Massive primary pulmonary artery rhabomyosarcoma: A case report.

BACKGROUND: Pulmonary artery sarcomas (PAS) are rare tumours causing an insidiously progressive obstruction of the pulmonary circulation. The clinical presentation is often indistinguishable from chronic thromboembolic pulmonary hypertension (CTEPH). However, the atypical appearance of a heterogeneous filling defect in CT pulmonary angiography (CTPA) should prompt further investigation. CASE PRESENTATION: A previously healthy young man presented with massive haemoptysis, acute respiratory distress, and progressive exertional dyspnea since the year before. Echocardiography demonstrated severe right ventricular dysfunction and highly probable pulmonary hypertension. CTPA revealed an extensive filling defect with an appearance concerning PAS. Due to syncopal episodes at rest, the patient underwent urgent pulmonary artery endarterectomy (PEA). A massive tree-like tumour was excised as a result. Post-operatively, reperfusion injury and refractory pulmonary oedema mandated extracorporeal membrane oxygenation (ECMO). Unfortunately, ECMO was complicated with massive haemolysis and acute kidney injury. The patient succumbed to multi-organ failure. Through tissue analysis established a diagnosis of embryonal rhabdomyosarcoma. DISCUSSION: Unfortunately, the patient had not reached out for his worsening dyspnea. PASs should not be mistaken for a thrombus and anticoagulation should be avoided. The urgent condition precluded biopsy and tissue diagnosis. Similarly, neoadjuvant chemotherapy was not feasible. Post-operatively, reperfusion injury and pulmonary oedema ensued, which mandated ECMO. This complication should be anticipated preoperatively. There is a need for more data on PASs to establish a consensus for management.

Novel Aortic Valve Replacement Technique for Reducing Complete Heart Block.

Background: Aortic valve replacement (AVR) may complicate conduction abnormalities and require permanent pacemaker (PPM) implantation. New techniques that lessen this challenge may lead to the development of new approaches. Our objective was to evaluate the contemporary incidence of early postoperative PPM implantation in patients undergoing isolated AVR and root disease with the standard AVR surgical technique compared with the novel suture AVR technique. Methods: The clinical data of 354 patients (250 male, 104 female) who underwent surgery for isolated AVR and root disease in different referral cardiology departments in Tabriz, Iran, over 4 years were analyzed. Patients with preoperative significant conduction abnormalities were excluded from the study. The patients were evaluated for in-hospital mortality, postoperative PPM implantation, and their stay in the ICU after surgery. Results: The mean age of the patients was 52.46±16.13 years. Totally, 183 patients (51.7%) were operated on with the new suture AVR technique. In-hospital mortality was lower in this group than in the group that underwent the "classic" surgical technique (2.5% vs 3.7%). PPM implantation was required in 3 patients (0.8%) after the novel suture AVR technique, whereas it was needed in 12 patients (3.4%) in the other group (P=0.024). The mortality rate was 9 patients (2.5%) in group 1 and 13 patients (3.7%) in group 2, which was not statistically significant (P=0.296). According to the logistic regression, the survival rate in the group operated on with the classical surgical method was 0.27 times higher than that in the patients operated on with the new method. Conclusion: Permanent complete AV block is a critical complication after AVR surgery. A lower PPM requirement and higher survival in patients operated on with the new method was the main finding of this study. New techniques with lower PPM requirements may be suitable for cardiac surgery.

Vegetation Formation and Aortitis as a Possible Sequela of COVID-19 in a Patient with an Aortic Stent: A Case Report.

