A rare etiology of frequent ventricular ectopy: Embolic complication of a venous iliac stent to the right ventricle.

Peripheral venous stent migration is an exceedingly rare complication of endovascular stenting. In this clinical vignette, we present a case of a 74-year-old male with a history of endo-venous laser ablation therapy of the right greater saphenous vein complicated with an occlusion requiring a left iliac vein stent. The patient presented to the clinic months after the procedure with complaints of palpitations. Multimodality imaging revealed a stent that had become dislodged and was now located in the right ventricle, trapped within the tricuspid valve apparatus.

Tricuspid regurgitation and in-hospital outcomes after transcatheter aortic valve replacement in high-risk patients.

BACKGROUND: The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear. METHODS: Retrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR. RESULTS: A total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7-13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR) (95% CI): 14.67 (1.35-159.51) and 5.09 (1.14-22.72), respectively], and those with severe TR post-TAVR had longer hospital stay [median (IR): 9.9 (2.9-17.0) days]. No improvement or worsened TR (greater than mild) post-TAVR was associated with higher CV and all-cause mortality [adjusted RR (95% CI): 21.5 (1.81-255.96) and 8.19 (1.67-40.29), respectively]. Right ventricular systolic pressure (RVSP) was independently associated with TR severity pre and post TAVR. CONCLUSIONS: Significant TR was common among patients undergoing high risk TAVR, and is associated with increased in hospital mortality and longer hospital stay. Patients with elevated RVSP and persistent moderate or severe TR after TAVR are at higher risk of in hospital death.

Successful Use of Sternal-Sparing Minimally Invasive Surgery for Proximal Ascending Aortic Pathology.

BACKGROUND: A sternal-sparing approach to surgery of the proximal aorta could decrease postoperative morbidity. METHODS: To determine the potential benefits of using a minimally invasive right thoracotomy approach for the treatment of ascending aortic pathology, we retrospectively reviewed our experience in patients who required circulatory arrest for the treatment of ascending aortic pathology (with or without aortic valve involvement) between January 2009 and November 2014 (N = 177). We compared baseline characteristics, intraoperative characteristics, and postoperative clinical outcomes between those who underwent a sternotomy (n = 103) and those who underwent a minimally invasive right thoracotomy approach (n = 74). All surgical procedures were performed by a single surgeon. Propensity score matching was performed to account for baseline differences between groups. RESULTS: More patients in the minimally invasive group had bicuspid aortic valve, degenerative aortic valve, or aortic insufficiency than in the sternotomy group, but other baseline characteristics were similar between groups. No strokes occurred. In the unmatched cohort, 30-day mortality was 2.7% for the minimally invasive group compared with 1.9% for the sternotomy group (p = 1.00). In the propensity score-matched cohort, 30-day mortality was 3.2% for both groups; circulatory arrest times were longer in the minimally invasive group than in the sternotomy group (p < 0.0001), but the minimally invasive group had fewer red blood cell transfusions, shorter ventilation times, and shorter intensive care unit and hospital length of stay. CONCLUSIONS: A sternal-sparing approach to surgery of the proximal aorta is safe when performed by an experienced surgeon and conserves hospital resources.

Isolated and concomitant minimally invasive minithoracotomy aortic valve surgery.

OBJECTIVE: To evaluate whether the outcomes of minimally invasive aortic valve surgery were similar in younger versus older patient groups, as well as whether concomitant minimally invasive aortic valve replacement (AVR) surgeries added significant risks in these populations. METHODS: We performed a single-institution retrospective analysis of 1018 patients undergoing isolated AVR and 378 patients undergoing concomitant AVR procedures over a 6-year period. All surgeries were via a right minithoracotomy approach, and patients who underwent reoperation were excluded. RESULTS: Mortality was 1.3% in the isolated AVR group and 3.2% in the concomitant AVR group. The incidence of permanent stroke was low in both the isolated and concomitant AVR groups (0.8% and 1.1%, respectively). In both groups, femoral cannulation was associated with equally low stroke rates (0.8% and 0.6%, respectively). When analyzing operative outcomes by age, mortality was similar for the isolated AVR group (age <80 vs ≥80 years, 0.9% vs 2.2%; P = .07) and the concomitant AVR group (<80 vs ≥80 years, 3.2% vs 3.2%; P = .99), whereas transfusion requirements, intensive care unit and hospital lengths of stay, and atrial fibrillation rates were greater in the older subsets of both AVR groups. CONCLUSIONS: Minimally invasive right thoracotomy AVR surgery was associated with low stroke and mortality rates in all age groups within 30 days of surgery. Similarly, minithoracotomy concomitant AVR surgery demonstrated excellent results and is deemed feasible in patients with multiple pathologies.

