Total pulmonary arterial reconstruction in a patient with arterial tortuosity syndrome affecting the pulmonary artery: a case report and review of the literature.

BACKGROUND: Arterial tortuosity syndrome is a rare Autosomal recessive disease that leads to a loss of function of the connective tissues of the body, this happens due to a mutation in the solute carrier family 2 member 10 (SLC2A10) gene. ATS is more likely to occur in Large and medium-sized arteries including the aorta and pulmonary arteries. This syndrome causes the arteries to be elongated and tortuous, This tortuosity disturbs the blood circulation resulting in stenosis and lack of blood flow to organs and this chronic turbulent flow increases the risk of aneurysm development, dissection and ischemic events. CASE PRESENTATION: A 2 years old Arabian female child was diagnosed with ATS affecting the pulmonary arteries as a newborn, underwent a pulmonary arterial surgical reconstruction at the age of 2 years old due to the development of pulmonary artery stenosis with left pulmonary artery having a peak gradient of 73 mmHg with a peak velocity of 4.3 m/s and the right pulmonary artery having a peak gradient of 46 mmHg with a peak velocity of 3.4 m/s causing right ventricular hypertension. After surgical repair the left pulmonary artery has a peak pressure gradient of 20 mmHg, with the right pulmonary artery having a peak pressure gradient of 20 mmHg. CONCLUSION: ATS is a rare genetic condition that affects the great arteries especially the pulmonary arteries causing stenotic and tortuous vessels that may be central branches or distal peripheral branches that leads to severe right ventricular dysfunction and hypertension. We believe that surgical treatment provides the optimum outcomes when compared to transcather approaches especially when the peripheral arteries are involved. Some challenges and hiccups might occur, especially lung reperfusion injury that needs to be diagnosed and treated accordingly.

Simultaneous repair of diaphragmatic hernia and ventricular septal defect with postoperative complication in a Down syndrome child.

Morgagni hernia (MH) is a rare form of congenital diaphragmatic hernia, typically occurring predominantly on the right side and exhibiting a higher prevalence in females. Usually diagnosed incidentally, MH may coexist with congenital heart defects, chest wall abnormalities and certain genetic syndromes such as Down syndrome. A 4-year-old boy with Down syndrome underwent simultaneous repair of MH and closure of a ventricular septal defect (VSD). A vertical midline sternotomy was performed, and the VSD was repaired using the right atrium approach. Subsequently, MH repair was conducted. Three weeks after the surgery, this patient developed a complete heart block, which lead to the implantation of a VVI pacemaker.

Hybrid approach to management for a patient with culture negative infective endocarditis with profunda femoris mycotic pseudoaneurysm: A case report and review of the literature.

Mycotic pseudoaneurysms can be a serious and life threatening complication of left sided infective endocarditis. They most commonly affect the major axial vessels. Profunda femoris artery (PFA) aneurysms are rare and present in only 0.5% of all peripheral aneurysms, regardless of the underlying etiology. We present a case of a patient who underwent mitral valve repair for severe mitral regurgitation secondary to culture negative IE which was complicated by multiple mycotic pseudoaneurysm. The PFA pseudoaneurysm which was affected and was complicated with a large hematoma compressing the femoral nerve. This was managed by a staged hybrid approach. Endovascular stenting was performed first to seal the pseudoaneurysm and facilitate open surgical repair using a reversed interposition saphenous vein graft. To the best of our knowledge, this is the first reported case of a PFA mycotic aneurysm (MA) being managed by a hybrid approach using endo-vascular and open surgical repair. MAs and pseudoaneurysms are complex and life threatening conditions requiring meticulous planning for optimal management. Endovascular stenting can be considered as an alternative to surgical management in certain cases or as a bridge to definitive open surgical repair depending on anatomical location and associated complications.

Aortic root abscess and Brucella endocarditis in a patient with mechanical aortic valve prosthesis: a case report.