Bacteria, especially staphylococcal groups, cause aortic graft infection. Infection stems from synthetic materials that repair aneurysms or artery blockages. Aortic stent infection and vegetation formation are rare, and heterogeneous presentations and ambiguous findings in routine diagnostic modalities render the diagnosis challenging. A 25-year-old man with a history of catheter-based aortic stenting for hypertension associated with severe aortic coarctation was referred to our tertiary care hospital. Five months before the presentation, the patient had been infected with COVID-19, but he recovered after mild symptoms. Nevertheless, 3 months later, he developed erythematous lesions, progressive anorexia, epigastric pain, fever, and weakness. The results of blood tests, blood cultures, transthoracic echocardiography, plain chest radiography, computed tomography angiography, and electrocardiography were unremarkable. We found severe infectious aortitis, crescent thickness surrounding the aorta, pseudoaneurysm development, and a mass with dimensions of 17 mm×8 mm within the aortic stent on transesophageal echocardiography (TEE). Broad-spectrum antibiotic therapy was initiated, and the patient was transferred to the operating room, where the infected stent and adhesive vegetation were removed. The patient recovered remarkably after the surgery and was discharged. At 6 months' follow-up, he was in good condition. Our findings highlight the significance of maintaining vigilance and a high level of clinical suspicion for the possibility of vegetation formation and aortitis as the possible sequelae of COVID-19, particularly in patients with an implanted stent. Furthermore, we strongly suggest TEE in patients with implanted stents to detect vegetation and aortitis.

Carotid artery stenting prior to coronary artery bypass grafting in patients with carotid stenosis: Clinical outcomes.

OBJECTIVES: Management of patients undergoing coronary artery bypass grafting (CABG) with obstructive disease of the carotid arteries is still a matter of debate. We compared the results of staged carotid artery stenting (CAS) before CABG in patients with carotid lesions. MATERIALS AND METHOD: Patients with significant carotid artery disease who were deemed to simultaneously suffer from an obstructive coronary artery disease requiring CABG from 2008 to 2018 were screened and enrolled in this study. We performed a staged CAS in cases with ≥60% stenosis and neurological symptoms or asymptomatic patients with ≥80% carotid artery stenosis. Patients with bilateral carotid lesions received sequential CAS within three weeks. Six weeks after the CAS procedure, all patients underwent CABG. RESULTS: A total of 142 patients were included. Eighty-five of these had neurological symptoms, while the remaining 40% were asymptomatic. Thirty-one patients underwent sequential CAS for bilateral lesions. The cerebrovascular event (CVE) following CAS (3 patients) and CABG (3 patients) was 4.2%. There was only a single case of mortality in this cohort. Although it was not statistically significant, CVE after CABG was more frequent in patients with bilateral carotid disease. CONCLUSIONS: Our results showed that staged CAS could be performed with minimal adverse outcomes in patients suffering from a simultaneous occlusive disease of carotids and coronary arteries before CABG. Bilateral CAS will further decrease cerebrovascular events and could be performed consequently or concomitantly.

Outcome of Surgery for Chronic Thromboembolic Pulmonary Disease without Pulmonary Hypertension.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition that results from incomplete resolution of thromboemboli in pulmonary arteries. Symptomatic patients with chronic thromboembolic disease may have normal hemodynamic at rest. The aim of this study is to evaluate the outcome of pulmonary endarterectomy (PEA) in symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension as currently defined (mean pulmonary artery pressure [mPAP] < 20 mm Hg). PATIENTS AND METHODS: Here, we report four symptomatic patients with chronic thromboembolic and normal hemodynamic at rest (mPAP ≤20 mm Hg or 20 < mPAP < 25 mm Hg and pulmonary vascular resistance [PVR] < 240 dyn·s/cm5) who underwent PEA between September 2015 and September 2019. The main outcome measures were functional New York Heart Association class, 6-minute walk distance (6MWD), hemodynamic measures in right heart catheterization (RHC), morbidity, and mortality. RESULTS: There were significant improvement in function class (2.6 ± 0.54 vs. 1 ± 0.2, p = 0.00), mPAP (preoperative: 23.3 ± 0.5 mm Hg vs. postoperative: 18.6 ± 1.5 mm Hg, p = 0.02), 6MWD (preoperative: 378.2 ± 68.7 m vs. postoperative: 432.9 ± 44.5 m, p = 0.01), and PVR (215.33 ± 91 vs. 101 ± 32 dyn·s/cm5, p = 0.1) 6 months after surgery based on data from RHC which was done during exercise. Also, RHC showed a significant decrease in mPAP (preoperative: 37 ± 7.7 mm Hg vs. postoperative 28 ± 3.2 mm Hg, p = 0.06). CONCLUSION: PEA could improve function class and hemodynamic in patients with CTEPD. Considering hemodynamic improvement in this group of patients after PEA, definition of CTEPH may need to be revised.

