Variations in the branching patterns of pulmonary artery during thoracoscopic pulmonary resection.

PURPOSE: The knowledge of variations in the branching patterns of pulmonary artery may have important clinical implications in the field of thoracic surgery. METHODS: At the Department of Thoracic Surgery of Monaldi Hospital in Naples, between January 2017 and December 2019, 569 anatomic pulmonary resections via video-assisted thoracic surgery, including lobectomy and segmentectomy, were performed. RESULTS: Among the 569 thoracoscopic pulmonary resections, 24 variations in the branching patterns of pulmonary artery were identified and documented. Anatomic variations on the left were more frequent than on the right. CONCLUSION: This paper, providing a summary of vascular anomalies identified during major lung resections, could help surgeons avoid intraoperative complications, especially during minimally invasive procedures where the visual field is more restricted than open surgery.

Pulmonary artery perforation caused by a left atrial appendage closure device.

We describe a female patient who received hybrid catheter intervention and occlusion of the patent ductus arteriosus (PDA) and left atrial appendage (LAA). Four hours after the procedure, pericardial tamponade suddenly occurred. Surgical exploration of the heart found that a fixation hook of the WATCHMAN device, had protruded through the LAA wall and tore the dilated pulmonary artery (PA). This is the first case report to describe PA perforation caused by barbs of the WATCHMAN device, and more attention should be paid to the relationship between the LAA and its adjacent structures before LAA closure.

Targeting mitochondria-associated membranes as a potential therapy against endothelial injury induced by hypoxia.

Mitochondrial dysfunction plays a principal role in hypoxia-induced endothelial injury, which is involved in hypoxic pulmonary hypertension and ischemic cardiovascular diseases. Recent studies have identified mitochondria-associated membranes (MAMs) that modulate mitochondrial function under a variety of pathophysiological conditions such as high-fat diet-mediated insulin resistance, hypoxia reoxygenation-induced myocardial death, and hypoxia-evoked vascular smooth muscle cell proliferation. However, the role of MAMs in hypoxia-induced endothelial injury remains unclear. To explore this further, human umbilical vein endothelial cells and human pulmonary artery endothelial cells were exposed to hypoxia (1% O2 ) for 24 hours. An increase in MAM formation was uncovered by immunoblotting and immunofluorescence. Then, we performed small interfering RNA transfection targeted to MAM constitutive proteins and explored the biological effects. Knockdown of MAM constitutive proteins attenuated hypoxia-induced elevation of mitochondrial Ca2+ and repressed mitochondrial impairment, leading to an increase in mitochondrial membrane potential and ATP production and a decline in reactive oxygen species. Then, we found that MAM disruption mitigated cell apoptosis and promoted cell survival. Next, other protective effects, such as those pertaining to the repression of inflammatory response and the promotion of NO synthesis, were investigated. With the disruption of MAMs under hypoxia, inflammatory molecule expression was repressed, and the eNOS-NO pathway was enhanced. This study demonstrates that the disruption of MAMs might be of therapeutic value for treating endothelial injury under hypoxia, suggesting a novel strategy for preventing hypoxic pulmonary hypertension and ischemic injuries.

Left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome: A review of literature on therapy, intervention, and management.

Coronary artery anomalies (CAA) are anatomical aberrations in the origin, structure, and course of the epicardial arteries. Literature has detailed common anomalies or fistulas formed because of coronary artery bypass grafting (CABG) manipulation of intrathoracic vessels. Despite the commonality of the CABG procedure, there are a few CAA and fistula findings which remain extremely rare. We present a case of left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome that presented symptomatically as a malignant arrhythmia. Following a literature review of therapy, intervention, and management we recommend a team based approach when faced with this extremely rare case presentation. The goal of management should to reduce symptoms, and ischemia, by reducing or stopping flow through the fistula and out of the coronary blood supply.

Pediatric Pulmonary Artery Rehabilitation: A Review of Our Experience and a Novel Approach Using Bronchial Blockers.