Rare but potentially fatal, brucellosis prosthetic valve endocarditis is a complication of brucellosis caused by Brucella species. The symptoms of brucellosis can be nonspecific, making the diagnosis challenging. Osteoarticular involvement is the most common complication of brucellosis. Mortality from brucellosis is low except for endocarditis and involvement of the central nervous system. The diagnosis is based on laboratory tests and clinical manifestations. Serological tests are preferred, as culture methods can be unreliable. A 59-year-old woman presented with gastrointestinal bleeding, fever, anorexia and malaise. She had a history of aortic valve replacement with a mechanical prosthesis for severe bicuspid aortic stenosis. Investigations revealed a multiloculated aortic root abscess encircling the prosthetic valve. She was diagnosed with brucella endocarditis, treated with antibiotics and underwent cardiac surgery. Her symptoms improved following the surgery. Brucellosis prosthetic valve endocarditis is a rare presentation of this disease.

Female Gender in Cardiac Surgery: Is it Still a Significant Risk? A Retrospective Study in Saudi Arabia.

BACKGROUND: Female sex is considered an independent predictor for mortality and morbidity following cardiac surgery. This study is to review the outcomes of adult cardiac surgery between males and females in a Saudi tertiary referral hospital. METHOD: This was a retrospective study for 925 adult patients operated on for ischemic coronary artery disease and acquired aortic and mitral valvular heart disease from 2015 to August 2023. We analyzed patient characteristics, intraoperative data, and postoperative results to compare outcomes between males and females. RESULTS: Preoperative risk factors were not significantly different in both groups. Postoperative outcomes showed gender-based differences. In univariable analysis, females, compared to males, had significantly greater odds of prolonged postoperative ventilation (>24 hours), 32.8% of females compared to 20.7% of males (p < 0.001). Also, sternal wound infection was notably higher among females (13.3%) (p < 0.001). Mortality also exhibited a significant association, with 14.2% of females experiencing mortality compared to 9.4% of males (p = 0.049). In the multivariable analysis for elevated postoperative troponin, the use of pre-operative intra-aortic balloon pump, urgent/emergent surgery, elevated pre-operative troponin and combined bypass grafting with valve surgery, were also predictive of higher post-operative troponin concentrations (beta = 0.43, 95% CI: 0.25 to 0.62, p < 0.001). CONCLUSION: Females in Saudi Arabia have an increased risk of short-term morbidity and mortality after cardiac surgery compared to males. Vague and delayed presentation and then the late diagnosis and referral are likely the main contributing factors. This highlights the need to implement preoperative measures to improve early diagnosis and referral to eliminate gender bias.

Pericardiectomy for Constrictive Pericarditis in a Young Patient With Erdheim-Chester Disease.

Erdheim-Chester Disease (ECD) is an extremely rare non-Langerhans histiocytosis that most often presents in the fifth to seventh decades of life. In this case report, we present a 34-year-old woman who underwent successful pericardiectomy for constrictive pericarditis secondary to ECD, which is the youngest reported patient with ECD to undergo pericardiectomy. (Level of Difficulty: Advanced.).

Carotid to Left Subclavian Artery Bypass Grafting for the Treatment of Coronary Subclavian Steal Syndrome.

Recurrent angina after coronary artery bypass grafting is rarely caused by left subclavian artery (LSCA) stenosis resulting in reduced left internal mammary artery blood flow. We present 2 cases of coronary-subclavian artery steal syndrome resulting from LSCA stenosis and their successful surgical management with left carotid to LSCA bypass. Based on the successful management described in this case report, and the limitations of other options in addressing coronary-subclavian artery steal syndrome, left carotid to LSCA bypass surgery should be considered for revascularization in patients who develop postoperative coronary-subclavian artery steal syndrome due to LSCA stenosis.

La récidive d'angine après le pontage aortocoronarien est rarement causée par la sténose de l'artère sous-clavière gauche (ASCG) entraînant la réduction du débit sanguin de l'artère mammaire interne. Nous présentons deux cas de syndrome du vol coronaro-sous-clavier résultant de la sténose de l'ASCG et la réussite de leur prise en charge par pontage entre l'artère carotide gauche et l'ASCG. Compte tenu de la réussite de la prise en charge décrite dans cette observation et des limites des autres options dans le traitement du syndrome du vol coronaro-sous-clavier, le pontage entre l'artère carotide gauche et l'ASCG devrait être envisagé lors de la revascularisation des patients qui présentent le syndrome du vol coronaro-sous-clavier postopératoire en raison de la sténose de l'ASCG.

