Safety of Aortic Coarctation Treatment in Patients with Turner Syndrome: A Single-Country Case Series and Literature Review.

BACKGROUND: Coarctation of the aorta is a common cardiac disease in Turner syndrome. Evidence indicates that surgery and balloon angioplasty in infants and small children do not have any added risk of mortality or complication in these patients. Stenting in older patients may, however, pose higher risks of arterial wall injury and mortality. METHODS: In this case series, we describe 15 patients with coarctation of the aorta in Turner syndrome: 9 received stenting, 4 underwent surgery, and 2 were treated via balloon angioplasty. RESULTS: Dissection occurred in 2 patients after stenting: 1 in the aorta and the other in the external femoral artery. Both were managed promptly without any mortality or serious damage, one percutaneously and the other surgically. CONCLUSIONS: Awareness of increased risks and preparedness for prompt interventions in case of an acute arterial wall injury are recommended when coarctation stenting is done for a patient with Turner syndrome.

ZipFix Versus Conventional Sternal Closure: One-Year Follow-Up.

BACKGROUND: The present study aimed to compare postoperative complications commonly revealed after sternotomy closure by new sternal ZipFix™ (Synthes GmbH, Oberdorf, Switzerland) implant and conventional steel wire. METHODS: Among the initial 360 subjects, 326 patients enrolled in this randomised control trial who were candidates for cardiac surgery from April 2014 to March 2015. After the surgery, the sternal closure was randomly done with poly-ether-ether-ketone (PEEK) based sternal ZipFix (ZF) on the sternal body (n=168) or with conventional wires (CWs) (n=158). Patients were followed postoperatively as well as 1, 3, 6, and 12 months after discharge regarding postoperative complications such as pain severity, dehiscence, and infection including incisional infections (superficial or deep), and organ/space infection (mediastinitis or osteomyelitis). RESULTS: The mean age of the ZF and CW groups were 63.58±10.9 and 62.42±7.1years, respectively (p=0.262). In addition, there was no significant difference between the two groups' baseline characteristics (p>0.05). Our study showed higher mean pain severity score in the conventional closure group compared with ZipFix closure group at all study time points (p<0.001). Infection was seen in 2.76% of the overall participants with no significant difference of incisional and organ infection between the two groups throughout the study. After 1-month follow-up, five patients in the CW group had sternal dehiscence whereas no patients in ZF had dehiscence (p<0.001). CONCLUSIONS: Our trial demonstrates greater clinical advantages in terms of pain and sternal dehiscence post surgery by using sternal ZipFix compared to conventional steel wire.

Selective serotonin reuptake inhibitors and cardiovascular events: A systematic review.

BACKGROUND: Given the importance of the role of depression in predicting the outcome of cardiovascular disorders, current medications for treating depression, particularly selective serotonin reuptake inhibitors (SSRIs), are taken into consideration. This study aimed to systematically review the published findings in the use of SSRIs and the risk for cardiac events. MATERIALS AND METHODS: An independent review of the Web of Science, PubMed, Scopus, Cochrane, CINAHL, index Copernicus, and Google Scholar, up to 2014, was performed. We identified studies evaluating the effect of SSRIs, on cardiovascular events. Articles in English with full text availability, review articles, and experimental studies were included in the study. Among 150 studies reviewed based on the included keywords, 17 met the study criteria and were finally reviewed. RESULTS: The use of some types of SSRIs may prevent platelet adhesion and aggregation; control the cardiovascular risk profile including hypertension, insulin resistance, and body weight; and also inhibit inflammatory processes. The appearance of adverse cardiac events, including cardiac arrhythmias (torsade de pointes and QT prolongation), syncope, increased systolic and diastolic right ventricular volume, and the production of pro-inflammatory cytokines leading atherosclerosis development, has also been expected with the chronic use of some types of SSRIs. CONCLUSION: According to our systematic review, both beneficial and adverse cardiovascular events can be established following the chronic use of various types of SSRIs. Therefore, when taking SSRIs, the cardiovascular effect of each SSRI has to be carefully considered, based on patients' cardiovascular risk profiles.

Repair of aorto-left ventricular tunnel arising from the left sinus of valsalva.