Recent advances in the field of pediatric interventional cardiology have resulted in therapies for patients in need of augmented pulmonary artery (PA) flow. Catheter-based PA rehabilitation can be performed safely but not without the potential risk of pulmonary hemorrhage. When severe, this bleeding has the ability to contaminate the bronchi and trachea, and possibly occlude the endotracheal tube. This can result in a critical inability to ventilate and oxygenate these patients. Herein, we review our institutional experience with pulmonary hemorrhage associated with these procedures and the feasibility of predicting this outcome. The secondary aim was to discuss our novel anesthetic approach to a select group of these patients, involving the use of bronchial blockers to preemptively prevent contamination of bilateral bronchi and occlusion of the endotracheal tube.

Horticultural Homicide: Stab Wound to the Chest Masquerading as Impalement by Rose Bush.

Instruments that create stab wounds are required to possess tips of sufficient strength and rigidity to breach the integrity of the skin. Knives, the most common weapons used to create stab wounds, have cutting edges that cleave the skin, leaving unabraded margins. On rare occasions, blunt objects are driven with sufficient force to pierce the skin and become impaled within the body. The morphologic differences between the cutaneous injuries and wound tracks of stab wounds from sharp objects and impalement with blunt ones provide clear delineation of the two. However, elements from the scene and obscuring hemorrhage can make initial differentiation difficult. The authors report the death of a 59-year-old woman found near the entryway steps of her home with a stab wound to her chest. Law enforcement did not discover any weapons. Investigation focused on blood around and on a broken rose bush planted near the steps with the belief that the decedent had fallen upon the vegetation. When presented with information that conflicts with autopsy findings, careful consideration of proposed weapons and thorough examination of the wound are required to discount confounding material.

[Hemothorax due to Idiopathic Rupture of Pulmonary Artery with Defect of Tunica Media].

A 47-years-old man with hemodynamic shock was refered to our hospital by an ambulance. Chest computed tomography(CT)showed left hemothorax and the extravasation of contrast media in his left lung. Emergency operation was done. A lot of intrathoracic hematoma and pulsating bleeding from the lung was found, and lingular segmentectomy was performed. Pathologically, the rupture of pulmonary artery of 2.2 mm in diameter was found without the finding of imflammation nor degeneration due to any basal diseases. Around the lesion, some artery of 0.3~3.0 mm in diameter showed defect of tunica media. This vascular anomaly was considered to lead his hemothorax.

Pulmonary artery perforation and coronary air embolism-two fatal outcomes in percutaneous left atrial appendage occlusion.

Percutaneous left atrial appendage (LAA) closure is a routinely performed method to reduce the risk of stroke in patients suffering from atrial fibrillation, when an oral anticoagulation is no longer indicated due to relevant bleeding complications. Currently, the Amplatzer Amulet and the Watchman system are two equally used systems. While there is an acute success rate of more than 95 per cent for this intervention, several minor and major complications such as pericardial effusions, air embolism, vascular lesions in proximity to the heart or even death can occur. Here, we report two cases of very rare fatal outcomes in percutaneous LAA occlusion. Eight hours after deployment of an Amplatzer Amulet a patient died, after the pulmonary trunk was perforated by a hook of the occluder device causing pericardial tamponade. In the second case during final radiological position control of the deployed Watchman occluder air was injected accidentally. The patient immediately died due to coronary air embolism. Forensic autopsies are necessary to solve the cause and manner of death, to evaluate and develop medical devices and to rule out medical malpractice. Thus, a close collaboration of legal medicine and the various cardiologic departments is proposed.

Internal mammary artery-to-pulmonary vasculature fistula: Systematic review of case reports.

The formation of a fistula between the internal mammary artery and the pulmonary vasculature (IMA-to-PV) is a rare anomaly. The etiology can be congenital; however, most recent cases have been associated with coronary artery bypass grafting, trauma, inflammatory conditions, chronic infections, or neoplasia. The knowledge base on the formation of these fistulas is derived primarily from case reports. To our knowledge, no systematic reviews or guidelines are available that provide information on how to manage these cases, and the treatment of an IMA-to-PV fistula is controversial. To our knowledge, this report is the first to review 80 cases of IMA-to-PV fistulas reported in the literature. We describe the etiologies, clinical presentation, and management of these fistulas.

Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience.