Right ventricular laceration caused by sternal wire fracture following cardiac surgery: a case report.

Sternal dehiscence and sternal wire fractures are of significant concern for patients post cardiac surgery. Right ventricular laceration resulting from injury secondary to fractured sternal wires is a rare cause of life-threatening postoperative hemorrhage. A 68-year-old male presented for coronary artery bypass grafting (CABG). Postoperatively, he experienced an exacerbation of chronic obstructive pulmonary disease (COPD) which initially responded to medical treatment. While mobilizing, the patient experienced acute hemodynamic decompensation. Chest X-ray revealed a new left pleural effusion and a bedside echocardiogram revealed significant pericardial effusion. The patient was taken urgently for re-exploration with a diagnosis of cardiac tamponade. All sternal wires were found to be fractured and a right ventricular laceration was identified. The laceration was repaired primarily with sutures and the sternum was closed with reinforced sternal wires. The patient recovered well postoperatively and was discharged without further complication. Postoperative hemorrhage is a known complication of cardiac surgery but is rarely caused by laceration secondary to sternal wire fracture. Alternative sternal closure techniques should be considered in high-risk groups of patients. A high index of suspicion should be maintained for patients with sternal dehiscence. Furthermore, these patients should be monitored closely and definitive management implemented immediately when sternal wire fracture and resulting injury are suspected.

Coagulopathy Management of an Acute Type A Aortic Dissection in a Patient Taking Apixaban.

This paper reports the successful management of a patient with acute type A Penn B thoracic aortic dissection who was on apixaban therapy for atrial fibrillation. Emergency surgery was performed due to the patient's clinical deterioration, with innominate artery compromise and severe aortic valve regurgitation. The anesthesia team used point-of-care rotational thromboelastometry-guided coagulation replacement therapy consisting of prothrombin concentrate, fibrinogen, and platelets. The surgical team used a complementary approach with topical hemostatic agents and a pericardial patch. No additional blood products were required. The patient recovered fully and was discharged home.

Prediction of temporary epicardial pacing wire use in cardiac surgery.

BACKGROUND: Placement of temporary epicardial pacing wires (TEPW) at the end of open heart surgery cases is routine but can be associated with complications. Identification of patients who are high risk for requiring pacing would be beneficial on guiding selective TEPW placement. The purpose of this study was to identify predictors of temporary pacing immediately post cardiac surgery. METHODS: A retrospective analysis of patients undergoing cardiac surgery from 2005 to 2016 at the Maritime Heart Center was conducted. Analysis was performed of patients who require pacing on arrival to the cardiovascular intensive care unit (CVICU) compared with those who were not paced. Multivariable logistic regression was used to determine each variable's risk adjusted likelihood of pacing for the entire cohort. Subgroup analysis was performed in the isolated procedures. RESULTS: A total of 11 752 patient underwent surgery from the year 2005 to 2016. Two thousand and fifty-one (17.5%) required pacing on arrival to CVICU. Older age, female sex, preoperative renal failure, lower ejection fraction (EF), preoperative arrhythmia, preoperative use of calcium channel blockers, and longer cross-clamp times were risk factors for pacing. In the isolated coronary artery bypass grafting and aortic valve replacement groups, findings were similar to the overall cohort. Only age, obesity, and chronic obstructive pulmonary disease were risk factors for pacing in the isolated mitral valve (MV) repair group and only preoperative arrhythmia in the isolated MV replacement group. CONCLUSION: We have identified risk factors for TEPW use following cardiac surgery and in isolated procedure subgroups. These risk factors may help guide selective TEPW placement.

Incidence of tamponade following temporary epicardial pacing wire removal.

