Budd-Chiari syndrome following abdominal trauma.

We report a case of Budd-Chiari syndrome (BCS) in a 44-year-old man with inferior vena cava (IVC) thrombosis and nephrotic syndrome. This case was complicated by right atrial clot and pulmonary emboli. Endothelial injury of the IVC was the likely mechanism, following a kick from a donkey. Abdominal ultrasonography revealed a large thrombosis located in a segment of IVC near its orifice in the right atrium. Transthoracic echocardiography (TTE) revealed IVC thrombosis that extended to the right atrium; however, pulmonary emboli (PE) were not documented in TTE. Intraoperative exploration revealed multiple clots in the main and left pulmonary artery branches. The patient recovered well after open-heart surgery with resection of the right atrium, IVC, and pulmonary artery emboli. BCS should be routinely considered for patients with nephrotic syndrome.

Combined chest wall and liver hydatid cyst.

BACKGROUND: Hydatid cysts (HC) are primarily found in the liver, with secondary occurrences in the lungs and other organs. The presence of HCs in the anterior chest wall is notably rare, and even more so when associated with HCs in the liver. CASE PRESENTATION: A 53-year-old male reported to our facility with a non-painful lump on his chest's front wall. A thoraco-abdominal CT scan identified cysts within the chest wall's subcutaneous layer, showing no spread to nearby soft tissues or involvement of the lungs and ribs. Despite an echinococcal test returning negative, the initial diagnosis leaned towards a dermoid cyst. After surgical removal and detailed examination, the cysts were confirmed as HCs. Further investigation revealed an additional liver HC. The patient was referred for surgery where he underwent laparotomy and drainage of cyst content. CONCLUSION: This case underscores the importance of considering HCs when diagnosing palpable lesions on the chest wall, particularly in regions where HCs are endemic.

A rare case of volvulus after off-pump coronary artery bypass graft surgery in an opium addict patient revised.

BACKGROUND: Volvulus of colon is a very rare phenomenon in post cardiac surgery course, and their predicting factor in most patients is unknown. Between colonic volvulus, splenic flexure is the rarest site for torsion in general population. The main symptoms are vague abdominal pain, vomiting and distension. The primary diagnostic images include plain chest x-ray, CT scan and colonoscopy. CASE PRESENTATION: We report the case of a 57-year -old opium male addict, who was. Admitted for abdominal pain, nausea, and vomiting five days after off-pump coronary artery bypass surgery (OPCAB). An abdominal x-ray reported a colonic volvulus. Exploratory laparotomy showed acute abdomen resulting from a gangrene of long segment of splenic flexure caused by volvulus. CONCLUSION: Gastrointestinal complication such as volvulus is an exceedingly rare complication of OPCAB, despite the absence of anatomic abnormalities only complete colonic malrotation as the result of mega colon and constipation, the main pathogenetic causes. This patient was unique because of careful literature search revealed that this case was the first reported volvulus that has been described so far.

HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) versus adult T-cell leukemia/lymphoma (ATLL).

OBJECTIVES: Human T cell leukemia virus-1 (HTLV-1) infection may lead to one or both diseases including HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) or adult T cell leukemia lymphoma (ATLL). The complete interactions of the virus with host cells in both diseases is yet to be determined. This study aims to construct an interaction network for distinct signaling pathways in these diseases based on finding differentially expressed genes (DEGs) between HAM/TSP and ATLL. RESULTS: We identified 57 hub genes with higher criteria scores in the primary protein-protein interaction network (PPIN). The ontology-based enrichment analysis revealed following important terms: positive regulation of transcription from RNA polymerase II promoter, positive regulation of transcription from RNA polymerase II promoter involved in meiotic cell cycle and positive regulation of transcription from RNA polymerase II promoter by histone modification. The upregulated genes TNF, PIK3R1, HGF, NFKBIA, CTNNB1, ESR1, SMAD2, PPARG and downregulated genes VEGFA, TLR2, STAT3, TLR4, TP53, CHUK, SERPINE1, CREB1 and BRCA1 were commonly observed in all the three enriched terms in HAM/TSP vs. ATLL. The constructed interaction network was then visualized inside a mirrored map of signaling pathways for ATLL and HAM/TSP, so that the functions of hub genes were specified in both diseases.

The Ruptured Pericardial Cyst to the Right Atrium: A Case Report.