Aortico-left ventricular tunnel (ALVT) is a rare congenital cardiac defect that bypasses the aortic valve via a para-valvular connection from the left ventricle to the aorta. In most cases, the tunnel arises from the right aortic sinus. In this case report, we are presenting a case of ALVT, of which the aortic orifice arose from the left aortic sinus, requiring special attention to avoid the left coronary artery injury at the time of surgical repair.

Five chambered heart: case of a huge left atrial appendage aneurysm.

Aneurysmal enlargement of the left atrial appendage is an extremely rare pathology and can predispose to adverse events, including cardiac arrest, respiratory distress, arrhythmia, heart failure, systemic thromboembolism, or rupture. It is usually diagnosed incidentally or after the occurrence of atrial tachyarrhythmias or thrombotic events in the second to fourth decades of life. We describe a rare case of a symptomatic giant congenital left atrial appendage aneurysm (LAAA) in a 26-year-old man presenting with neurologic event, in whom surgical resection of the aneurysm was successfully performed. This is the largest LAAA reported in the literature so far.

Video assisted thoracoscopic surgery cases with right-sided aortic arch aneurysm and complete vascular ring: Case report.

INTRODUCTION: Right-sided aortic arch with aberrant left subclavian artery and ligamentum arteriosum, after double aortic arch, is the second most common complete vascular ring. It was traditionally treated by open surgical thoracotomy and recently video assisted thoracoscopic surgery (VATS) has been used in some cases. PRESENTATION OF CASE: We describe the cases of two infants who presented with gastroesophageal reflux, dyspnea, dysphagia secondary to aneurysmal dilatation of the retroesophageal arch confirmed by imaging data. VATS procedure was performed through a left thoracoscopic approach. Ligamentum arteriosus compressed esophagus was clipped, sectioned and then released the esophagus in one case; also, In the second case, we clipped and sectioned aorta, distal to the origin of aberrant left subclavian artery. DISCUSSION: CT angiography and MRI are known to be the most effective available imaging methods for vascular ring detection. Also, there are several surgical approaches to vascular rings such as, thoracotomy and thoracoscopy. There is a large body of evidence confirming the safety, efficacy and convenience of VATS as a therapeutic option for congenital heart disease including right-sided aortic arch and aberrant left subclavian artery. CONCLUSION: VATS is a less invasive and safe strategy for management of right-sided aortic arch with aberrant left subclavian artery and ligamentum arteriosum.

Antidepressants and cardiovascular adverse events: A narrative review.

BACKGROUND: Major depression or deterioration of previous mood disorders is a common adverse consequence of coronary heart disease, heart failure, and cardiac revascularization procedures. Therefore, treatment of depression is expected to result in improvement of mood condition in these patients. Despite demonstrated effects of anti-depressive treatment in heart disease patients, the use of some antidepressants have shown to be associated with some adverse cardiac and non-cardiac events. In this narrative review, the authors aimed to first assess the findings of published studies on beneficial and also harmful effects of different types of antidepressants used in patients with heart diseases. Finally, a new categorization for selecting antidepressants according to their cardiovascular effects was described. METHODS: Using PubMed, Web of Science, SCOPUS, Index Copernicus, CINAHL, and Cochrane Database, we identified studies designed to evaluate the effects of depression and also using antidepressants on cardiovascular outcome. A 40 studies were finally assessed systematically. Among those eligible studies, 14 were cohort or historical cohort studies, 15 were randomized clinical trial, 4 were retrospective were case-control studies, 3 were meta-analyses and 2 animal studies, and 2 case studies. RESULTS: According to the current review, we recommend to divide antidepressants into three categories based on the severity of cardiovascular adverse consequences including (1) the safest drugs including those drugs with cardio-protective effects on ventricular function, as well as cardiac conductive system including selective serotonin reuptake inhibitors, (2) neutralized drugs with no evidenced effects on cardiovascular system including serotonin-norepinephrine reuptake inhibitors, and (3) harmful drugs with adverse effects on cardiac function, hemodynamic stability, and heart rate variability including tricyclic antidepressants, serotonin antagonist and reuptake inhibitors, and noradrenergic and specific serotonergic antidepressants. CONCLUSION: The presented categorization of antidepressants can be clinically helpful to have the best selection for antidepressants to minimizing their cardiovascular harmful effects.

