Fatal Acute Myocardial Infarction With Normal Epicardial Coronary Arteries Shortly Following COVID-19 Vaccination.

Myocarditis and acute myocardial infarction (AMI) have been reported after COVID-19 messenger ribonucleic acid vaccination. Nearly all reported patients with myocarditis or AMI after COVID-19 vaccination have survived and become asymptomatic. Described herein is a previously healthy man who developed severe heart decompensation shortly after receiving a COVID-19 vaccination and died approximately 40 hours later. An autopsy disclosed massive AMI.

Classification of the Urgency of the Procedure and Outcome of Acute Type A Aortic Dissection.

Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge.

Examination of Non-Infected Operatively-Excised Bioprostheses in the Aortic Valve Position to Determine the Reason for their Dysfunction.

Described herein are findings in 55 non-infected bioprostheses that had been in the aortic valve position from 2 to 276 months (mean 107). The major purpose of this study was to illustrate the variable causes prompting excision of the bioprostheses. Fifty-three (96%) patients survived ≥ 30 days following the bioprosthetic excision and 50 (91%) patients lived ≥1 year postoperatively. The techniques used to explant the bioprostheses appear to vary considerably among the operating surgeons.

Causes of Malfunction of Bioprostheses Inserted Percutaneously in the Aortic Valve Position in Patients Whose Native Aortic Valve Was Congenitally Bicuspid and Stenotic.

Transcatheter aortic valve implantation (TAVI) has brought in recent years relief of cardiac-induced symptoms to a large number of patients with aortic stenosis. Whether it is better to use TAVI for the treatment of aortic valve stenosis superimposed on a congenitally bicuspid valve has been debated in contrast to its proved usefulness in aortic valve stenosis involving a tricuspid aortic valve. From January 2020 to March 2023, surgical aortic valve replacement of TAVI valve and native aortic valve was done in 6 patients. The clinical findings of the patients and morphologic findings from the surgical specimens submitted to the cardiac pathology department were subsequently examined. All the 6 native aortic valves had bicuspid configuration. The TAVI valve in each patient was excised from 9 to 88 months (mean 36 months) after it had been implanted because of paravalvular leak in 4, severe stenosis of the prosthetic valve in 1, and bioprosthetic cuspal degeneration in 1. Prosthetic valve endocarditis was clinically suspected in 2 patients, but the specimen culture was negative. Before surgical aortic valve replacement, 3 patients experienced stroke after TAVI. All 6 patients had low hemoglobin levels (mean 9.5 mg/100 ml) and low hematocrit levels (mean 29.5%). Reticulocyte count was available in 4 patients and was increased in all (mean 3.5%). When the stenotic native aortic valve configuration is bicuspid, the raphe tends to be calcified first and located perpendicular to the flow of the blood and may prevent the ring of the caged bioprosthesis from being transferred to the aortic wall, which is a requirement for full opening of the lumen of the bioprosthesis. Thus, thorough consideration needs to be made before performing TAVI in patients whose native aortic valve is stenotic and bicuspid.

Cardiac Findings at Necropsy in Acute Type A Aortic Dissection.

Described herein are necropsy findings in 97 patients aged 22 to 82 years (mean 55), 37 women, 60 men, studied at necropsy with acute aortic dissection (AD) with the intimal-medial tear in the ascending aorta. The cases were studied from 1966 to 1989, a period when echocardiography and computed tomography were relatively infrequently available for diagnosis of AD. Arteriography was the method for diagnosis in most cases. Of the 97 cases, 30(31%) had operative intervention and 67 did not. Most appeared to have had systemic hypertension before the acute AD; only 4 had previous heart failure; only 8 had considerable atherosclerotic coronary disease; only 4 had a left ventricular (LV) scar and in each it was small; most (96%) had a normal-sized LV cavity (suggesting normal cardiac indices in them), and the other 4 had only a mildly dilated cavity; the heart weight in all 97 patients was increased; the quantity of subepicardial adipose tissue was increased in most patients, and the frequency of a congenitally malformed aortic valve was much higher than in the general population (6% - vs- 1%), but still uncommon. Thus, in > 90% of patients with acute Type A AD, coronary atherosclerosis was insignificant, myocardial fibrosis is absent, and the aortic valve has 3 cusps without stenosis.

Aortic Valve Replacement for Active Infective Endocarditis Limited to the Native Aortic Valve.

Described herein are certain clinical and morphologic findings in 27 patients who underwent aortic valve replacement (AVR) for active infective endocarditis (IE) limited to the aortic valve. The major focus was to describe and illustrate the operatively-excised aortic valves. The aortic valves were tricuspid in 17 patients, and in each of them the infection appeared to involve a previously normal valve as evidenced by the cusps being entirely normal in areas where vegetation was not present. The infection in the tricuspid valves produced considerable regurgitation. Of the 10 patients in whom the IE involved a congenitally bicuspid valve, 3 were considerably calcified and stenotic before the IE occurred and the IE produced ring abscess in each of these 3 patients. In contrast, ring abscess occurred in only 1 of the 17 patients with tricuspid aortic valves. The cuspid tissue in the other 7 patients with bicuspid valves was either minimally scarred, entirely normal, and free of calcific deposits.