PURPOSE: Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery. METHODS: We defined "unexpected intraoperative bleeding" as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels. RESULTS: Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3 %) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n = 13) and vein (n = 3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5 days, average, p = 0.20) and postoperative hospital stay (12.7 vs. 11.0 days, average, p = 0.08) were not significantly different. CONCLUSIONS: The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.

Frequency, Indications And Complications Of Pulmonary Artery Catheter Insertion In Adult Open-Heart Surgery Patients Of A Tertiary Care Hospital.

BACKGROUND: Patients presenting for cardiac surgery have unstable cardiovascular disease and haemodynamics with multiple coexisting diseases. Optimal monitoring in the perioperative period is very important for best perioperative outcome. The introduction of the flow-directed pulmonary artery catheter (PAC) into clinical practice is one of the most important and popular advances in the field of cardiac anaesthesia. The objective of the study was to determine the frequency, indications and complications of pulmonary artery catheter insertion in adult open-heart surgery patients. METHODS: A Prospective observational study was conducted at cardiac operating rooms and Cardiac Intensive care unit (CICU) of Aga Khan University Hospital for a period of six months from Nov 2015 to April 2016.Two hundred and seven patients were included in this study. PAC was inserted through right/left internal jugular vein or subclavian vein. Complications noted were arrhythmias (atrial and ventricular), right bundle branch block, coiling and knotting, pulmonary artery rupture, and infection up to 72 hours of PAC insertion. Frequency and percentage were computed for gender, comorbids (Hypertension, Diabetes, Chronic kidney disease, Chronic Obstructive Pulmonary Disease) and PAC frequency of insertion, indications and complications were noted. RESULTS: The frequency of PAC insertion was 47.83%. Major indications for PAC insertion were poor left ventricular function, acute coronary syndrome, cardiogenic shock, significant left main disease and valvular heart disease patients. Minor complications were found in 23.22% cases, which included arrhythmia in 19.2% cases and coiling in 4.02%. CONCLUSIONS: TPulmonary artery catheter insertion is a safe technique with useful clinical application in the management of high-risk cardiac surgical patients. The PAC insertion rationale must be standardized to confirm the judicious use.

[Pulmonary Artery Catheter Injured by Ablation Device during Maze Procedure].

We report a case of pulmonary artery catheter (PAC) injury by radio frequency device for maze procedure. A 64-year-old female with severe mitral insufficiency, tricuspid insufficiency and paroxysmal atrial fibrillation was scheduled for mitral valve repair, tricuspid annulo- plasty and maze procedure including right-sided maze. Under general anesthesia, a PAC was inserted to pul- monary artery (PA) uneventfully. After radio frequency maze procedure and mitral valve repair, PAC was removed from right atrium by the surgeon for tricus- pid annuloplasty. Thereafter, the surgeon reinserted the PAC under transesophageal echocardiographic guidance since PAC balloon could not be inflated. PA pressure and cardiac output were not shown despite other parameters were correct We removed the PAC and reinserted a new one after the surgery. The PAC was compressed at about 25 cm from the tip and it appears to have been injured during right-sided maze procedure with radio frequency device. Complications of PAC are well known, including PA rupture and suture entrapment to the right atrium. To best of our knowledge, this is the first reported case of PAC injury by radio frequency device. Fortunately the PAC was not torn in our case ; however, there might have been a risk of infection through the thermodilu- tion cable.

Pop goes the PA! and the aorta! iatrogenic aortopulmonary connections.

Iatrogenic aortopulmonary connections may occur after pulmonary artery angioplasty, stent or trans-catheter pulmonary valve implantation Patients with Ross autograft or arterial switch procedure may be at particular risk for this complication Timely diagnosis is facilitated by post-intervention aortic angiogram.

Iatrogenic left pulmonary artery to left atrium fistula.

Trans-catheter balloon angioplasty is a well-established treatment modality for pulmonary artery (PA) stenosis in children with congenital heart disease. We report a case of an unusual complication where a fistula developed between the left PA and the left atrium during balloon angioplasty in a patient with history of tetralogy of Fallot. This was successfully treated with placement of a covered stent.

Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations.