The pericardial cysts (PC) are rare congenital anomaly. They are usually asymptomatic or incidentally found during surgery or by an imaging modality. We report a 35-yr-old man referred to Imam Ali Hospital, Kermanshah, western Iran in 2017, with palpitation, chest pain and dyspnea and physical exam revealed sign and symptoms of right atrial compression and tamponade.

Minimal Invasive Technique in Atrial Septal Defect Surgery.

BACKGROUND: Median sternotomy with minimal skin incision (MSWMSI) and modified anterior mini-thoracotomy (MAMT) approach that both are innovative techniques modified from previous documented techniques are important alternative to conventional median sternotomy in atrial septal defect (ASD) repair. Our aim is to explain the details of two performed techniques in our center and explain the results. METHODS: Totally 54 children with ASD (20 female and 34 male) were operated with two different techniques i.e. MAMT and MSWMSI in Imam Ali heart surgery center between May 2010 and May 2013. Intra and postoperative variables such as cardiopulmonary bypass time and aortic cross-clamp time, intensive care unit stay time, length of incision, postoperative hematoma and seroma, dehiscence mortality, exploration for postoperative bleeding, neurologic complication, infection and amount of blood transfusion were recorded. RESULTS: Mean cardiopulmonary bypass time was 30 ± 11 min, and mean aortic cross-clamp time was 7 ± 2 min. The mean amount of blood transfusion was 150 ± 39 mL, and the mean chest tube drainage after surgery was 140 ± 57 mL. Superficial skin infection occurred in three patients. Subcutaneous hematoma and seroma were founded in six patients. In 50 cases the defect was secundum type, in two patients it was sinus venosus type, and in two with associated perimembranous ventricular septal defect repair. CONCLUSION: Both approaches are safe and may be the surgical techniques of choice for secundum ASD repair in all age groups; and we can also utilize these techniques for more complicated kinds of surgery, for instance, sinus venosus type ASD with or without partial anomalous defect.

The diagnosis of microorganism involved in infective endocarditis (IE) by polymerase chain reaction (PCR) and real-time PCR: A systematic review.

Broad-range bacterial rDNA polymerase chain reaction (PCR) followed by sequencing may be identified as the etiology of infective endocarditis (IE) from surgically removed valve tissue; therefore, we reviewed the value of molecular testing in identifying organisms' DNA in the studies conducted until 2016. We searched Google Scholar, Scopus, ScienceDirect, Cochrane, PubMed, and Medline electronic databases without any time limitations up to December 2016 for English studies reporting microorganisms involved in infective endocarditis microbiology using PCR and real-time PCR. Most studies were prospective. Eleven out of 12 studies used valve tissue samples and blood cultures while only 1 study used whole blood. Also, 10 studies used the molecular method of PCR while 2 studies used real-time PCR. Most studies used 16S rDNA gene as the target gene. The bacteria were identified as the most common microorganisms involved in infective endocarditis. Streptococcus spp. and Staphylococcus spp. were, by far, the most predominant bacteria detected. In all studies, PCR and real-time PCR identified more pathogens than blood and tissue cultures; moreover, the sensitivity and specificity of PCR and real-time PCR were more than cultures in most of the studies. The highest sensitivity and specificity were 96% and 100%, respectively. The gram positive bacteria were the most frequent cause of infective endocarditis. The molecular methods enjoy a greater sensitivity compared to the conventional blood culture methods; yet, they are applicable only to the valve tissue of the patients undergoing cardiac valve surgery.

Right atrial fibroma in an adult patient.

Left atrial fibroma as a benign tumor is an exceedingly rare left atrial mass. It has various clinical signs and symptoms and sometimes leads to serious complications such as lethal arrhythmia and death. We report a case of right atrial fibroma in a 40-year-old male who presented with dyspnea and atrial fibrillation. Transthoracic echocardiography revealed a large sessile mass attached to interatrial septum near the coronary sinus valve in the right atrium. The patient underwent surgical resection of tumor through the right atrium. The postoperative course was unremarkable. Histopathological examination showed that it was a fibroma. The 6-month follow-up revealed that the patient was in well condition with no evidence of tumor recurrence.

Multiple Complications by Hydatid Cyst-induced Budd Chiary Syndrome: A Case Report.