Iranian Society of Cardiac Surgeons COVID-19 task force version II, restarting elective surgeries.

Given the nature of heart disease and the importance of continuing heart surgery during the pandemic and its aftermath and in order to provide adequate safety for the surgical team and achieve the desired result for patients, as well as the optimal use of ICU beds, the medical team, blood, blood products, and personal protective equipment, it is essential to change the usual approach during the pandemic. There are still a lot of evidences and experiences needed to produce the perfect protocol. Some centers may have a special program for their centers during this period of epidemics that can be respected and performed. Generally, in pandemic conditions, the use of non-surgical approaches is preferred if similar outcomes can be obtained.

Giant mass but small symptoms; huge thrombosis in the right atrium originating from the superior vena cava and protruding to the right ventricle: a case report.

BACKGROUND: Thrombosis of the superior vena cava with propagation to the right heart chambers can be seen in the presence of chronic indwelling catheters. Moreover, the idiopathic right atrial thrombi may become entrapped in Chiari's networks, and idiopathic thrombosis of the superior vena cava may occur rarely because of the underlying coagulation disorders or malignancies. CASE PRESENTATION: A 43-year-old Iranian (Persian) woman was admitted to our hospital with palpitation of 2 years' duration and mild to moderate dyspnea of 10 days' duration. Her past medical history, basic laboratory test results, and cardiac enzyme measurements were unremarkable. Imaging studies revealed a 1.4-cm × 7.4-cm multilobulated, hypermobile mass in the right atrium, extending into the right ventricle, that appeared to be emanating from the superior vena cava. Moreover, partial filling defects were visible in the distal parts of both right and left pulmonary arteries extending to their branches, suggesting massive pulmonary emboli. The patient's huge mass and emboli were removed by surgery, and pathologic evaluations confirmed that all of the specimens were thrombosis. A number of mutations known as risk factors of thrombosis were detected during genetic evaluations. However, mild symptoms of the patient along with a huge mass in the right atrium, thrombosis in the superior vena cava, and massive thromboembolism remained unexplained. CONCLUSION: Huge and dangerous thrombosis inside the heart and superior vena cava can evolve without expected considerable symptoms. Also, detecting the underlying causes of these thromboses sometimes is not feasible by only checking the prevalent known risk factors. Therefore, comprehensive evaluations should be carried out in these patients.

Left Atrial Malignant Fibrous Histiocytoma with Right Atrium Invasion.

BACKGROUND: Primary cardiac tumors are rare (0.001 to 0.03%). Malignant tumors account for 25%, of which 75% are cardiac sarcomas. CASE PERSENTATION: Here, we report a case of a 57-year-old male with palpitation and history of left atrial (LA) myxoma resection presented to cardiology clinic for postsurgical follow up and transthoracic echocardiography revealed a large non-homogenous mass in LA with right atrium invasion, which was confirmed by trans-esophageal echocardiography. The patient underwent surgical resection of tumor and the pathological diagnosis was malignant fibrous histiocytoma (MFH). CONCLUSION: MFH could be asymptomatic and the diagnosis be established as a surgical or complementary examination. In patients with history of myxoma resection and cardiac masses, further evaluation is recommended.

Construction and Development of a Cardiac Tissue-Specific and Hypoxia-Inducible Expression Vector.

