Antiphospholipid antibody syndrome complicating infective endocarditis - case report.

A 37-year-old lady with infective endocarditis of the mitral valve presented in congestive cardiac failure. However, the clinical scenario became complicated when she was also found to have antiphospholipid antibody syndrome. Meticulous optimization and timely surgical intervention by a multidisciplinary team helped mitigate this not so common situation and lead to successful outcome.

Aortic endarterectomy: a useful technique to utilize for aortic valve replacements in hostile aorta.

Calcified aorta poses a significant technical challenge in the performance of surgical aortic valve replacement (AVR). Aortic endarterectomy is a less utilized approach and is suitable in select cases for aortic decalcification during AVR. Here, we report a case of calcified ascending aorta who underwent ascending aortic endarterectomy and AVR with the technical details of the procedure.

Rare case of proximal coronary plaque regression after distal arterial grafting.

The metabolically active endothelium of arterial grafts is reported to slow the atherosclerotic process in the distal coronary territories to which they are grafted with improved patency. The literature on arterial grafting causing proximal plaque regression is scant. We report here a case of proximal left anterior descending artery (LAD) plaque regression following distal arterial grafting with a left internal mammary arterial (LIMA) graft to LAD. This rarely documented regression resulted in "stringing" of the arterial graft, while there was a significant progression of atherosclerotic disease in the right coronary with patent venous graft and de novo lesion in circumflex territory necessitating percutaneous coronary intervention, in spite of aggressive medical therapy. The dichotomous progression of disease in two out of three coronary arterial systems and regression of the proximal plaque in LAD grafted with LIMA 12 years ago suggests the protective effect of arterial grafting in reversing the atherosclerotic process.

"Cryptic" mediastinal tuberculosis with myasthenia-thymoma complex.

Mediastinal tuberculosis, although common in endemic areas, is rare in association with myasthenia-thymoma complex. Immunosuppressive therapy for myasthenia with thymoma might increase the susceptibility for mediastinal tuberculosis. Previous reports suggest aggravation of myasthenic symptoms with this association. This rare combination of pathologies adds to the diagnostic dilemma of the surgeon. Further research is warranted in the management aspects of this combination as regards to the timing of radiotherapy, weaning of immunosuppression and anti-tubercular therapy after maximal thymectomy. This case report emphasises the possibility of mediastinal tuberculosis as a differential diagnosis for mediastinal lymphadenopathy in the setting of a preoperative diagnosis of invasive thymoma.

del Nido cardioplegia in adult cardiac surgery - scopes and concerns.

The convenience offered by a single-dose cardioplegia strategy is the avoidance of interruption of the flow of surgery and, more importantly, a significant reduction in the cross-clamp time. del Nido cardioplegia is an extracellular cardioplegic solution which serves these purposes and has been used successfully in pediatric cardiac surgery. The subsequent extrapolation of its use in adult cardiac surgery has returned encouraging results, as evidenced by recent literature. The use of del Nido cardioplegia in adults has been reported to shorten the cross-clamp time, cardiopulmonary bypass time and overall operating time. Intraoperative peak glucose value and insulin requirement have also been reported to be lower with del Nido cardioplegia, which can have prognostic significance. There have been reports of lesser incidence of atrial fibrillation and the number of defibrillations required with use of this technique. However, some unique concerns still remain. The lack of prospective randomized trials, the trend of elevation in CKMB (as reported by one study) and the need for a protocol-based approach to its use in adults are to be given due consideration while adopting its use in adults. This review attempts to have an overview on del Nido cardioplegia, its advantages, the recent studies comparing it with conventional cardioplegia techniques and the potential areas of concern with its use in adult cardiac surgery.

Strategies for the coronary surgeon to remain "competitive and co-operative" in the PCI era.

BACKGROUND: The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong. METHODS: Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization. RESULTS: The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature. CONCLUSIONS: Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.

Composition of plasma and atheromatous plaque among coronary artery disease subjects consuming coconut oil or sunflower oil as the cooking medium.

OBJECTIVES: Coconut oil, which is rich in medium-chain saturated fatty acids, is the principal cooking medium of the people of Kerala, India. Replacement of saturated fat with polyunsaturated fat is effective in reducing serum cholesterol levels. However, the effect of substituting coconut oil with sunflower oil on the fatty acid composition of plaque has not been thoroughly investigated. We therefore evaluated and compared the fatty acid composition of plasma and plaque among subjects consuming coconut oil or sunflower oil as the cooking medium. METHODS: Endarterectomy samples and plasma samples were obtained from subjects who underwent coronary artery bypass grafts (n = 71). The subjects were grouped based on the type of oil they were using as their cooking medium (coconut oil or sunflower oil). The fatty acid composition in the plaques and the plasma was determined by HPLC and the data were analyzed statistically. RESULTS: Sunflower oil consumers had elevated concentrations of linoleic acid (p = 0.001) in plasma, while coconut oil users had higher myristic acid levels (p = 0.011) in plasma. Medium-chain fatty acids did not differ significantly between the two groups in the plasma. Medium-chain fatty acids were detected in the plaques in both groups of subjects. In contrast to previous reports, long-chain saturated fatty acids dominated the lipid content of plaque in this population, and the fatty acid composition of plaque was not significantly different between the two groups. No correlation between fatty acids of plasma and plaque was observed in either group. CONCLUSION: A change in cooking medium, although it altered the plasma fatty acid composition, was not reflected in the plaque composition.

Left ventricular posterior wall pseudoaneurysm: a rare sequela of mitral valve infective endocarditis in a chronic patient of HLA-B27 positive spondyloarthritis.

Left ventricular posterior wall pseudoaneurysm after native mitral valve infective endocarditis is a very rare occurrence. We report such a case in a patient with HLA-B27-associated spondyloarthritis and normal coronary arteries. Excision of the aneurysm with left ventricular reconstruction and mitral valve replacement resulted in an excellent outcome.