Pericardial Herniation of Small Bowel Post Minimally Invasive Hybrid Maze of Atrial Fibrillation.

BACKGROUND: Herniation of intraabdominal contents into the pericardial cavity is exceptionally rare, and when seen, it is most often the result of trauma, postsurgical complication, or genetic defect. There have been only a few case reports describing spontaneous bowel herniation into the pericardium in minimally invasive cardiac procedures like cardiac ablation, pacemaker placement, and minimally invasive coronary artery bypass graft. CASE REPORT: We report the case of a 65-year-old man who presented to an urgent care center complaining of abdominal and chest pain. This patient had recently undergone a laparoscopic hybrid maze procedure and ultimately had an incarcerated loop of small bowel herniate into the pericardial sac. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the diagnosis of a pericardial hernia in patients presenting with gastrointestinal or cardiorespiratory symptoms after surgical procedures involving the diaphragm.

Outcomes of a hybrid approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement.

BACKGROUND: In patients requiring coronary revascularization and aortic valve replacement, a combined approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement may be a viable treatment strategy. METHODS: The outcomes of 123 consecutive patients with significant coronary artery and aortic valve disease, who underwent percutaneous coronary intervention followed by elective minimally invasive aortic valve replacement between February 2009 and April 2014, were retrospectively evaluated. RESULTS: The cohort consisted of 80 males and 43 females, with a mean age of 75.7±8.1 years. Drug-eluting stents were used in 69.9% of the patients, and 64.2% were on dual anti-platelet therapy at the time of aortic valve replacement. Within a median of 39 days (IQR 21-64), 83.7% of the patients underwent primary and 16.3% underwent re-operative minimally invasive aortic valve replacement. Post-operatively, there was 1 (0.8%) cerebrovascular accident, 1 patient (0.8%) required a re-operation due to bleeding, and 2 (1.6%) developed acute kidney injury. Thirty-day mortality occurred in 2 (1.6%) patients. Follow-up was available for all of the patients, and at a mean follow-up period of 14.3±12.5 months, 4 (3.3%) had an acute coronary syndrome, and 1 (0.8%) required a repeat target vessel revascularization. The actuarial survival rate at 1- and 3-year was 92.7% and 89.4%, respectively. CONCLUSIONS: In a select group of patients with coronary artery and aortic valve disease, a combined approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement can be safely performed with excellent short-term and midterm outcomes.

Percutaneous coronary intervention followed by minimally invasive valve surgery compared with median sternotomy coronary artery bypass graft and valve surgery in patients with prior cardiac surgery.

BACKGROUND: In patients with prior cardiac surgery requiring re-operative coronary and valve surgery, a hybrid approach of percutaneous coronary intervention followed by minimally invasive valve surgery (PCI + MIVS) may be an alternative to the standard median sternotomy coronary artery bypass and valve surgery (CABG + valve). METHODS: The outcomes of patients with prior cardiac surgery, presenting with coronary artery and valvular disease, who underwent PCI + MIVS (N=39) were retrospectively compared with those who underwent CABG + valve (N=28) via a repeat median sternotomy, between February 2009 and April 2014. RESULTS: The mean age for the PCI + MIVS versus CABG + valve group was 75±9 and 72±11 years (P=0.54), respectively. The baseline characteristics were similar between groups, with the exception of a greater prevalence of 1-vessel coronary artery disease and clopidogrel or dual antiplatelet therapy at the time of surgery in the PCI + MIVS group, and more 3-vessel coronary artery disease in those undergoing CABG + valve surgery. The PCI + MIVS approach was associated with a decreased aortic cross-clamp (94 vs. 131 minutes, P=0.001) and cardiopulmonary bypass (128 vs. 190 minutes, P<0.001) times, fewer intraoperative packed red blood transfusions (1.3 vs. 3.8 units, P=0.001), shorter intensive care unit length of stay (41 vs. 71 hours, P<0.001), and decreased incidence of prolonged mechanical ventilation (12.8% vs. 35.7%, P=0.03), re-intubation (2.6% vs. 17.9%, P=0.04), when compared with CABG + valve. The thirty-day and two-year mortality were similar, being 7.7% vs. 7.1% (P=0.66), and 12.8% vs. 10.7% (P=0.55), in the PCI + MIVS vs. CABG + valve group, respectively. CONCLUSIONS: Hybrid PCI + MIVS in patients with prior cardiac surgery is associated with shorter operative times and intensive care unit length of stay, less need for intraoperative blood cell transfusions, decreased use of mechanical ventilation, and similar short-term and follow-up survival, when compared with CABG + valve surgery via median sternotomy. Randomized trials and multicenter registries are needed to further evaluate this approach.