A simple modified Bentall technique for surgical reconstruction of the aortic root - short and long term outcomes.

BACKGROUND: Since the first introduction of the Bentall technique, several modifications have been proposed to improve patient outcomes and decrease intra- and post-operative complications. We describe a simplified modification of the technique that tries to lessen the intra-operative time, improve homeostasis and miminize early and late complications. Our experience with the technique and short- and long-term patient outcomes are reported. METHODS: From August 1996 to October 2013, 110 consecutive patients underwent this modified technique. The procedure used Dacron composite graft with a mechanical valve (St. Jude Medical®) for aortic root replacement. To avoid intra-operative complications, no mobilization of coronary ostia was done. Additionally, the tubular aorta was kept minimally unchanged. RESULTS: Total bleeding after the operation was 450 ± 105 mL. The mean duration of intensive care unit and hospital stay were 2 ± 1 and 5 ± 2 days, respectively. Sixty-six patients (60 %) were discharged from the surgical intensive care unit on the first postoperative day, 34 patients (30.9 %) were discharged on the second day and ten patients (9.1 %) needed more time to stay in the intensive care unit due to haemodynamic or respiratory problems. At 5-years follow up, survival rate was 97 %. In the three deceased patients, causes of death were mediastinitis, sepsis and myocardial infarction. No operation-related complications such as anticoagulant-related hemorrhage, valve or graft thrombosis, or coronary pseudoaneurysm were occurred during follow-up. CONCLUSIONS: The proposed modification of the Bentall technique seems to minimize late intra-operative blood loss, improves homeostasis, shortens the operation time and is associated with excellent long-term outcomes in patients undergoing composite graft replacement of the aortic root.

Unruptured Aneurysm of Sinus of Valsalva Coexisting with the Large Ventricular Septal Defect and Severe Aortic Regurgitation in a Young Man.

Introduction. Unruptured sinus of valsalva aneurysm (SVA) is a rare congenital anomaly, particularly, when it coexists with a ventricular septal defect (VSD) and aortic regurgitation due to the prolapse of the elongated aortic cusp into the VSD. In this report, we present the case of a 19-year-old young man with VSD challenging in spite of dyspnea and lower limb edema. Presentation of Case. Its diagnosis was made on the basis of transthoracic echocardiography results. Surgical management consisted of replacing the SVA with mechanical valve prosthesis. A Gore-Tex patch repaired the VSD. Discussion. In the follow-up periods, clinical and echocardiographic tests showed that the patient was in excellent status. Conclusion. SVA requires a surgical procedure due to its high risk of mortality in unoperated patients and a good safety of surgery.

Nicorandil Versus Nitroglycerin for Symptomatic Relief of Angina in Patients With Slow Coronary Flow Phenomenon: A Randomized Clinical Trial.

OBJECTIVE: Patients with the coronary slow flow phenomenon frequently experience angina episodes. The present study aimed to compare the efficacy of nicorandil versus nitroglycerin for alleviation of angina symptoms in slow flow patients. METHODS: In a single-center, single-blind, parallel-design, comparator-controlled, randomized clinical trial (NCT02254252), 54 patients with slow flow and normal or near-normal coronary angiography who presented with frequent angina episodes were randomly assigned to 1-month treatment with nicorandil 10 mg, 2 times a day (n = 27) or sustained-release glyceryltrinitrate 6.4 mg 2 times a day (n =27). Frequency of angina episodes, pain intensity, and the Canadian Cardiovascular Society (CCS) grading of angina pectoris were assessed at baseline and after 1 month of treatment. RESULTS: In all, 25 patients in the nicorandil arm and 24 patients in the nitroglycerin arm were analyzed. After 1 month, patients treated with nicorandil had fewer angina episodes (adjusted mean number of episodes per week, nicorandil versus nitroglycerin; 1.68 ± 0.15 vs 2.29 ± 0.15, P = .007, effect size = 14.6%). Patients also reported greater reductions in pain intensity with nicorandil versus nitroglycerin (adjusted mean of self-reported pain score; 3.03 ± 0.29 vs 3.89 ± 0.30, P = .046, effect size = 8.4%). A significantly higher proportion of patients in the nicorandil arm were categorized in CCS class I (76% vs 33.3%, P = .004) or class II (16.0% vs 45.8%, P = .032). CONCLUSION: In slow flow patients, nicorandil provides better symptomatic relief of angina than nitroglycerin.