A case of the Budd Chiary Syndrome (BCS) in a 43-yr-old man with hydatid cyst (HC) in the liver is reported from Imam Ali Hospital, Kermanshah, western Iran in 2016. This case was complicated by inferior vena cava (IVC) thrombosis, right atrial clot and pulmonary emboli. Compression of IVC was the likely mechanism. Abdominal ultrasonography revealed a huge HC located in segments near IVC and caused compression of IVC. Transthoracic echocardiography (TTE) revealed IVC and right atrium thrombosis, however pulmonary emboli was not documented in TTE but intra operative exploration showed multiple clot in main and left pulmonary artery branch. The patient recovered after open-heart surgery with removal of right atrial, IVC and pulmonary artery emboli. BCS should be looked for routinely in patients with HC of the liver.

Right ventricular outflow tract endocarditis caused by brucellosis.

Right-ventricular outflow tract (RVOT) endocarditis is a very rare presentation of right-sided infective endocarditis (RSIE) by brucellosis. RSIE occurs most commonly in immune-suppressed cases and illicit drug abuser. The patients with RSIE and an incompetent immune system usually have a prosthetic foreign body in blood circulation such as catheter, pacemakers, or central venous lines and may be accompanied with tricuspid or pulmonary valve dysfunction. The most common site for RSIE is the tricuspid valve. We describe an exceedingly rare condition of RVOT endocarditis in a patient with brucellosis in which vegetation is attached to a muscle bundle of the RVOT. Despite appropriate antibiotic therapy, the general condition of the patient deteriorated and was finally scheduled for open-heart surgery. The mass was resected and the patient recovered uneventfully and was discharged on the 9th day of surgery with appropriate oral antibiotics.

Large In-transient Left Ventricular Thrombus due to Anabolic Steroid-induced Cardiomyopathy.

The presence of small or moderate size thrombosis is not uncommon in left ventricle (LV) as results of basic co-moribund disease, but huge LV thrombosis that protrudes to aortic valve in the LV outflow tract (LVOT) tract is an exceptionally rare phenomenon. We report a 34-year-old bodybuilder athlete with cardiomyopathy and massive LV thrombosis. The thrombosis extended to LVOT and protruded through the aortic valve in systole and posed a high risk of systemic emboli. The patient underwent open heart surgery, and the clot was removed. The operation was complicated by low cardiac output syndrome that managed by intra-aortic balloon pump and high dose of inotropic drugs and hemodialysis. The patient died on the 15th day after surgery with multiorgan failures.

Diaphragmatic Rupture and Hernia after Cardiopulmonary Resuscitation.

A 55-year-old man underwent surgical replacement of a mitral valve 10 years earlier. In a retrospective evaluation of a chest radiograph, the diaphragm was intact at the time of initial surgery. He was then admitted to our emergency room with a complaint of vertigo. During evaluation, he developed decreased consciousness. Ventricular fibrillation was diagnosed, and external massage and full cardiopulmonary resuscitation were performed. After 20 minutes, his sinus rhythm returned and hemodynamic status stabilized with inotropic drugs. Transthoracic echocardiography showed normal valvular function and no evidence of left cardiac malfunction or clot. Electrocardiography showed ST elevation in inferior leads, and levels of cardiac enzymes were elevated. Angiography showed an embolic lesion in the mid right coronary artery that was treated with percutaneous coronary intervention (PCI) and insertion of a stent. After 24 hours, the patient was extubated in good condition, but had mild dyspnea that progressed to CO2 narcosis and subsequent reintubation. Post-extubation chest radiography showed herniation of abdominal organs into the right hemithorax. The diaphragmatic defect was closed with a polytetrafluoroethylene patch by a thoracic surgeon, and the postoperative course was uncomplicated.

Isolated Right Atrial Mass in a Candidate of Coronary Bypass Grafting.

Hepatocellular carcinoma (HCC) is not uncommon neoplasm, and its occurrences with coronary artery disease (CAD) is more confronted by cardiac surgeon today. In most cases, when the HCC is detected, it has invaded to regional or distant sites. The most frequent location of HCC metastasis includes pulmonary system, musculoskeletal, lymphatic system, and central nervous system. Indeed, intra-atrial metastasis is a rare phenomenon and associated with poor outcome. We report a case of CAD with known HCC that referred for CABG before scheduling for hepatic tumor management. His severe typical chest pain, aggravated by mild activity so his abdominal pain is shadowed by chest pain. The abdominal ultrasound revealed a large mass in the left hepatic lobe. Chest x-ray was unremarkable. Routine preoperative transthoracic echocardiography (TEE) exhibits a large sessile mass in the right atrium. The patient underwent combined resection of right atrial mass and off-pump coronary artery bypass grafting. The most of HCC patients with RA involvement usually presenting with lengthy thrombus that continues from vascular invasion site to RA, however, as in our patient, isolated and sole metastasis to RA is an exceptional phenomenon in HCC. The clinical postoperative course was uneventful, and the patient discharged on the 10th day of operation. The six-month follow-up revealed no recurrence of right atrial mass when the patient completed his treatment by hepatic lobectomy and combined adjuvant chemotherapy.