BACKGROUND AND AIM OF STUDY: Placement of temporary epicardial pacing wires (TEPW) is common practice in cardiac surgery. Removal of TEPW in the postoperative period can lead to serious bleeding necessitating surgical intervention and conferring high morbidity. The purpose of this study is to determine the incidence of TEPW removal complications. METHODS: A retrospective review of all major cardiac operations at our institution from 2005 to 2016 was conducted. Patients were identified using the Maritime Heart Center Database. We reviewed preoperative, intra-operative, and postoperative characteristics of patients who returned to the operating room more than or equal to 3 days after their index operation to identify those who had bleeding and/or tamponade as a consequence of TEPW removal and any subsequent morbidity. RESULTS: A total of 11 754 patients underwent cardiac surgery at our institution between 2005 and 2016. Of these patients, 88 (0.75%) went back to the operating theater for bleeding and/or tamponade more than or equal to 3 days from their initial index operation. Of these, 11 (0.09%) were secondary to TEPW removal where two (0.017%) suffered irreversible anoxic brain injury. All 11 patients were on antiplatelet therapy with the addition of either deep venous thrombosis (DVT) prophylaxis or therapeutic anticoagulation, which is the standard of care at our institution. CONCLUSIONS: Bleeding complications following TEPW removal are rare but have significant consequences including increased hospital length of stay, resource utilization, and morbidity. Standardized practice to address antiplatelet, DVT prophylaxis, and anticoagulation before removal may help further reduce the incidence of serious bleeding events.

Migrated fractured sternal wire in proximity to the main pulmonary artery: Case report and review.

BACKGROUND: We present a case of a 83-year-old man with a prior history of coronary artery bypass who presented to his family physician with progressive symptoms that raised concern for heart failure exacerbation. A chest X-ray was performed, which showed a fractured topmost sternal wire in the lateral projection and indicated that the sternal wire had migrated into the anterior mediastinum. An emergent electrocardiogram-gated flash computed tomography angiography confirmed the location of the fractured wire to be in close proximity to the main pulmonary artery. A discussion of migrated sternal wires with a literature review of cases is provided as well. AIMS: To present a case of a migrated sternal wire and a literature review. METHODS: An extensive literature review using pubmed and medline with relevant keywords was preformed. RESULTS: 11 known cases of migrated sternal wires with various complications, as detailed in the review table. The mortality rate is low but can be associated with significant morbidity. DISCUSSION: Fractured wires are quite common and are usually a benign radiographic finding. However, migration of sternal wires is an extremely rare phenomenon. Only a few reported cases in the literature were sternal wires have migrated beyond the sternum, leading to catastrophic clinical consequences, as detailed in the review table. CONCLUSION: Sternal wire complications secondary to migration beyond the sternum are rare but potentially fatal. Precise wire location and risk assessment with CT are more appropriate when wire location cannot be clearly delineated by plain film radiography.

When is the optimal time to discontinue clopidogrel before in-hospital coronary bypass surgery? A closer look at the current literature.

BACKGROUND: Clopidogrel and other P2Y12 inhibitors have become the standard of care among patients presenting with acute coronary syndromes. A substantial proportion of these patients require surgical revascularization during index hospitalization. HYPOTHESIS: Guidelines recommend a 5-day waiting period off clopidogrel before coronary artery bypass grafting (CABG) to reduce hemorrhagic complications. These recommendations are not routinely followed in clinical practice, while recent studies also propose shorter waiting periods off clopidogrel for patients awaiting in-hospital CABG. METHODS: A preliminary PubMed search was conducted using the following MeSH terms under the publication type "Hemorrhage:" "Clopidogrel," AND "Coronary Artery Bypass." Relevant studies and guidelines were then reviewed and selected based on a predetermined criteria. Studies that formulated the current recommendations for stopping clopidogrel preoperative to CABG are discussed in detail this review. RESULTS: A comprehensive review of recent evidence illustrates mixed bleeding and transfusion outcomes among CABG patients with preoperative exposure to clopidogrel in less than 5 days. CONCLUSIONS: The optimal discontinuation time of clopidogrel before CABG is still poorly defined. The recommendation of a 5-day washout period for clopidogrel should be reconsidered to be on par with current clinical practice.