An unusual case of endotipsitis: persistent infection and migration to the right atrium of a transjugular intrahepatic portosystemic shunt (TIPS).

Endotipsitis is an underdiagnosed entity mainly because it requires a high initial level of suspicion. It should be considered in the differential diagnosis of persistent bacteremia in the cirrhotic patient with TIPS. Most cases are treated conservatively with a long-term antibiotherapy, due to the impossibility of surgical removal of the TIPS, except in a liver transplant or autopsy. The patient we present had endotipsitis that manifested as persistent bacteremia with thrombosis of the TIPS. Initially, conservative management with intravenous antibiotherapy was performed; however, due to mechanical complications caused by migration of the original endoprosthesis, it was decided to perform surgery.

Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Coronary pseudoaneurysm after Bentall-Bono intervention: A novel treatment to a rare surgery complication.

We present a rare case of a coronary pseudoaneurysm after a Bentall-Bono procedure. During a routine follow-up computed tomography scan, a pseudoaneurysm located between the aorta and the proximal portion of the right coronary artery was diagnosed. Contrast extravasation was observed with partial thrombosis of the pseudoaneurysm. Coronary angiography and intravascular ultrasound were performed showing the point of contrast extravasation dependent of the right coronary artery in its proximal portion. An angioplasty procedure was performed sealing the pseudoaneurysm with the implantation of a covered stent. After an uneventful postoperative follow-up, the patient was discharged home. Learning objective: The development of a coronary artery pseudoaneurysm (CAP) after complex cardiac surgeries, like Bentall-Bono procedure, could be a life-threatening condition. The possible derived complications of CAP are rupture, compression of surrounding structures, or coronary ischemia.Although surgical approach to a CAP may have an extremely high surgical risk, most of the cases require a complex surgical repair. We describe a novel possible treatment option by angioplasty and sealing of the CAP with the implantation of a covered stent.

Two giant sinus of Valsalva pseudoaneurysms as a casual finding.

BACKGROUND: Pseudoaneurysms of the sinus of Valsalva are infrequent cardiac pathologies that usually involve a single sinus. MATERIAL AND METHODS: We present a case of a 63-year-old male who was diagnosed with ascending aortic aneurysm during a routine echocardiogram. CONCLUSION: We report here a patient with giant pseudoaneurysms of two sinuses of Valsalva who successfully underwent a sinus of Valsalva reconstruction.

Differences in life expectancy between men and women after aortic valve replacement.

OBJECTIVES: Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences. METHODS: All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death. RESULTS: For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03). CONCLUSIONS: After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.

Takotsubo syndrome after mitral valve surgery: a case report.

BACKGROUND: Takotsubo syndrome is a frequent entity; however, it has never been described after a mitral valve surgery. CASE SUMMARY: We present the case of a 79-year-old woman, with background of atrial fibrillation and a left atrial appendage closure device, who was admitted for elective mitral valve replacement, because of asymptomatic severe primary mitral regurgitation. Biologic mitral valve was implanted without incidences, but in the postoperative, she developed cardiogenic shock. Electrocardiogram (ECG) showed inverted T waves in precordial leads and an echocardiography showed severe left ventricular (LV) dysfunction with mid to distal diffuse hypokinesis, and better contractility in basal segments. Troponin levels were mildly elevated. With the suspicion of a postoperative acute coronary syndrome, a coronary angiography was performed and showed no significant coronary lesions. The haemodynamic situation was compromised for the next 48 h, in which vasoactive support and intra-aortic balloon counterpulsation were implemented. After 48 h, the haemodynamic situation suddenly improved. The ECG was normalized, and a control echocardiogram showed partial recovery of the LV function with resolution of regional wall motion abnormalities. The patient could be discharged at 1 week. The clinical picture was interpreted as a stress cardiomyopathy after mitral valve surgery. DISCUSSION: Takotsubo syndrome is a threatening condition; complications in acute phase could lead to a fatal outcome. Mitral valve surgery has to be considered as a trigger for this entity, after excluding coronary involvement, specially of left circumflex artery.

Recurrent haemorrhagic pericardial effusion due to idiopathic pericarditis: a case report.

