Massive intercostal hemorrhage after implantation of an intrapericardial ventricular assist device: A case report.

Left ventricular assist devices (LVADs) have become integral to the treatment of advanced heart failure. Surgical bleeding is a known complication of LVAD placement but is most associated with intraperitoneal pump locations. Here we describe a case of massive postoperative hemorrhage secondary to erosion of an intrapericardial LVAD into an intercostal artery with an associated rib fracture.

The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation.

EXECUTIVE SUMMARY: Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant mitral operations to restore sinus rhythm. (Class I, Level A) Surgical ablation for AF can be performed without additional operative risk of mortality or major morbidity, and is recommended at the time of concomitant isolated aortic valve replacement, isolated coronary artery bypass graft surgery, and aortic valve replacement plus coronary artery bypass graft operations to restore sinus rhythm. (Class I, Level B nonrandomized) Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy or both is reasonable as a primary stand-alone procedure, to restore sinus rhythm. (Class IIA, Level B randomized) Surgical ablation for symptomatic persistent or longstanding persistent AF in the absence of structural heart disease is reasonable, as a stand-alone procedure using the Cox-Maze III/IV lesion set compared with pulmonary vein isolation alone. (Class IIA, Level B nonrandomized) Surgical ablation for symptomatic AF in the setting of left atrial enlargement (≥4.5 cm) or more than moderate mitral regurgitation by pulmonary vein isolation alone is not recommended. (Class III no benefit, Level C expert opinion) It is reasonable to perform left atrial appendage excision or exclusion in conjunction with surgical ablation for AF for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C limited data) At the time of concomitant cardiac operations in patients with AF, it is reasonable to surgically manage the left atrial appendage for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C expert opinion) In the treatment of AF, multidisciplinary heart team assessment, treatment planning, and long-term follow-up can be useful and beneficial to optimize patient outcomes. (Class I, Level C expert opinion).

The ABLATE Trial: Safety and Efficacy of Cox Maze-IV Using a Bipolar Radiofrequency Ablation System.

BACKGROUND: The Cox Maze-IV procedure (CMP-IV) has replaced the Cox Maze-III procedure as the most common approach for the surgical treatment of atrial fibrillation (AF). The Food and Drug Administration-regulated AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation (ABLATE) trial sought to demonstrate the safety and efficacy of the CMP-IV performed with the Synergy ablation system (AtriCure, Inc, Cincinnati, OH). METHODS: Fifty-five patients (aged 70.5 ± 9.3 years), 92.7% of whom had nonparoxysmal AF, underwent CMP-IV to terminate AF during a concomitant cardiac surgical procedure. Lesions were created using the AtriCure Synergy bipolar radiofrequency ablation system. All patients were seen for follow-up visits after 30 days, 3 months, and 6 months, with 24-hour Holter monitoring at 6 months. Late evaluation was performed by 48-hour Holter monitoring at an average of 21 months. RESULTS: The primary efficacy endpoint, absence of AF (30 seconds or less) at 6-month follow-up off antiarrhythmic medications (Heart Rhythm Society definition), indicated 76% (38 of 50) were AF free (95% confidence interval: 62.6% to 85.7%). The primary safety endpoint, the rate of major adverse events within 30 days, was 9.1% (5 of 55; 95% confidence interval: 3.9% to 19.6%), with 3.6% mortality (2 of 55). Secondary efficacy endpoints included being AF free with antiarrhythmic drugs (6 months, 84%; 21 months, 75%), successful pulmonary vein isolation (100%), and AF burden at 6 and 21 months. The results, together with those for the secondary safety endpoint (6-month major adverse events), demonstrated that the Synergy system performs comparably to the cut-and-sew Cox Maze-III procedure. CONCLUSIONS: The CMP-IV using the AtriCure Synergy system was safe and effective for cardiac surgical patients who had persistent and longstanding persistent AF.

Metastatic Hurthle Cell Carcinoma of the thyroid presenting as a Breast Lump: A Case Report.