Radiofrequency atrial fibrillation ablation technique in patients with mitral valve surgery and left atrial reduction procedures.

BACKGROUND: About half of all patients who undergo mitral valve surgery suffer from atrial fibrillation (AF). Cox described the surgical cut-and-sew Maze procedure, which is an effective surgical method but has some complications. This study was designed to evaluate the efficacy of a substitution method of radiofrequency ablation (RFA) for patients undergoing mitral valve surgery with AF. METHODS: We evaluated 50 patients, comprising 40 men and 10 women at a mean age of 61.8 ± 7.5 years, who underwent mitral valve surgery with RFA between March 2010 and August 2013. All the patients had permanent AF with an enlarged left atrium (LA). The first indication for surgery was underlying organic lesions. Mitral valve replacement or repair was performed in the patients as a single procedure or in combination with aortic valve replacement or coronary artery bypass grafting. Radiofrequency energy was used to create continuous endocardial lesions mimicking most incisions and sutures. We evaluated the pre- and postoperative LA size, duration of aortic cross-clamping, cardiopulmonary bypass time, intensive care unit stay, and total hospital stay. RESULTS: The mean preoperative and postoperative LA sizes were 7.5 ± 1.4 cm and 4.3 ± 0.7 cm (p value = 0.0001), respectively. The mean cardiopulmonary bypass time and the aortic cross-clamping time were 134.3 ± 33.7 minand 109.0 ± 28.4 min, respectively. The average stay at the intensive care unit was 2.1 ± 1.2 days, and the total hospital stay was 8.3 ± 2.4 days. Rebleeding was the only complication, found in one patient. There was no early or late mortality. Eighty-two percent of the patients were discharged in normal sinus rhythm. Five other patients had normal sinus rhythm at 6months' follow-up, and the remaining 4 patients did not have a normal sinus rhythm after 6 months. CONCLUSION: Radiofrequency ablation, combined with LA reduction, is an effective option for the treatment of permanent AF concomitant with mitral valve surgery.

Immunohistochemistry comparing endoscopic vein harvesting vs. open vein harvesting on saphenous vein endothelium.

OBJECTIVE: The present study attempts to compare the immunohistochemistry (IHC) of von Willebrand factor (vWf) , endothelial cadherin, Caveolin and endothelial Nitric Oxide Synthase (eNOS) in VasoView Endoscopic Vein Harvesting (EVH) versus traditional Open Vein Harvesting (OVH) techniques for Coronary Artery Bypass Graft (CABG) Surgery performed in Javad al Aemeh Hospital of Mashhad, Iran in 2013,. METHODS AND MATERIALS: Forty-seven patients were scheduled for CABG (30 EVH and 17 OVH) among whom patients with relatively same gender and similar age were selected. Three separate two cm vein samples were harvested from each patient's saphenous vein. Each portion was collected from distal, middle and proximal zones of the saphenous vein. The tissues were deparaffinized, and antigen retrieval was done using EZ-retriever followed by an immunohistochemistry evaluation with vWf, e-cadherin, Caveolin and eNOS. In addition, demographic questioner as of Lipid profile, FBS, BMI, and cardiovascular risk factors were collected. Data analyses, including parametric and nonparametric tests were undertaken using the SPSS 16 software. A P value < 0.05 was regarded as statistically significant. RESULTS: The mean age of the EVH and OVH groups were 63.76 ± 9.51 and 63.63 ± 8.31 years respectively with no significant difference between them (p = 0.989). In addition, there was no great difference between the EVH and OVH groups in lipid profile, DM, HTN, smoking history, CVA, and valvular dysfunction (P > 0.05). Qualitative report of vWf, e-cadherin, Caveolin and eNOS reveals no significant difference between the EVH and OVH (P > 0.05). CONCLUSION: This study indicates that VasoView EVH technique causes no endothelial damage in comparison with OVH. This study could be a molecular confirmation for the innocuous of EVH technique.