BACKGROUND: Haemorrhagic pericardial effusion (PE) has been described in pericarditis due to infection, neoplasm, collagen vascular disease, uraemia, pericardial inflammation after acute myocardial infarction, trauma, irradiation, and idiopathic pericarditis. Patients with large haemorrhagic PE develop recurrence or constrictive pericarditis (CP) frequently as complication without being treated intensively. CASE SUMMARY: A 22-year-old female patient with a previous episode of pericarditis with severe PE was admitted for acute pericarditis. Three days before, she was evaluated at the emergency department and presented normal laboratory workup and no significant findings in the transthoracic echocardiogram (TTE). A new TTE showed severe PE and laboratory work-up showed low haemoglobin levels. Fifteen days later, due to slow evolution, a left anterior mini-thoracotomy pericardial window procedure was performed finding minimal haemorrhagic PE with clots. We performed a complete work-up for a cause without significant findings and treated intensely to prevent recurrence or CP. DISCUSSION: This is a case of recurrent haemorrhagic PE due to idiopathic pericarditis. Physicians should perform an intensive workup in order to find the cause because of its clinical implications and possible treatments. An intensive treatment must be initiated as soon as possible to prevent recurrence or CP.

Prophylactic treatment with coenzyme Q10 in patients undergoing cardiac surgery: could an antioxidant reduce complications? A systematic review and meta-analysis.

Coenzyme Q10 (CoQ10) is a lipid-soluble antioxidant that could have beneficial effects in patients undergoing cardiac surgery with cardiopulmonary bypass. There is no clear evidence about its clinical effects or a systematic review published yet. We aimed to conduct a systematic review and meta-analysis of the literature to elucidate the role of coenzyme Q10 in preventing complications in patients undergoing cardiac surgery with cardiopulmonary bypass. We searched the PubMed Database using the following keywords: Coenzyme Q10, ubiquinone, ubiquinol, CoQ10, Heart Surgery, Cardiac surgery. Articles were systematically retrieved, selected, assessed and summarized for this review. We performed separate meta-analyses for different outcomes (inotropic drug requirements after surgery, incidence of ventricular arrhythmias and atrial fibrillation, cardiac index 24 h after surgery and hospital stay), estimating pooled odds ratios (ORs) or mean differences of the association of CoQ10 administration with the risk of these outcomes. Eight clinical trials met our inclusion criteria. Patients with CoQ10 treatment were significantly less likely to require inotropic drugs after surgery {OR [95% confidence interval (CI) 0.47 (0.27-0.81)]}, and to develop ventricular arrhythmias after surgery [OR (95% CI) 0.05 (0.01-0.31)]. However, CoQ10 treatment was not associated with Cardiac index 24 h after surgery [mean difference (95% CI) 0.06 (-0.30 to 0.43)], hospital stay (days) [mean difference (95% CI) -0.61 (-4.61 to 3.39)] and incidence of atrial fibrillation [OR (95% CI) 1.06 (0.19-6.04)]. Since none of the clinical trials included in this review report any adverse effects associated to CoQ10 administration, and coenzyme Q10 has been demonstrated to be safe even at much higher doses in other studies, we conclude that CoQ10 should be considered as a prophylactic treatment for preventing complications in patients undergoing cardiac surgery with cardiopulmonary bypass. However, better quality randomized, controlled trials are needed to clarify the role of CoQ10 in patients undergoing cardiac surgery with cardiopulmonary bypass.

Left atrial appendage occlusion by invagination and double suture technique.

Left atrial appendage (LAA) plays a crucial role as a source of atrial thrombus in patients with atrial fibrillation (AF). Thus, the need to close LAA becomes evident in patients with AF who undergo concomitant mitral valve surgery. Unfortunately, it has been reported a high rate of unsuccessful LAA occlusion, regardless of the technique employed.We propose a safe and simple method for LAA occlusion consisting in invagination of the appendage into the left atrium, followed by two sutures (purse string suture around the base of the LAA and a reinforce running suture).

Lipomatous hypertrophy of the interatrial septum: report of two cases where histological examination and surgical intervention were unavoidable.

Lipomatous hypertrophy of the interatrial septum (LHIS) is an increasingly recognized heart condition characterized by fatty deposits in the interatrial septum with sparing of the fossa ovalis. Its distinctive characteristic features by imaging techniques, benign nature, and the fact that most patients remain asymptomatic, has limited the need for histological confirmation and operative intervention in most cases. In this report, we describe two cases of LHIS where cardiac surgical intervention was indispensable: in the first patient, due to the presence of an additional left atrial tumour found out as mixoma and in the second, to relief a superior vena cava obstruction together with bypass grafts for severe coronary artery disease. Histological samples of the interatrial septal lesion were obtained in both cases either because of uncertainty of the diagnosis (Case 1) or to confirm the diagnosis (Case 2).