Mending Hearts and Building Bridges: The Save a Child's Heart Foundation.

CONTEXT: Save a Child's Heart addresses the challenges of heart care for children in underdeveloped countries. OBJECTIVE: Save a Child's Heart has created a center of excellence for pediatric cardiac care at the Wolfson Medical Center in Israel, helped develop partner sites for evaluation and referral, and trained medical teams to return and build their own capacity for local cardiac care. RESULTS: Save a Child's Heart has treated more than 3600 children from 48 countries, with 50% from Iraq, Jordan, the Palestinian Authority, and Syria. In cooperation with the Palestinian Authority, Save a Child's Heart has examined more than 6000 children and treated 1750 children, trained 21 medical personnel, and conducted seminars for Palestinian medical personnel. The "Heart of the Matter Project," funded by the European Union, US Agency for International Development, the Palestinian Ministry of Health, and the Israeli Ministry of Regional Cooperation, is currently training a team at the Wolfson Medical Center from the Palestine Medical Complex in Ramallah and provides funds for Palestinian children's care in Israel. CONCLUSIONS: Save a Child's Heart is a model of a global humanitarian health care initiative with a single focus on heart disease in children. The "Heart of the Matter Project" is a model of health care based on regional cooperation despite local political tensions.

Giant left atrium associated with massive thrombus formation.

Giant left atrium is a condition characterized by huge enlargement of the left atrium with a diameter exceeding 65mm. It is most commonly associated with long standing rheumatic mitral valve disease. We present a 45-year-old female patient with rheumatic mitral stenosis associated with giant left atrium occupied by an 11 × 10 × 5 cm thrombus weighing 500 gms. The patient underwent successful mitral valve replacement and thrombectomy through an inverted T-shaped biatrial incision.

Double-balloon valvuloplasty of calcified bioprosthetic pulmonary valve twenty-three years after implantation.

Balloon valvuloplasty to dilate stenotic bioprosthetic valves is rarely used, but has been applied successfully to dilate bioprosthetic mitral, aortic, tricuspid and, to a lesser extent, pulmonary valves. The case is reported of a 45-year-old male patient with right-sided heart failure who underwent a successful dilatation of a stenotic, calcific bioprosthetic pulmonary valve using double-balloon valvuloplasty.

Surgical management of coronary artery disease associated with malignancy.

Surgical management of patients with combined coronary artery disease and malignancy remains a challenge. In this review the time of surgical intervention, whether to treat the malignancy or the coronary artery disease first, and which bypass technique should be used during myocardial revascularization are reviewed to determine the most optimal strategy to manage patients who require coronary surgical revascularization and present with an underlying malignancy.

Internal mammary arteries as major blood supply to lower limb in coronary artery disease with peripheral vascular disease.

We describe a case of severe peripheral vascular disease in a patient presenting for coronary artery bypass grafting (CABG). There was an occlusion of the abdominal aorta with collaterals from the internal mammary arteries (IMA) and inferior epigastric arteries (IEA) supplying the lower limb. Off-pump CABG was carried out without harvesting the IMA. In presence of concomitant severe peripheral vascular disease, lower limb blood flow should be evaluated with Doppler ultrasound, and in selected cases, computed tomography angiogram should be performed to rule out IMA-IEA collaterals dependent limb perfusion.

Iatrogenic diversion of inferior vena cava to the left atrium presented as recurrent foetal loss: a case report.

Background: Iatrogenic diversion of inferior vena cava (IVC) to the left atrium (LA) after atrial septal defect repair (ASD) is an unusual complication. It rarely occurred nowadays due to trans-oesophageal echocardiography (TEE) check during surgery, but there are still few numbers of patients who survived from an old operation during childhood and reached adulthood undiagnosed. Case summary: We present a 27-year-old female post ASD repair in childhood with a unique presentation of recurrent abortion in adulthood besides exertional dyspnoea. A full workup of investigations was normal except for haemoglobin of 21 and oxygen saturation of 70%. TEE revealed abnormal drainage of IVC to the LA. Surgical correction was done to release the IVC opening to drain in the right atrium and the oxygen saturation reached 99% after weaning from the bypass machine. The postoperative course was uneventful, and the patient was discharged 5 days later. Two years later, she got pregnant twice and completed her pregnancies to term with well-developed infants. Discussion: The diversion of the IVC may be either complete or partial. Such complications may result in intraoperative death on the table or may present as early desaturation, shortness of breath, cyanosis, and clubbing, or it may present with such symptoms in adulthood. Rarely, it may present with cerebral stroke. Our case presented with the unexpected presentation of recurrent abortion. So, even if it is rare, echocardiography should be considered as a workup for recurrent abortion in a patient with a history of congenital heart surgery.

