Preoperative Transcatheter Diagnosis of Right Atrial Hemangioma.

A 34-year-old man with unremarkable past medical history presents with night sweats and a recent diagnosis of intracardiac mass. The initial diagnostic workup did not provide a definitive diagnosis, so a cardiac biopsy under intracardiac echocardiography guidance was performed, revealing a hemangioma, which was then successfully resected. (Level of Difficulty: Advanced.).

Intra-atrial course of right coronary artery: A case report.

BACKGROUND: Intra-atrial right coronary artery (RCA) is a rare and generally asymptomatic anomaly of development of the coronary arteries. This malformation could potentially expose the patient to a catastrophic outcome in the case of injury during interventional or surgical procedures. Currently, only a few case reports and no systematic reviews are available in the literature. CASE SUMMARY: We report the case of a 54-year-old man with atypical chest pain who underwent multi-detector computed tomography angiography (MDCTA). The exam revealed no significant coronary artery stenoses; however, an intra-atrial course of mid RCA was evident. Medical therapy was administered, and the patient was discharged to home without undergoing a conventional angiography. Previously reported autoptic and clinical cases were retrieved from the PubMed literature database to compare the clinicopathological features of this case. CONCLUSION: MDCTA depicted the abnormal course of the coronary artery in this patient as an intra-atrial course of the mid RCA. Finding this abnormality was crucial to avoid an inadvertent injury during interventional or surgical procedures.

A rare cause of effusive-constrictive pericarditis.

Effusive-constrictive pericarditis (ECP) is an uncommon diagnosis, frequently missed due to its heterogeneous presentation, but a potentially reversible cause of heart failure. A 62-year-old Caucasian male presented with remittent right heart failure and mild-moderate pericardial effusion. Following an initial diagnosis of idiopathic pericarditis, indomethacin was started, but the patient shortly relapsed, presenting with severe pericardial effusion and signs of cardiac tamponade, requiring pericardiocentesis. ECP was diagnosed on cardiac catheterization. Cardiac computed tomography showed non-calcified, mildly thickened and inflamed parietal pericardium. Pericardiectomy was performed with symptoms remission. On histological examination of pericardium, chronic non-necrotizing granulomatous inflammation was noted. Polymerase chain reaction assay was positive for non-tuberculous mycobacteria. This case represents a rare finding of ECP with unusual presentation due to atypical mycobacteriosis in a non-immunocompromised patient and in a non-endemic area. Pericardiectomy can be an effective option in cases unresponsive to anti-inflammatory treatment, even in the absence of significant pericardial thickening or calcification.

Coronary Artery Bypass Grafting in Elderly Patients: Insights from a Comparative Analysis of Total Arterial and Conventional Revascularization.

The benefits of total arterial (TAR) versus conventional (CR) revascularization are controversial in the higher-risk cohort of elderly patients. Taking for granted its benefit on long-term survival, we evaluated the effect of TAR on safety (death, myocardial infarction, and stroke) of patients undergoing CABG. Between 2000 and 2009, 487 patients >75 years underwent isolated CABG at our institution (150 TAR and 337 CR). Patients with arterial free-grafts were excluded. After propensity matching, the outcomes of 131 TAR and 127 CR patients were compared. TAR patients had lower incidence of post-operative myocardial infarction (p = 0.025) and stroke (p = 0.005). They also experienced shorter intensive care unit (p = 0.046) and ward stay (p = 0.028), lower output of TnI (p = 0.035), and less wound complications (leg included) (p = 0.0001), while mortality was comparable (p = 0.57). In our cohort of elderly patients with multivessel disease, TAR was associated with lower rates of myocardial infarction, stroke, and shorter hospital stay.

Comparison of Efficacy and Cost of Iodine Impregnated Drape vs. Standard Drape in Cardiac Surgery: Study in 5100 Patients.

We sought to examine the efficacy in preventing surgical site infection (SSI) in cardiac surgery, using two different incise drapes (not iodine-impregnated and iodine-impregnated). A cost analysis was also considered. Between January 2008 and March 2015, 5100 consecutive cardiac surgery patients, who underwent surgery in our Institute, were prospectively collected. A total of 3320 patients received a standard not iodine-impregnated steri-drape (group A), and 1780 patients received Ioban(®) 2 drape (group B). We investigated, by a propensity matched analysis, whether the use of standard incise drape or iodine-impregnated drape would impact upon SSI rate. Totally, 808 patients for each group were matched for the available risk factors. Overall incidence of SSI was significantly higher in group A (6.5 versus 1.9 %) (p = 0.001). Superficial SSI incidence was significantly higher in group A (5.1 vs 1.6 %) (p = 0.002). Deep SSI resulted higher in group A (1.4 %) than in group B (0.4 %), although not significantly (p = 0.11). Consequently, the need for vacuum-assisted closure (VAC) therapy use resulted 4.3 % in group A versus 1.2 % in group B (p = 0.001). Overall costs for groups A and B were 12.494.912 € and 11.721.417 €, respectively. The Ioban(®) 2 offered totally 773.495 € cost savings compared to standard steri-drape. Ioban 2 drape assured a significantly lower incidence of SSI. Additionally, Ioban(®) 2 drape proved to be cost-effective in cardiac surgery.