Purpose: Cardiovascular gene therapy is a sophisticated approach, thanks to the safety of vectors, stable transgene expression, delivery method, and different layers of the heart. To date, numerous expression vectors have been introduced in biotechnology and biopharmacy industries in relation to genetic manipulation. Despite the rapid growth of these modalities, they must be intelligently designed, addressing the cardiac-specific transgene expression and less side effects. Herein, we conducted a pilot project aiming to design a cardiac-specific hypoxia-inducible expression cassette. Methods: We explored a new approach to design an expression cassette containing cardiac specific enhancer, hypoxia response elements (HRE), cardiac specific promoter, internal ribosome entry site (IRES), and beta globin poly A sequence to elicit specific and inducible expression of the gene of interest. Enhanced green fluorescent protein (eGFP) was sub-cloned by BglII and NotI into the cassette. The specificity and inducible expression of the cassette was determined in both mouse myoblast C2C12 and mammary glandular tumor 4T1 as 'twin' cells. eGFP expression was evaluated by immunofluorescence microscope and flow cytometry at 520 nm emission peak. Results: Our data revealed that the designed expression cassette provided tissue specific and hypoxia inducible (O2<1%) transgene expression. Conclusion: It is suggested that cardiac-specific enhancer combined with cardiac-specific promoter are efficient for myoblast specific gene expression. As well, this is for the first time that HRE are derived from three well known hypoxia-regulated promoters. Therefore, there is no longer need to overlap PCR process for one repeated sequence just in one promoter.

Freedom from atrial fibrillation after cox maze III ablation during follow-up.

BACKGROUND: Nearly 60% of patients undergoing mitral valve (MV) operations are affected by atrial fibrillation (AF). Cox Maze III ablation is one of the effective ways for restoring sinus rhythm for patients undergoing open heart surgery. The aim of present study was to evaluate efficacy of Maze III ablation procedure for restoring sinus rhythm among patients who had underwent open heart surgery. MATERIALS AND METHODS: During present descriptive-analytic prospective study 114 patients with chronic AF had undergone open heart surgery for their valvular or coronary artery diseases in Educational-Medical centres of Tabriz University of Medical Sciences (Tabriz, Iran) 2006-2012, were included in the study. For all patients Maze III ablation was done. Patients were evaluated by 12 lead electrocardiography (ECG) and 24 hours ambulatory ECG monitoring after 3-6 years (mean 4.8) of follow-up. RESULT: Patients' rhythm before Cox Maze III surgery was chronic AF in all patients. All patients were discharged from operating room with sinus rhythm. During intensive care unit (ICU) hospitalization, rhythm of 34 patients changed to AF and 80 patients had sinus rhythm. Sixteen patients had undergone electrical cardioversion for restoring sinus rhythm which was successful in 12 patients. Ninety-two patients had sinus rhythm when discharged from the hospital. After termination of follow-up, freedom from atrial fibrillation was 51%. Patients with AF during follow-up on surface ECG didn't have episodes of sinus rhythm in their ambulatory monitoring. One patient implanted cardiac pacemaker due to persistent sinus bradycardia. CONCLUSION: Based on the results of this study, Cox Maze III ablation procedure is an effective and safe way for restoring sinus rhythm among patients who are candidate for open heart surgery, while no significant complication was seen among patients.

Evaluation of Early and Intermediate Outcomes of Cryo-MazeProcedure for Atrial Fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in patients with mitral valve disease affecting 50% of patients undergoing mitral valve surgery, contributing to increased risks of systemic embolization, anticoagulant- related hemorrhage and mortality. The maze procedure is an effective way to treat AF. Over the last several years, cryoablation was substituted for atrial incision in many reports to simplify the maze procedure. However, few studies have been carried out to evaluate the results of cryoablation surgery. In the present study we evaluated the results of this procedure. METHODS: In this cross sectional study, 47 AF patients were treated with Cryo-Maze surgery method. Rhythm assessment using electrocardiographic and echocardiographic survey was performed in all patients before surgery, during the patients' hospital stay, on discharge and after six months. RESULTS: Survival rate of the studied patients at six months was 93.6%. Sinus rhythm restoration rate in Cryo-Maze patients was 72.1% on discharge and 76.7% six months after their operation. CONCLUSION: The present study revealed that Cryo-Maze procedure is an effective and safe therapeutic modality in AF while normal sinus rhythm can be achieved in patients following this intervention.