Congenital intrathoracic kidney in a patient undergoing coronary artery bypass surgery.

Intrathoracic kidney is a rare congenital anomaly. It appears as a posterior mediastinal mass on chest X-ray. Most cases are asymptomatic and are discovered accidentally. We present a 48-year-old male patient with intrathoracic kidney discovered during routine investigation for coronary artery bypass surgery.

Surgical treatment of circumflex coronary aneurysm with fistulous connection to coronary sinus associated with persistent left superior vena cava.

Circumflex coronary arteriovenous fistula associated with aneurysmal dilatation and draining into coronary sinus (CS) is rare. A 57-year-old female presented with progressive dyspnea and was found to have a tortuous multiloculated aneurysm of the circumflex coronary artery terminating into the CS associated with a persistent left superior vena cava. The operative repair and management of coronary arteriovenous fistula are the subject of this case report and review.

Acute mitral valve endocarditis complicated by right atrial fistula in beta-thalassemia major.

Infection is considered to be among the major complications encountered in beta-thalassemia major, with an incidence that may reach 13%. The majority of cases are caused by repeated blood transfusion potentiated by the associated immune defects among these patients. The present case represents a severe form of infection affecting the mitral valve, causing acute heart failure and a fistulous communication between the left ventricle and right atrium.

Use of off-pump coronary artery bypass surgery among patients with malignant disease.

BACKGROUND: Patients undergoing coronary artery surgery associated with malignant disease are high-risk patients. The surgical strategy among these patients remains controversial. We present our experience of using a two-staged surgical strategy of managing coronary artery disease using off-pump bypass followed by tumor management. PATIENTS AND METHODS: During a six-year period from 2002 to 2007, 350 patients underwent myocardial revascularization using off-pump bypass. Among these patients, associated malignant disease was found in six patients (1.7%). Two of them had papillary carcinoma of the bladder, one patient had chronic lymphocytic leukemia, and the rest suffer from carcinoma affecting the prostate, colon, and right lung. Their mean age was 54 years. Their data was evaluated. Patients were followed up to evaluate their symptoms and progress of their disease. RESULTS: All patients were managed successfully. Complete revascularization was achieved in all patients except one due to small nongraftable vessels. The mean number of grafts was 1.8 +/- 0.8. There was no evidence of postoperative infraction or stroke. The mean hospital stay was 5 +/- 1.1 days. Management of cancer was done during the same hospital admission in two patients with bladder cancer. The rest had a mean interval of 6.6 +/- 5.4 days. Two patients underwent surgery in the form of left hemicolectomy and right lower lobectomy. The rest had chemotherapy as a sole treatment. All patients were followed up completely for a period of 12 to 84 months (mean 39.2 +/- 26.7 months). We had no late mortality. All patients remained asymptomatic except one, who had angina of class III and had recurrence of her bladder tumor, which necessitated two sessions of endoscopic resection. CONCLUSION: We believe that staged operation to treat coronary artery disease and malignancy can be performed safely. The use of off-pump technique to revascularize the myocardium can be performed without any complications.

Multiple left ventricular myxomas arising from the interventricular septum and ventricular trabeculae: a case report.

Myxoma is the most common tumor of the heart, with an estimated incidence of 0.5 to 1 per million per year. The majority of these tumors arise from the left atrium, and 20% arise from the right atrium with the remaining 5% arising in either the right or left ventricle. We present a rare case of multiple myxomas of the left ventricle arising from the interventricular septum and nearby ventricular trabeculae that clinically presented with an occlusion of the left axillary artery. The patient was successfully treated using cardiopulmonary bypass, during which the tumor was completely removed using a transventricular approach.

Pulmonary artery agenesis associated with coronary collaterals among adults.

Unilateral agenesis of the pulmonary artery is a rare congenital anomaly, which commonly involves the right side. Cases are associated with systemic collaterals, that may also rarely arise from the coronary arteries.Two adult patients are presented with a right pulmonary artery agenesis associated with collaterals from the right coronary artery. The implications of such an anomaly on pulmonary artery pressure and lung pathology differs among both cases. The association of coronary collaterals is rare and its implication is variable among various patients.