Outcomes of minimally invasive double valve surgery.

BACKGROUND: Double valve surgery is associated with an increased peri-operative morbidity and mortality. A less invasive right thoracotomy approach may be a viable alternative to median sternotomy surgery in these higher-risk patients. METHODS: We retrospectively analyzed the baseline demographics, operative characteristics, and post-operative outcomes of patients who underwent minimally invasive double valve surgery between January 2009 and December 2011 at our institution. RESULTS: The cohort consisted of 117 patients, of which 68 (58.1%) were female. The mean age was 73±11 years, and the mean left ventricular ejection fraction was 52±11%. There were 43 (36.8%) patients with a history of congestive heart failure, 45 (38.5%) with chronic obstructive pulmonary disease, and 5 (4.3%) had a history of chronic kidney disease. The patients underwent primary (90.6%) or re-operative (9.4%) double valve surgery, which consisted of 50 (42.7%) aortic valve replacement and mitral valve repair, 31 (26.5%) mitral and tricuspid valve repair, 18 (15.4%) aortic and mitral valve replacement, 17 (14.5%) mitral valve replacement with tricuspid valve repair, and 1 (0.9%) aortic valve replacement with tricuspid valve repair. Post-operatively, there were 40 (34.2%) cases of prolonged ventilation, 9 (7.7%) acute kidney injury, 6 (5.1%) re-operations for bleeding, 1 (0.9%) cerebrovascular accident, and 15 (12.8%) cases of atrial fibrillation. The mean total hospital length of stay was 12±12 days, with an in-hospital mortality of 2 (1.7%). CONCLUSIONS: A minimally invasive right thoracotomy approach to primary or re-operative double valve surgery is feasible, may be utilized with acceptable peri-operative morbidity and mortality.

Hybrid repair of aortic arch aneurysms: a comprehensive review.

Open total arch replacement (TAR) has become safer with refinements in cerebral protection techniques. The frequent extension of aortic arch aneurysms into the descending thoracic aorta customarily requires a two-staged conventional elephant trunk procedure, carrying relatively high mortality and morbidity risks and high rates of rupture in the interval between the two open surgeries. The technical demands and invasive nature of TAR has therefore precluded many high-risk patients from being surgical candidates for aneurysm repair. As a result, hybrid techniques and approaches to the aortic arch have become common since the adoption of thoracic endovascular aortic repair (TEVAR) and advancement in the commercial grafts that are available. The results of hybrid aortic arch repairs have been encouraging, though with higher rates of re-interventions than TAR and variable reported rates of stroke and spinal cord ischemia. The aim of this publication is to review the current literature on hybrid repair of aortic arch aneurysms.

Complications Associated With Femoral Cannulation During Minimally Invasive Cardiac Surgery.

BACKGROUND: Different types of cannulation techniques are available for minimally invasive cardiac surgery. At our institution, we favor a femoral platform for most minimally invasive cardiac procedures. Here, we review our results utilizing this cannulation approach. METHODS: We retrospectively reviewed all minimally invasive valve surgeries that were performed at our institution between January 2009 and January 2015. Operative times, lengths of stay, postoperative complications, and mortality were analyzed. RESULTS: We identified 2,645 consecutive patients. The mean age was 69.7 ± 12.77 years, and 1,412 patients (53.4%) were male. Three hundred fifty-eight patients (13.5%) had a history of cerebrovascular accident, 422 (16%) had previous heart surgery, and 276 (10.4%) had a history of peripheral vascular disease. The procedures performed were isolated aortic valve replacements (42.1%), isolated mitral valve operations (40.6%), tricuspid valve repairs (0.57%), double valve surgery (15%), triple valve surgery (0.3%), and ascending aortic aneurysm resection with and without circulatory arrest (5%). Femoral cannulation and central cannulation were utilized in 2,400 patients (90.7%) and 244 patients (9.3%), respectively. The median aortic cross-clamp time and cardiopulmonary bypass time were 81 minutes (interquartile range, 65 to 105) and 113 minutes (interquartile range, 92 to 142), respectively. The median postoperative hospital length of stay was 6 days (interquartile range, 5 to 9). There were 31 cerebrovascular accidents (1.17%), no aortic dissections, two compartment syndromes, two femoral arterial pseudoaneurysms, and 174 (6.65%) groin wound seromas. The overall 30-day mortality was 57 patients (2.15%). CONCLUSIONS: Minimally invasive cardiac surgical procedures utilizing femoral cannulation techniques have a low risk of complications.