Simultaneous operation of hydatid cyst of the heart and liver: a case report.

Primary echinococcosis of the heart is exceptionally uncommon and is reported 0.5% to 2% of all hydatid cyst sites in comparison with liver (70%) or lung (20%) involvement. Hydatid disease of the heart is caused by the cestode tapeworm echinococcosis granulosis or alveolaris. We present a 29-year-old female with hydatid disease of the liver and heart. She only complained of abdominal pain and palpitation. Echocardiography and multi-slice computed tomography (MSCT) showed a 120×101 mm cyst in the liver and 64 mm in the right ventricular free wall. Both cysts were excised within one procedure successfully.

Neurocognitive impairment after off-pump and on-pump coronary artery bypass graft surgery - an Iranian experience.

BACKGROUND: Coronary artery bypass graft (CABG) surgery is one of the most commonly performed surgical procedures worldwide, and it may be accompanied by postoperative neurocognitive impairment. Although this complication has been attributed to the use of cardiopulmonary bypass, it is still a matter of debate whether the switch from on-pump to off-pump technique affects the cognitive function. OBJECTIVE: The aim of this study was to compare the impact of the on-pump and off-pump techniques on neurocognitive impairment in low-risk CABG surgery groups. METHODS: In a descriptive and analytic study, 201 CABG patients with left-ventricular ejection fraction >30%, and without cardiac arrhythmia were enrolled. Before the elective operation, all patients underwent neurological examination and neurocognitive test, Mini-Mental State Examination (MMSE). Two months following the operation, both on- and off-pump, the patients were re-examined by MMSE to detect any neurocognitive impairment. RESULTS: Out of 154 patients included in the study, 95 (61.6%) and 59 (38.3%) patients were in off-pump and on-pump groups, respectively. Mean age of the patients was 57.17 ± 9.82 years. A 2-month postoperative neurocognitive impairment was detected among 17 patients of on-pump group (28.8%) and in 28 cases of off-pump group (29.4%) (P = 0.54). The mean postoperative MMSE scores were not comparable between groups (25.01 ± 4.49 in off-pump group versus 23.73 ± 4.88 in on-pump group, P = 0.09). CONCLUSION: The present study revealed that in low-risk patients undergoing CABG surgery, either the techniques of on-pump or off-pump did not differ regarding the neurocognitive outcome 2 months after the procedure.

Outcome of coronary artery bypass grafts: comparison between on pump and off pump.

The present study was undertaken to compare the in hospital results of coronary artery bypass graft (CABG) with (on pump) or without (off pump) cardiopulmonary bypass (CPB). Data were collected on all first-time isolated CABGs with saphenous vein and/or artery grafts at Shahid Madani Hospital in Tabriz-Iran, between 2006 and 2009. Age and clinical profile were marched between on pump and off pump group patients. Patients with concomitant cardiac operations or beating pump technique were excluded from the study. The study included 994 patients; CABG with CPB (ONCABG) was done in 578 (58%) and CABG without CPB (OPCABG) in 416 (42%). For pump and off pump group respectively, mortality rate was 2/3%, and 0.2%, the number of grafts was 2/92 +/- 0.82 and 2/12 +/- 0.73 and the use of intra aortic balloon-pump (IABP) was 1.5% and5.4%. Post operative ejection fraction (EF) was improved in off pump group (47.9 +/- 0.6) versus on pump group (44.53 +/- 1.5) and the latter group had more post operative atrial fibrillation, Stroke, acute renal failure, bleeding rate and blood products transfusion, prolonged intubation time but was not statistically significance. Meanwhile Hospitalization time and use of inotrops was less in comparison with former patients group. Off pump CABG was a safe method in our series. Patients with comparable risk profiles have similar prevalence's of selected complications after ONCABG and OPCABG, though some clinical and hemodynamic results are better with off pump technique.