Ostium secundum atrial septal defect endocarditis caused by brucella infection.

The most common cardiovascular presentation of brucellosis (a zoonotic infection) in Iran is aortic valve endocarditis. Brucellosis is a systemic infection and may involve any congenital heart defect with various clinical signs and symptoms. We report brucella endocarditis in an atrial septal defect (ASD) in a 55-year-old man who presented with fever and hemiplegia. Echocardiography showed a secundum ASD with large vegetations of 0.5×1 cm arising from the rim of the ASD. Serological analysis was positive for Brucella agglutinin, thus confirming the diagnosis. The brain CT scan revealed a large ischaemic zone in the left hemisphere. At surgery, large vegetations were excised and the defect was closed with fresh pericardium. After surgery the patient was treated with a 4- week course of antibiotics. His recovery was uneventful except for the neurological deficit (hemiplegia); he was discharged on postoperative day 35.

Efficacy of Preoperative Color Doppler Sonography of Lower Extremity Veins on Postoperative Outcomes in Candidates of Saphenectomy: A Randomized Clinical Trial.

BACKGROUND: Doppler sonography is a type of sonography used for imaging the blood flow in the vessels and heart. This technique uses ultrasound waves with high frequency. In some patient candidates for venous graft, the identification of the suitable vein is not possible with clinical examination. OBJECTIVE: This study compared the effects of preoperative color Doppler sonography of lower extremity veins on the postoperative outcomes of saphenectomy. METHODS: This randomized clinical trial was conducted on 100 candidates of an off-pump coronary artery bypass graft (CABG) hospitalized in Afshar Hospital in Yazd in 2015. Patients were divided into two groups: 50 patients in the study group and 50 patients in the control group. Patients in the study group underwent color Doppler sonography of lower extremity veins using the Medison 8000 Live device. Patients in the control group were assessed preoperatively by routine venous examination without undergoing color Doppler sonography. The prepping and draping methods and also the preoperative antibiotics were the same for both groups. The patients were assessed for wound infection, edema, hematoma, and DVT 2 days, 1 week, and 1 month after surgery. Data were analyzed by SPSS version 16 using t-test, Chi-square, and Fisher's exact test. RESULTS: The length of incision for saphenectomy was 29.20 ± 3.71 cm in the Doppler group and 28.98 ± 3.72 cm in the non-Doppler group with no significant difference between the two groups (p=0.768). The two groups were not significantly different with respect to age, gender, diabetes, hypertension, hyperlipidemia, smoking, and history of peripheral vessels disease, postoperative infection, postoperative organ edema, postoperative hematoma, and postoperative DVT. CONCLUSION: Preoperative color Doppler sonography of the saphenous vein before saphenectomy has no effect on reducing the postoperative complications, and saphenectomy on the basis of intraoperative examination of the vein course by the surgeon has acceptable consequences. CLINICAL TRIAL REGISTRATION: The trial was registered at the Thai Clinical Trials Registry (TCTR) (http://www.clinicaltrials.in.th) with the TCTR ID: TCTR20160708001. FUNDING: The authors received no financial support for the research, authorship, and/or publication of this article.

Preoperative Emboli in a Pregnant Woman with Myxoma.

The left atrium is the most common location of myxomas, which are benign tumors. Only a few cases of myxomas in pregnancies have been reported. Our thorough medical literature search showed only 17 reported cases in the course of pregnancy. Myxomas during pregnancy and in the preterm period constitute a serious phenomenon that can mimic an early sign of a life-threatening pathology like severe mitral stenosis. We describe a 33-year-old woman, who presented with acute dyspnea to a gynecology center and was referred to our hospital for further evaluation of pulmonary embolism. Transthoracic echocardiography showed a huge left atrial myxoma, and computed tomography scan illustrated paradoxical pulmonary embolism in the left upper lung lobe via a large patent foramen ovale. The tumor required urgent cardiac surgery. In this article, we review causes of dyspnea in pregnancy and the cardiovascular effects of myxomas in pregnancy. We also describe the pathophysiological effects of cardiopulmonary bypass on the mother, fetus, and the feto-placental system during open-heart surgery. We performed a successful surgical resection of a myxoma in a pregnant woman. Given the rarity of such cases, individual multidisciplinary assessment and management strategies are essential.