OBJECTIVES: To investigate the spectrum, etiology, and management of traumatic aortopulmonary (AP) communications after transcatheter interventions on the pulmonary circulation. BACKGROUND: An iatrogenic AP communication is an unusual complication after balloon pulmonary artery (PA) angioplasty or stenting, or transcatheter pulmonary valve replacement (TPVR). However, with the increasing application of transcatheter therapies for postoperative PA stenosis and right ventricular outflow tract (RVOT) dysfunction, including percutaneous pulmonary valve replacement, consideration of the etiology, diagnosis, and management of this problem is important for interventional cardiologists performing such procedures. METHODS AND RESULTS: We present three new cases, as well as gross anatomy and histopathology data, related to AP communications after PA interventions. We also review the literature relevant to this topic. Including these new cases, there have been 18 reported cases of iatrogenic AP communication after transcatheter interventions on the PAs or RVOT, primarily patients with transposition of the great arteries who underwent PA angioplasty after an arterial switch operation, or after TPVR in patients who had undergone a Ross procedure. The likely cause of such defects is PA trauma plus distortion of the neo-aortic anastomosis resulting from angioplasty or stenting of the RVOT or central PAs, with subsequent dissection through the extravascular connective tissue and into the closely adjacent vessel through the devitalized tissue at the anastomosis. CONCLUSIONS: Cardiologists performing PA or RVOT interventions should be aware of the possibility of a traumatic AP communication and consider this diagnosis when confronted with suggestive signs and symptoms.

A Patient with Aortic Arch Aneurysm Perforating the Left Pulmonary Artery.

An aortic arch aneurysm rarely perforates the pulmonary artery, but once this occurs symptoms of heart failure may develop rapidly and result in a serious course. Here, we report such a case that was treated with life-saving emergency surgery. The patient was an 86-year-old man in whom aortic arch aneurysm had been pointed out 8 years earlier, but left untreated. In January 2014, dyspnea developed and he visited the emergency unit of our hospital. Continuous murmur was heard on auscultation, and aorta-pulmonary artery shunt was noted on transthoracic echocardiography. Chest computed tomography revealed a giant aortic arch aneurysm of size 106 mm that had perforated the left pulmonary artery (LPA). Emergency surgery was performed for a diagnosis of acute heart failure associated with perforation of the LPA by a giant aortic arch aneurysm. The postoperative course was favorable, and the patient was discharged with independent walking on postoperative day 28.

Lung salvage by pulmonary arterioplasty after vascular injury during video-assisted thoracoscopic surgical right upper lobectomy.

Video Assisted Thoracoscopic Surgical (VATS) lobectomy is now considered feasible and safe. Nevertheless, thoracic surgeons need to be aware of dramatic complications that may occur during this procedure and how best to manage them. We report the case of a severe tear of the right pulmonary artery (PA) during elective VATS upper lobectomy, leading to emergency conversion to control the bleeding. Initial arterial repair was performed by end-to-end anastomosis. Early CT angiography showed thrombosis of the right PA due to anastomotic stenosis. We performed emergency pulmonary arterioplasty with a prosthetic patch to save the right lung. A CT scan days after surgical lung salvage confirmed the permeability of the PA and normal vascularization of the two remaining right lobes. We discuss herein this dramatic complication of VATS lobectomy, the viability of the lung after pulmonary arterial thrombosis, and advocate for early postoperative imaging after pulmonary arterioplasty.

[Successful Resuscitation from Cardiac Arrest due to Pulmonary Artery Rupture Utilizing Cardiopulmonary Bypass].

We report a case of successful resuscitation from cardiac arrest due to pulmonary artery rupture utilizing cardiopulmonary bypass. A 79-year-old man was diagnosed with lung cancer; segment resection of the upper lung was scheduled under general anesthesia. Anesthesia was induced uneventfully and surgery began in the right lateral position. During lung resection, the pulmonary artery was ruptured and led to cardiac arrest with pulseless electrical activity. Astriction, volume overload, and hypertensive medication led to vital sign recovery. Percutaneous cardiopulmonary support was achieved with improvements in the blood flow of the femoral vein and artery. Yet, bleeding from the ruptured artery did not stop. Cardiopulmonary bypass with pulmonary artery blood removal and femoral artery blood transmission stopped the bleeding of the damaged part, leading to the repair of the artery. Rapid establishment of cardiopulmonary bypass may be useful in cases of pulmonary artery damage.