Diagnosing aortic syphilis.

Described herein is a morbidly obese 57-year-old man with an aneurysm involving the tubular portion of the aorta. Examination of the wall of the operatively resected aneurysm disclosed classic findings of aortic syphilis, a condition that clearly has not disappeared. If there is an aneurysm involving the tubular portion of the ascending aorta in the absence of aortic dissection or involvement of the sinuses of Valsalva, the most likely diagnosis is aortic syphilis. In these circumstances, the serologic test for syphilis is often negative.

Circumferential Fibrosis of the Ascending Aorta After COVID Infection.

After recovering from severe COVID-19 infection, 2 women presented with chest pain. Computed tomographic angiography suggested acute ascending aortic dissection. At operation in both patients, the ascending aorta was encased in dense fibrous tissue, within which were focal collections of mononuclear cells, including many plasma cells. There was no entry tear or dissection. Such findings we have not encountered previously, and PubMed search of "periaortic fibrosis and COVID-19" yielded no similar cases or possible relation.

Acute Dissection of Epicardial Coronary Arteries Shortly Following Full Term Delivery Resulting in Acute Myocardial Infarction and Leading to Orthotopic Heart Transplantation.

Described herein is a 28-year-old woman who developed acute dissection of the left main, left anterior descending, and left circumflex coronary arteries shortly after delivering a full-term normal infant. The consequence was acute myocardial infarction leading to a severely depressed left ventricular ejection fraction (<10%) and resulting in life-saving orthotopic heart transplantation procedure not previously reported in patients with spontaneous isolated coronary dissection.

Combined Cardiovascular Syphilis and Type A Acute Aortic Dissection.

The occurrence of acute aortic dissection with the initiating tear in the ascending aorta superimposed on cardiovascular syphilis is an exceedingly rare occurrence. Such was the case, however, in a recently seen patient who presented with typical features of acute dissection (type A). Operative repair yielded the entire ascending aorta to examine both grossly and histologically and classic features of both conditions were observed.

Morphologic Findings in Native Mitral Valves Replaced for Isolated Acute Infective Endocarditis.

Described here are some clinical and morphological observations in 37 adults having mitral valve replacement for active infective endocarditis limited to the mitral valve. The operatively-excised mitral valves are illustrated in 11 of the 37 patients, and photographs in them show that mitral valve repair in them would have been fruitless. Of the 37 patients, 32 (86%) survived the early operative period (30 days) and 31 (84%) were alive one year after the mitral operation. Of the 37 patients, 34 (92%) appeared to have had anatomically normal mitral valves before the infective endocarditis appeared.

Aortic Intimal-Medial Tear Without Dissection, the Marfan Syndrome, and Its Forme Fruste Variety.

Acute aortic dissection is a relatively common disease involving the aorta. All aortic dissections start with an intimal-medial tear prior to the medial dissection. Several cases of aortic intimal-medial tear without dissection have been reported previously, but only one article presented a photograph of the intimal-medial tear. Herein, we describe 16 patients whose ascending aortas were operatively excised because of what clinically was believed to be acute aortic dissection. Of the 16 patients, 14 had aortic intimal-medial tears without dissection and the other 2 had acute medial dissection of the aorta adjacent to a healed aortic intimal-medial tear without dissection. These aortic intimal-medial tears have been seen in the Marfan syndrome, but none of our 16 patients had the Marfan syndrome. At least 9 of the 16 patients, however, had had aortas similar to those seen in the Marfan syndrome (forme fruste variety). Although the 8 surgeons who operated on these 16 patients described the intimal-medial tears as "aortic dissection", only 2 had acute dissection adjacent to a healed intimal-medial tear without dissection. In conclusion, although the aortic intimal-medial tear is the initiator of aortic dissection, some patients with intimal-medial tears have no accompanying dissection.

Infective Endocarditis Involving a Bioprosthesis in the Aortic Valve Position with Operative Excision.

Described herein are findings in 15 infected bioprostheses that had been in place from 5 to 120 months (mean 42). The major purpose was to show multiple photographs of the operatively-excised bioprostheses to illustrate the variable causes prompting excision of the bioprostheses. Eleven patients survived ≥ 30 days following the bioprosthetic excision and 9 patients lived longer than 1 year postoperatively. The techniques to explant the infected bioprosthesis appears to vary a bit among the operating surgeons.