The effect of magnesium sulfate on post off-pump coronary artery bypass grafting bleeding.

BACKGROUND: Magnesium level alteration may cause coagulation abnormality resulting in bleeding complication after off-pump coronary artery bypass grafting. In this study, we investigated the effect of magnesium on the postoperative coagulation profile and bleeding in OPCAB patients. METHODS: In a double blind clinical trial, six hundred patients were randomly allocated to two groups: group A (n=150) and group B (n=450). Group A received 50mg/kg of magnesium sulfate (MS) in 100ml 0.9% NaCl solution over 20min before the anesthesia induction. Group B or control group received only 100ml 0.9% NaCl solution at the same time points. OPCAB was performed with standard technique and device. Blood samples were collected 30min before and 6h after the surgery to analyze hemoglobin and blood coagulation tests. Postoperative exploration for bleeding, blood transfusion, and volume of transfusion was recorded. The two groups compared with t-test and χ(2) tests and p-valve <0.05 were considered as significant. RESULTS: However, postoperative hemoglobin was statistically lower in group A compared with group B, but platelet, PT, and aPTT tests were not statistically different between two groups. The serum MS level, exploration for bleeding, volume of packed cell transfusion, and volume of postoperative bleeding were statistically different between group A vs group B. CONCLUSION: Preoperative MS use may be associated with the postoperative platelet dysfunction and increased tendency to bleeding. This is an important risk factor for postoperative bleeding in the OPCAB in absence of CPB use.

Right Ventricular Thrombus and Cerebral Artery Aneurysm in a Patient with Behçet's Disease.

We report a 35-year-old woman referred to the Imam Ali Hospital, Kermanshah, Iran, in July 2014 for evaluation of postoperative dyspnoea after neurosurgery performed seven days previously for a ruptured cerebral artery aneurysm. She was known to have Behçet's disease with a history of recurrent oral and genital aphthous ulcers and uveitis. At referral, her symptoms included vertigo, dysarthria, palpitations and chest pain. Transthoracic echocardiography (TTE) revealed a large thrombus in her right ventricle outflow tract and open-heart surgery was performed eight days after the previous surgery to remove the clot. The postoperative period was complicated by transient acute renal failure, which resolved spontaneously. The patient was discharged 13 days after the cardiac surgery on warfarin, prednisolone, azathioprine and cyclophosphamide. Cyclophosphamide and azathioprine were discontinued after three months as the symptoms had completely resolved; however, prednisolone was continued due to recurrent uveitis. A 10-month follow-up TTE scan revealed no thrombus recurrence and treatment with warfarin and prednisolone was continued.

Simultaneous External Iliac Artery and Vein Rupture Following Percutaneous Balloon Angioplasty.

A 73-year-old woman who had undergone coronary artery bypass grafting for coronary artery stenosis six years ago, presented with right lower extremity claudication. Angiography revealed right external artery stenosis. Elective external iliac PTCA was performed complicated with simultaneous external iliac artery and vein rupture that was an exceedingly rare event. Retroperitoneal laparotomy with repair of ruptures took done, but the patient died with post-operative multi-organ failure.

Combination of a Giant Dissected Ascending Aortic Aneurysm with Multiple Fistulae into the Cardiac Chambers Caused by Prosthetic Aortic Valve Endocarditis.

The combination of a dissected ascending aortic aneurysm (AA) with multiple fistulae to the periaortic root structures is a life-threatening complication that occurs rarely after infective endocarditis of the prosthetic aortic valve. Many risk factors are potentially associated with this complication, including aortic diameter, connective tissue disease of the aortic wall, hypertension and infection. We report a rare case of dissected ascending AA with fistulae to the left atrium and pulmonary artery and a paravalvular leak in a 47-year-old woman with a history of an aortic valve replacement. The patient had presented to the Imam Ali Hospital, Kermanshah, Iran, in January 2015 with clinical features of heart failure. After initially being treated for congestive heart failure, she underwent open-heart surgery via a classic Bentall procedure and double fistula closure. She was discharged 23 days after the operation in good condition. A six-month follow-up showed normal functioning of the composite conduit prosthetic valve and no fistulae recurrence.