BACKGROUND: Hurthle cell carcinoma of the thyroid is a rare form of thyroid cancer. It may present as a low grade tumour or can present as a more aggressive metastatic carcinoma. Hurthle cell carcinoma has the highest incidence of metastasis among all differentiated thyroid cancers. Most commonly haematogenous spread to lungs, bones and brain, however spread to regional lymph nodes is not uncommon. The breast is a rare site for metastasis from extramammary sources. We present the first case of breast metastasis from Hurthle cell carcinoma of the thyroid. CASE PRESENTATION: We report a 77 year old lady who had total thyroidectomy and bilateral neck dissection followed by radiotherapy for a high grade metastatic Hurthle cell carcinoma of the thyroid. Ten months later she presented to the breast clinic with left breast lump and a lump at the left axilla. Fine needle aspiration cytology of the lumps and histology after wide local excision of the breast lump confirmed metastatic Hurthle cell carcinoma. CONCLUSION: The presence of breast lumps in patients with history of extramammary cancer should raise the possibility of metastasis.

Onlay patch for complete intercostal artery preservation during thoracic and thoracoabdominal aortic aneurysm repair.

BACKGROUND: Replacement of the thoracic aorta is associated with a potential for interruption of the blood supply to the spinal cord leading to paralysis. Techniques have been proposed to ameliorate this risk, including reimplantation of the intercostal arteries. We present a technique to simplify this approach. METHODS: In patients with extensive aneurysmal disease, a standard approach to the thoracic aorta via a left thoracotomy is performed. The patient is placed on full cardiopulmonary bypass with moderate hypothermia. The proximal anastomosis is performed unclamped with circulatory arrest. After completing the proximal and distal anastomosis separately, an onlay patch of Dacron is created and placed along the entire back wall of the aorta to cover all of the intercostal arteries. A side-to-side anastomosis between the patch and the distal graft is then performed and subsequently the anastomosis tested by retrograde flow. RESULTS: The technique allows direct inspection of all suture lines, tested to an adequate pressure, so that postoperative bleeding is minimal. CONCLUSION: Techniques to lessen the risk of paraplegia associated with aortic surgery include reimplantation of the intercostal arteries. This technique allows each suture line to be tested and easily visually inspected prior to closure of the chest.

Isolated internal iliac artery aneurysm resection and reconstruction: operative planning and technical considerations.

Isolated iliac artery aneurysms are rare but dangerous aneurysms associated with a high incidence of rupture (between 14 and 70%). Rupture is frequently associated with an exceedingly high mortality primarily because of the elusive nature of the presenting symptoms and the resulting major delays in treatment. Accordingly these aneurysms are best managed aggressively. Although emerging endovascular techniques show promise surgical resection and reconstruction remains the gold standard for definitive management and has withstood the test of time with excellent durable and unparalleled results. That said, from an operative perspective these aneurysms are technically demanding and remain one of the more formidable technical challenges in vascular surgery. To highlight the key elements involved in a successful repair we present a right internal iliac artery aneurysm with an associated contralateral common iliac artery occlusion, review the necessary preoperative planning and the available surgical treatment options, and detail the technical steps leading to a successful reconstruction. Careful operative planning is critical. Inadequate preoperative studies, inadequate preoperative decision making, and a poorly formulated operative strategy can lead to catastrophic results. Some of the most feared complications include pelvic venous injury with resulting massive hemorrhage and postoperative pelvic ischemia (with resulting rectal and/or spinal cord ischemia) which occurs as a result of inadequate contralateral collateral pelvic blood flow when the internal iliac artery is not reimplanted. Accordingly the preoperative workup must include a careful analysis of the adequacy of the contralateral pelvic blood flow to supply collateral flow in the event that the internal iliac is not reimplanted. In the presence of compromised contralateral internal iliac perfusion, resection and reconstruction or an alternative form of pelvic revascularization is mandatory. Excellent and unencumbered exposure is mandatory for a safe and successful repair. The retroperitoneal approach as illustrated in this case is strongly recommended. Although it is challenging excellent results can be achieved by resection of the aneurysm and reconstruction.

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children.

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.

Combined minimally invasive mitral valve repair and direct coronary artery bypass: a new alternative to sternotomy.

A case is presented in which significant single-vessel coronary artery disease and severe mitral valve regurgitation were successfully managed using combined minimally invasive direct coronary artery bypass and mitral valve repair. Although the management of coronary artery disease with simultaneous mitral valve disease has traditionally been approached using a median sternotomy, this combined minimally invasive approach led to a successful outcome and may serve as an alternative methodology for patients who are appropriate candidates.