Off-pump coronary artery bypass surgery in severe left ventricular dysfunction.

Our aim was to examine hospital outcomes of coronary artery bypass surgery in patients with and without left ventricular dysfunction, with regard to the surgical technique (off- or on-pump). Between March 2007 and March 2008, 689 consecutive patients underwent isolated first-time coronary artery bypass; 127 had ejection fractions < or = 30% (group 1) and 562 had ejection fractions >30% (group 2). Data of preoperative risk profiles and hospital outcomes were collected prospectively. Off-pump operations were performed in 49 (38.6%) patients in group 1 and 196 (34.9%) in group 2. The incidences of infectious, neurologic, and cardiac complications postoperatively were significantly higher in group 1. In multivariate analysis, preoperative ejection fraction < or = 30% was found to be an independent risk factor for postoperative complications and hospital mortality. The subgroup of patients undergoing off-pump surgery in both groups had a significantly lower rate of total complications than those undergoing conventional on-pump operations, but no significant difference in mortality was observed between those undergoing off-pump or conventional surgery in either group. Off-pump surgery helped to limit the increased morbidity rate after coronary bypass in patients with ventricular dysfunction.

Delayed presentation of posttraumatic aortic false aneurysm with chronic cough.

A chronic posttraumatic false aneurysm of descending aorta in a 19-year-old man who had been involved in a car accident 8 months earlier is described. He presented with chronic cough, and on chest roentgenogram, a mass in upper left mediastinum was noticed. Aortography and computed tomography scan revealed a false aneurysm of the descending aorta. The patient underwent aneurysm resection and graft replacement. Cough resolved after surgery and at 5 years follow-up the patient remained well and symptom-free.

A case of Aspergillus fumigatus mediastinitis after heart surgery in Madani Heart Center, Tabriz, Iran.

Reported here is the case of a 60-year-old male diabetic patient with mediastinitis caused by Aspergillus fumigatus following an open heart surgery that was successfully treated. A review of literature revealed that A. fumigatus as a cause of mediastinitis has been rarely described. Aspergillus infection should be considered in the differential diagnosis of mediastinitis after cardiac surgery, especially in a clinical setting of unexplained sepsis or nonhealing wound infection despite apparently adequate treatment.

Survey of operative outcome for aortic dissection.

OBJECTIVE: To survey the results of operative outcome for aortic dissection. METHODS: A retrospective study on 46 patients, admitted for operation in Shahid Madani Heart Hospital in Tabriz, Iran from 1994-2003. A questionnaire was used for collecting data. Statistical analysis was performed and was carried out through a descriptive statistical methods. RESULTS: We included 30 males (65%) and 16 females (35%). Seven (15.2%) died in the operating room before surgery, while 39 patients (59% male and 41% female) underwent surgery. The mean age of patients was 48.9 +/- 2.3 years old. Pre-operative diagnosis was carried out by transesophageal echocardiography and angiography. All patients were operated in an emergency situation. In 42% of patients aortic valve replacement (AVR) with ascending aorta was replaced. In 24% only the ascending aorta was replaced, and in 10% the aortic valve was repaired with acute aortic dissection. In 10% of patients, the ascending aorta with aortic arch was replaced. Four patients (14%) had distal aortic dissection and replacement. Major complications were hemorrhage (31%) and respiratory failure (13.8%). A total of 20.7% died in hospital, and only 21 patients (45.5%) could be followed for 10 years. CONCLUSION: Acute aortic dissection is a fatal disease. With early diagnosis and surgical intervention, we can save approximately 75% of patients with very good functional class and survival in the mid term.