Right Minithoracotomy Approach for Replacement of the Ascending Aorta, Hemiarch, and Aortic Valve.

A minimally invasive right anterior thoracotomy approach is the preferred technique used at our institution for isolated aortic valve pathology. We have recently introduced more complex concomitant minimally invasive procedures through this access site. Here, we describe how we perform a replacement of the ascending aorta and aortic valve with and without the use of circulatory arrest through a 6-cm right minimally invasive thoracotomy incision.

Outcomes of aortic valve and concomitant ascending aorta replacement performed via a minimally invasive right thoracotomy approach.

OBJECTIVE: Replacement of the aortic valve with concomitant replacement of the ascending aorta performed via a minimally invasive right anterior thoracotomy approach has not been reported. We evaluated the feasibility and safety of this procedure. METHODS: We retrospectively reviewed all minimally invasive aortic valve replacements (AVRs) with concomitant replacement of the ascending aorta performed at our institution between January 1, 2012, and December 30, 2012. The operative times, intensive care unit and hospital lengths of stay, postoperative outcomes, as well as mortality were analyzed. RESULTS: A total of 20 consecutive patients who underwent minimally invasive AVR with concomitant replacement of the ascending aorta were identified. There were 16 men (80%), with a mean (SD) age of 61 (13) years. The mean (SD) left ventricular ejection fraction was 58% (8%). The aortic valve was bicuspid in 18 patients (80%), with 14 (70%) being stenotic. The median aortic cross-clamp and cardiopulmonary bypass times were 163 [interquartile range (IQR), 141-170] minutes and 291 (IQR, 177-215) minutes, respectively. Hypothermic circulatory arrest was required in 19 patients (95%), with a median hypothermic circulatory arrest time of 35 (IQR, 33-39.5) minutes. The median intensive care unit and hospital lengths of stay were 24 (IQR, 23-41) hours and 5 (IQR, 4-6) days, respectively. There were no strokes, reoperations for bleeding, or conversions to sternotomy. The 30-day mortality was zero. CONCLUSIONS: Minimally invasive AVR with concomitant replacement of the ascending aorta, via a right anterior thoracotomy approach, can be performed with low morbidity and mortality.

Reducing blood utilization by implementation of a type-and-screen transfusion policy a single-institution experience.

OBJECTIVES: The Blood Utilization Committee implemented a standardized protocol for the preoperative blood order for cardiac patients. The aim of our study was to assess the improvement in blood utilization using the crossmatch to transfusion ratio (C:T). METHODS: Four months of retrospective data were collected, which included all RBC crossmatch requests and all RBC units transfused. Similar data were gathered for the period of the intervention. The difference in C:T was calculated. RESULTS: The retrospective group had 166 patients for whom blood products were ordered. There were 560 crossmatch requests and 237 transfused RBC units with a C:T of 2.36. The prospective group had 127 patients with 297 crossmatch requests, 190 transfused units, and a C:T of 1.56. There was a statistically significant difference in the C:T. The cost difference was $12,244.00. CONCLUSIONS: Implementing exact guidelines, with the introduction of a type-and-screen concept, allowed more efficient blood usage.

Multiple left internal mammary artery-to-pulmonary artery fistulae 15 years after coronary artery bypass grafting.

Left internal mammary artery (LIMA)-to-pulmonary artery fistulae rarely develop after coronary artery bypass grafting. Fewer than 30 cases of these fistulae have been reported since 1947. Nevertheless, this entity should be considered as a cause of recurrent angina after bypass surgery, in the absence of other causes. We present the case of a 67-year-old man with cardiac symptoms in whom multiple LIMA-to-pulmonary artery fistulae were found, 15 years after he had undergone coronary artery bypass grafting. The diagnosis was confirmed by means of coronary angiography with selective catheterization of the LIMA and by computed tomographic angiography of the heart. The patient underwent reoperative 2-vessel coronary artery bypass grafting and ligation of multiple fistulae; 16 months postoperatively, he was asymptomatic and doing well. In addition to reporting this case, we discuss relevant diagnostic and treatment considerations.