Video-assisted thoracoscopic patent ductus arteriosus closure in 2,000 patients.

Video-assisted thoracoscopic surgery has proved to be a safe and effective method with low complication and high success rates. From 1997 to 2008, 2,000 consecutive patients with patent ductus arteriosus underwent closure of the ductus with 2 titanium clips via a video-assisted thoracoscopic technique. Complete closure was confirmed using our handmade intraesophageal stethoscope. The mean age was 5.2 years, and mean weight was 9.8 kg. One death was reported 1 month after surgery, due to sepsis during hospitalization for chylothorax treatment. The procedure was converted to an emergency thoracotomy in one case, due to ductal wall rupture. There were 4 late residual shunts treated via thoracotomy. We observed transient laryngeal nerve dysfunction in 14 patients. All patients were reassessed by postoperative echocardiography. The mean procedure (skin-to-skin) time was 10 ± 2 min, and hospitalization was 21 h. This study indicates that video-assisted thoracoscopic closure of patent ductus arteriosus is a safe, simple, and cost-effective method with low complication and high success rates. Furthermore, the cosmetic benefits make it appropriate as an out-patient procedure.

Lipomatosis of interventricular septum and both ventricles: an extremely rare pattern.

Fatty masses of the heart are relatively uncommon. This report is about an extremely rare case of cardiac lipomatosis that implicates both ventricles and inter-atrial septum. The patient was a 27-year-old female who was accidentally diagnosed during a routine physical examination. Trans-thoracic echocardiography (TTE) discovered a large homogenous bi-lobed, non-encapsulated echogenic mass. Magnetic resonance imaging (MRI) showed soft tissue abnormal enhancement in the anterior left base of the heart and sub-aortic outflow tract. A trans-jugular echomyocardial biopsy was done because of a lack of a definite diagnosis by non-invasive techniques. Pathological study showed benign fatty infiltration suggestive for benign lipomatous hypertrophy.

Esophageal stethoscope: an old tool with a new role, detection of residual flow during video-assisted thoracoscopic patent ductus arteriosus closure.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for closure of a patent ductus arteriosus (PDA), but is associated with a minute rate of residual or recurrent duct patency. This study aims to analyze the efficacy of intraoperative esophageal stethoscopic monitoring in reducing the incidence of residual ductal flow during PDA clipping by VATS. METHODS: Between June 1997 and October 2009, we retrospectively assessed 2000 consecutive patients with PDA who underwent VATS. During the procedure, heart sounds were monitored by the anesthesiologist through an esophageal stethoscope. Changes in continuous cardiac murmurs were recorded before and after the PDA clipping and were confirmed to disappear completely. Color flow Doppler echocardiography was performed immediately before discharge, and patients were followed monthly for 3, 6, and 12 months and then annually to confirm the absence of residual or recurrent shunt. RESULTS: Mean age was 6.0 years (range, 1 month-35 years), mean weight was 11.1 kg (range, 6-65 kg), and mean PDA diameter was 5.5 mm (range, 3-9 mm). Ninety-two percent of patients showed no ductal flow after a single clipping. In the other 8% of patients, residual flow was detected intraoperatively after a single clipping, but was eliminated by the second clipping. Twelve patients (0.6%) presented with residual ductal flow immediately after the operation (detected by color Doppler echocardiography), which was eliminated by thoracotomy before discharge. All patients left the hospital with echocardiography documenting no evidence of residual PDA. At follow-up, the incidence of residual patency was 0.2% (4 of 2000). CONCLUSIONS: Our results demonstrate that the intraoperative esophageal stethoscope provides a remarkably effective technique for monitoring and evaluating PDA ligation by VATS, thus avoiding reintervention and the complications associated with residual ductal flow in most cases.

Congenital pulmonary arteriovenous malformation: a rare cause of cyanosis in childhood.

Pulmonary arteriovenous malformation (PAVM) is a rare condition in which there is abnormal connection between pulmonary arteries and veins. The disorder usually appears in late childhood or early adult life, with dyspnea on exertion, clubbing or cyanosis. We present two patients with severe cyanosis and their work-up to diagnosis of PAVM, as a rare cause of cyanosis in childhood.