequences of a floating thrombus in ascending aorta.

The ascending aorta may be the site of origin of systemic embolization of an unidentifiable cause. We report a case in which a free-floating thrombus of an unknown cause was detected in the ascending aorta via transesophageal echocardiography. The removal of this pedunculated thrombus, which was attached onto a macroscopically and histologically mildly atherosclerotic aortic wall, led to an uneventful recovery for the patient.

Cardiac and great vessel involvement in "Behcet's disease".

Behcet's disease is a multisystem disorder and classified as "vasculitic syndrome with a wide variety of clinical manifestations." Cardiac involvement is very rare but can occur with different presentations including: pericarditis, cardiomyopathy, endocarditis, endomyocardial fibrosis, intracavitary thrombosis, and coronary artery disease. Great vessel involvement is more common. Recurrent Phlebitis, commonly involving large vessels (superior vena cava, inferior vena cava, hepatic veins) and cerebral veins are the sole presentation in this regard. Arterial involvement is expressed by aneurysm or pseudoaneurysmal formation. Due to the wide variety of cardiovascular manifestations and the resulting high mortality, cardiac surgeons should be familiar with this disease. In this paper we review the articles and introduce our four cases presenting with aneurysm of ascending aorta with free aortic insufficiency, aneurysm of descending aorta, pulmonary artery aneurysm, and pseudoaneurysm of aortic arch.