Endovascular treatment of an acute ascending aortic intramural hematoma.

INTRODUCTION: Herein, we present a case of an elderly gentleman who presented with an extensive intramural hematoma of the aorta which was treated with a percutaneous placement of an endovascular stent. PRESENTATION OF CASE: A 79-year-old male with a history of hypertension presented to the emergency department because of sudden onset of substernal chest pain radiating to his back. A chest computerized tomography scan was performed that demonstrated a Type A aortic wall intramural hematoma involving the arch and ascending aorta dissecting both antegrade and retrograde from a penetrating ulcer located in the descending aorta, immediately distal to the left subclavian artery. No dissection flap was noted. The patient opted for an endovascular approach. He was treated with the placement of a stent just distal to the left subclavian artery, with good results noted on follow-up exam performed 3 months later. DISCUSSION: The treatment of a Type A IMH lacks consensus, but the majority do favor surgical management. The data are limited; however, there are reports of patients with Type A intramural hematoma treated with descending aortic endograft at the site of the culprit ulcerated plaque, with satisfactory results. CONCLUSION: In a select group of patients, an endovascular approach for the treatment of a Type A aortic wall intramural hematoma caused by an ulcerated plaque may be a viable treatment option.

Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery.

OBJECTIVES: Minimally invasive valve surgery has been associated with increased cerebrovascular complications. Our objective was to evaluate the incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery. METHODS: We retrospectively reviewed all the minimally invasive valve surgery performed at our institution from January 2009 to June 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed. RESULTS: A total of 1501 consecutive patients were identified. The mean age was 73 ± 13 years, and 808 patients (54%) were male. Of the 1501 patients, 206 (13.7%) had a history of a cerebrovascular accident, and 225 (15%) had undergone previous heart surgery. The procedures performed were 617 isolated aortic valve replacements (41.1%), 658 isolated mitral valve operations (43.8%), 6 tricuspid valve repairs (0.4%), 216 double valve surgery (14.4%), and 4 triple valve surgery (0.3%). Femoral cannulation was used in 1359 patients (90.5%) and central cannulation in 142 (9.5%). In 1392 patients (92.7%), the aorta was clamped, and in 109 (7.3%), the surgery was performed with the heart fibrillating. The median aortic crossclamp and cardiopulmonary bypass times were 86 minutes (interquartile range [IQR], 70-107) minutes and 116 minutes (IQR, 96-143), respectively. The median intensive care unit length of stay was 47 hours (IQR, 29-74), and the median postoperative hospital length of stay was 7 days (IQR, 5-10). A total of 23 cerebrovascular accidents (1.53%) and 38 deaths (2.53%) had occurred at 30 days postoperatively. CONCLUSIONS: Minimally invasive valve surgery was associated with an acceptable stroke rate, regardless of the cannulation technique.

Minimally invasive valve surgery with bypass to the right coronary artery.

Herein, we report the case of a 60-year-old woman who presented with increasing dyspnea on exertion. Echocardiography revealed significant aortic and mitral regurgitation, which were most likely secondary to previous radiation therapy for breast cancer. On cardiac catheterization a 90% ostial right coronary artery lesion was found and treated with a drug-eluting stent. During minimally invasive valve surgery, via a right anterior thoracotomy, it was noted that the stent had restenosed. Therefore, the right coronary artery was bypassed with a segment of venous graft through the same incision.

Cardiac angiofibroma: a rare primary cardiac tumor.

Cardiac angiofibromas are rare tumors. We report a patient with an angiofibroma of the mitral valve and discuss the management of these tumors.

Transatrial dual chamber biventricular pacemaker-defibrillator placement in a patient with SVC obstruction.

A patient with severe congestive heart failure and obstruction of the superior vena cava required biventricular pacing and ICD therapy. Via right minithoracotomy, a transatrial approach for lead placement was successfully utilized to provide cardiac resynchronization and ICD placement. This technique for pacing lead placement is reviewed and its application for biventricular pacemaker-defibrillator placement is reported.