Total 12-lead QRS voltage in patients with spontaneous acute aortic dissection with an initiating tear in the ascending aorta.

Because nearly all patients with acute aortic dissection have systemic hypertension, we examined electrocardiograms (ECGs) in 21 patients with spontaneous acute type A aortic dissection. An earlier study had shown that total 12-lead QRS voltage was the best criterion for determining left ventricular hypertrophy from the ECG. We measured total 12-lead QRS voltage in 21 patients with spontaneous (no previous cardiac or aortic operation) acute type A aortic dissection and operative repair. Using >175 mm as evidence of left ventricular hypertrophy, only 8 patients (38%) had hearts of increased mass. Total 12-lead QRS voltage corresponded slightly with age but not with body mass index. In conclusion, total 12-lead QRS voltage is not useful for diagnostic purposes in patients with acute type A aortic dissection undergoing operative repair.

Direct access of ascending aorta for endograft delivery in the descending thoracic aorta.

First-line therapy for aneurysm, dissection, or rupture of the descending thoracic aorta is now by the endovascular approach. Retrograde insertion of the endograft, through access from the femoral arteries, is the preferred approach. This case presents a new, innovative technique for delivery of an endoprosthesis into the descending thoracic aorta when hostile anatomy prevents delivery from the femoral arteries, iliac arteries, or infrarenal abdominal aorta in a patient not suitable for open repair.

The Layer Where the Coronary Arterial "Endarterectomy" Specimen Separates from the Underlying Artery.

Described herein is a patient who had a coronary endarterectomy at the time of coronary artery bypass grafting. Histologic study of cross-sections of the endarterectomy specimen disclosed that the layer of separation of the endarterectomy specimen from the underlying native artery was in the media. This layer or plane of excision is virtually always the media irrespective of the artery having the endarterectomy. The procedure might better be called "endomediaectomy?"

Perforation of a Stenotic Congenitally Bicuspid Aortic Valve Cusp by Heavy Calcium in the Other Cusp.

On occasion in patients with stenotic congenitally bicuspid aortic valves (BAVs), the quantity of calcium in one of the cusps is considerably greater than in the other cusp. We examined operatively excised stenotic congenitally BAVs in 630 patients having isolated aortic valve replacement (No other cardiac valve was replaced, and none had had infective endocarditis.) Of the 630 valves, 3 contained a perforation in the mildly calcified cusp due to a large calcific "spur" extending across the orifice from a heavily calcified cusp. In conclusion, heavy calcific deposits in 1 of 2 BAVs may extend across the orifice causing a perforation in the noncalcified portion of the opposing cusp.

Syphilitic aortitis: still a current common cause of aneurysm of the tubular portion of ascending aorta.

Aortic syphilis today is infrequently diagnosed clinically. Described herein are findings in 5 women who had resection of a fusiform aneurysm of the tubular portion of ascending aorta, and examination of the wall of the aneurysm disclosed classic features of aortic syphilis. The 5 patients were among 36 who had ascending aortic operations at Baylor University Medical Center in Dallas in 2018 and early 2019. Syphilitic aneurysm in each spared the sinus portion and involved diffusely the tubular portion of ascending aorta, beginning at the sinotubular junction. The aneurysmal wall was thicker than normal because of thickening of both intima and adventitia. The latter contained foci of lymphocytes and plasmacytes and thickened and narrowed vasa vasora. The media was disrupted by fibrous scars, which weakened the integrity of the aorta. Aortitis of the tubular portion of ascending aorta in syphilis is a diffuse process, but often is mistakenly called "atherosclerosis" which, when present in this portion of aorta, can be extensive but is focal. Aortic syphilis is important to diagnose so that patients can receive antibiotic therapy to delay, prevent, or treat neurosyphilis, a common accompaniment of aortic syphilis.

Hanging by a thread-urgent coronary artery bypass grafting for ST elevation myocardial infarction in a patient with isolated left main coronary artery disease.

A 78-year-old man presented with a left main stenosis as the culprit lesion in an acute myocardial infarction. He had no significant narrowing in any other coronary territory. This case describes findings in an isolated left main myocardial infarction and discusses appropriate treatment strategies.

The Case for Primary Prevention of Atherosclerotic Events from Study of a Single Patient.

This report describes a 64-year-old woman who presented with unstable angina pectoris, her first atherosclerotic event, and who underwent coronary bypass including endarterectomy of the entire right coronary artery which was diffusely and severely narrowed by atherosclerotic plaque. Preoperatively, she fulfilled none of the present-day criteria for lipid-lowering drug therapy. The report demonstrates the deficiency of present-day lipid-lowering drug guidelines and emphasizes the need to switch emphasis from decreasing risk of an atherosclerotic event to the prevention of arterial plaques, a goal which will require a much lower threshold of low-density lipoprotein cholesterol to initiate drug therapy.