Impact of vacuum-assisted closure therapy on outcomes of sternal wound dehiscence†.

OBJECTIVES: Sternal wound dehiscence (SWD) after cardiac surgery is a rare but serious condition associated with considerable costs and morbidity. We sought to evaluate the results of the introduction of vacuum-assisted closure (VAC) therapy in the management of sternal wound dehiscence, compared with those of previous conventional treatments. METHODS: We retrospectively collected 7148 patients who underwent cardiac surgery at our institution between January 2002 and June 2012. A total of 152 (2.1%) patients had a sternal wound dehiscence: 107 were treated with conventional treatments (Group A) and 45 were managed with VAC therapy (Group B). Patients were stratified according to preoperative risk factors and type of sternal wound dehiscence (superficial or deep; infected or not) and compared by means of a propensity-matched analysis. A cost analysis was also performed. RESULTS: Forty-five patients of each group matched for all preoperative risk factors and type of sternal wound dehiscence. SWD-related mortality rate was significantly lower in Group B (11 vs 0%; P = 0.05). Incidence of mediastinitis (P < 0.0001), sepsis (P = 0.04), delayed SWD infection (P = 0.05), other complication (P = 0.05), surgical sternal revision (P = 0.04) and surgical superficial revision (P < 0.0001) were all significantly lower in Group B. Mean patient cost was 31 106€ in Group A and 24 383€ in Group B, thus achieving a mean saving of 6723€ per patient. CONCLUSIONS: In our experience, the use of VAC therapy for the management of SWD was considerably effective in decreasing mortality (SWD related), incidence of complications and need for surgical procedures; thus, leading to a significant reduction of costs.

Extended (31 years) durability of a Starr-Edwards prosthesis in mitral position.

A 62-year-old man underwent mitral valve replacement with a Starr-Edwards caged-ball prosthesis in 1974. He was asymptomatic until February 2005 when he underwent a new cardiac evaluation because of increasing dyspnea and peripheral edema. The echocardiogram showed a severe aortic regurgitation and a mitral valve prosthesis well functioning. At reoperation, the mitral prosthesis and the aortic valve were replaced with St. Jude Medical((R)) bileaflet mechanical prostheses. At macroscopic and radiographic inspection the Starr-Edwards was free from signs of structural valve degeneration. This case demonstrates the impressive durability of a Starr-Edwards prosthesis in mitral position.

Biological versus mechanical aortic prosthesis? A nineteen-year comparison in a propensity-matched population.

BACKGROUND AND AIM OF THE STUDY: The choice of aortic valve substitutes remains controversial. Malfunction and systemic valve complications affect the results of mechanical and tissue valves. Two devices--the Sorin Monocast (tilting disk) valve and the Hancock Standard valve were compared, the study aim being to determine whether the valve model is a marker or a causal influence of poor outcome after aortic valve replacement (AVR). METHODS: Between January 1970 and January 1984, patients aged < 70 years and operated on for aortic valve disease were selected. A total of 379 patients received either Sorin (group S) valves (n = 213; median age 51 years) or Hancock Standard (group HcK) valves (n = 192; median age 50 years) (p = NS). Total follow up was 2,471 patient-years (pt-yr) for group S and 2,368 pt-yr for group HcK. Follow up was 98% complete; median duration was 15 pt-yr for group S and 13.2 pt-yr for group HcK. Propensity matching for available patient intrinsic and operative risk factors was ultimately used to investigate whether biological or mechanical valve models impact upon outcome after aortic valve surgery. Patient survival was analyzed according to the 'intention to treat' principle. RESULTS: The 30-day mortality was 7.5% for group S and 10.9% for group HcK (p = NS). The 19-year Kaplan-Meier freedom from valve-related mortality was 84% (group S) and 82% (group HcK) (p = NS), while overall survival was 42% (group S) and 35% (group HcK) (p = NS). Structural valve deterioration (SVD) was the major cause of reoperation in the HcK group. The 19-year freedom from all valve-related complications was 43% (group S) versus 19% (group HcK) (p = 0.0001). By propensity score, 61% of the valve replacements (247/405) were perfectly matched for available risk factors, with an equal distribution of risk covariates. When SVD and reoperation due to SVD were excluded, survival and freedom from all valve-related complications of the matched patients were identical between the prostheses under comparison. CONCLUSION: In this relatively young population, the Sorin valve showed a significantly lower valve-related complication rate than the Hancock Standard valve. The latter valve showed a significantly increasing rate of reoperation due to SVD, and thereby a relative inadequacy for use in younger patients. When analyzed according to an 'intention to treat' principle, the 19-year survival and freedom from valve-related complications of patients with the same propensity score for selection of either valve type were similar.