Congenital circumflex coronary arteriovenous fistula with aneurysmal termination in the pulmonary artery.

Coronary arteriovenous fistula is a rare congenital anomaly that is seen in 0.1 % to 0.2% of coronary angiograms. Aneurysmal formation in the fistula is even rarer. We report a case of congenital circumflex arteriovenous fistula with aneurysmal formation just near its termination in the pulmonary artery, associated with atherosclerotic left anterior descending coronary artery. The anomaly was successfully repaired.

Non-aneurysmal aberrant right subclavian artery causing dysphagia in a young girl: challenges encountered using supraclavicular approach.

Aberrant right subclavian artery is the most common anomaly of the aortic arch. Patients are often asymptomatic and discovered accidentally. Occasionally, they present with symptoms related to oesophageal or tracheal compression.A 13-year-old girl presented with dysphagia and stridor was found to have an aberrant right subclavian artery. Surgical division and reconstruction of the artery was performed initially through right supraclavicular approach. An additional left thoracotomy was performed to overcome the challenges encountered at initial operation.

Off-pump myocardial revascularization in a high-risk patient with essential thrombocythemia.

Essential thrombocythemia is a rare type of myeloproliferative disorder. Cerebral, myocardial, and peripheral thrombosis are all frequent complications of the disease. A 71-year-old man presented with severe coronary artery disease, associated with cerebral vascular ischemic changes and erythromelalgia. His platelet count was 1,486 ×10(3)/µL. The patient underwent successful myocardial revascularization by means of an off-pump technique after his platelet count had been reduced by hydroxycarbamide administration. We conclude that the use of off-pump cardiopulmonary bypass in high-risk patients with essential thrombocythemia is safe. Reducing platelet count via the administration of hydroxycarbamide and the careful balancing of antiplatelets and anticoagulants is crucial in determining the outcome of surgery.

Massive pulmonary embolism secondary to longstanding traumatic femoropopliteal pseudoaneurysm associated with arteriovenous fistula.

Pulmonary embolism is a common clinical condition associated with high mortality.The majority of pulmonary emboli originate from deep venous thrombosis in the popliteal and femoral veins.We present a rare case of a 21-year-old caucasian male patient with massive pulmonary embolism. The source of emboli originated from thrombosed femoropopliteal pseudoaneurysm associated with arteriovenous fistula which was caused by a bullet injury 7 years before. The patient underwent successful surgical pulmonary embolectomy followed by aneurysmectomy with reconstruction of femoral and popliteal vessels.

Left ventricular endocardial ecchinococcosis associated with multiple intracranial hydatid cysts.

Cardiac ecchinococcosis is a rare disease. Its incidence varies from 0.02-2%. Commonly seen in the left ventricle arising from the myocardium in the subepicardial region.We report a 15-year-old boy presented with a rare combination of a left ventricular subendocardial hydatid cyst associated with multiple cysts in the left cerebral hemisphere and right posterior occipital lobe. The patient underwent successful surgical excision of the left ventricular hydatid cyst using cardiopulmonary bypass.

Recurrent pannus formation causing prosthetic aortic valve dysfunction: is excision without valve re-replacement applicable?

Prosthetic valve dysfunction at aortic position is commonly caused by pannus formation. The exact etiology is not known. It arises from ventricular aspect of the prosthesis encroaching its leaflets causing stenosis or it may remain localized causing left ventricular outflow tract obstruction without affecting valve function.The difference in location entails different approaches in management. Such a pathology requires surgical excision of the pannus with or without valve re-replacement.A recurrent pannus was observed in a female patient who needed repeated surgical intervention to excise a localized pannus without re-replacement of a well functioning prosthetic valve.Management of our case presents several questions, whether recurrence of pannus is caused by sparing the prosthetic valve, is it simply an exaggeration of an inflammatory healing process in certain individuals or is it ideal to re-replace the valve despite a well preserved function.

Detrimental effect of cardiopulmonary bypass (CPB) on malignant disease.

Patients with coronary artery disease associated with malignancy are a difficult group of patients to treat. The ideal approach to manage them is still controversial. Both problems can be manage by either a combined or staged operation. The use of CPB during revascularization of the myocardium among patients with malignant disease, may have an effect on dissimination of malignant cells. This was observed among two of our patients. We believe that the use of off-pump technique to revascularize the myocardium is a safe approach and can be performed either in combined or staged surgery to resect malignant disease.