Mitral Annular Disjunction: Pathophysiology, Pro-Arrhythmic Profile and Repair Pearls.

Mitral annular disjunction (MAD) is a structural abnormality defined by a distinct separation of the mitral valve annulus-left atrial wall continuum and the basal aspect of the posterolateral left ventricle. This anomaly is often observed in patients with myxomatous mitral valve prolapse. Importantly, MAD has been strongly associated with serious ventricular arrhythmias and predisposes to sudden cardiac death. Therefore, we have to emphasize the need to diagnose this morphologic and functional abnormality in routine practice in order to facilitate optimal mitral valve repair and minimize patient risks. Nevertheless, clinical knowledge regarding MAD still remains limited. In the present review, we aim to shed light on several aspects of MAD, including distinct anatomical and pathophysiological characteristics, imaging modalities, association with ventricular arrhythmias, and current methods of treatment.

Surgical repair of anomalous aortic origin of coronary artery in adults.

Anomalous aortic origin of a coronary artery is a congenital abnormality of the origin or course of a coronary artery that arises from the aorta. The surgical treatment of this anomaly is highly variable and controversial and is achieved by implementing elaborate techniques of anatomic repair or by simple coronary artery bypass grafting. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers determined whether studies met the inclusion criteria. Eligible papers were published in English, clinical studies describing surgical repair of anomalous aortic origin of a coronary artery including coronary artery bypass in adults, and enrolled >5 patients. In the absence of multicentre trials, 7 single-center retrospective series were included, which demonstrated comparable short- and midterm outcomes of anatomic repair and coronary artery bypass in adults with anomalous aortic origin of a coronary artery. Coronary unroofing was the preferred technique when the anomalous artery has an intramural component, but there is a risk of aortic insufficiency. Anatomic repair is technically demanding and should be carried out in experienced centers. Coronary artery bypass with internal thoracic artery or vein grafts is technically straightforward with low operative risk and comparable midterm outcomes, however, long-term outcomes are unknown. Coronary artery bypass grafting is the technique of choice for older patients, in those with concomitant coronary artery disease, as a bailout procedure for failed anatomic repair, or in centers without experience in anatomic repair for anomalous aortic origin of a coronary artery.

Cardio-Protective Effects of Sodium-Glucose Co-Transporter 2 Inhibitors: Focus on Heart Failure.

BACKGROUND: Type 2 diabetes mellitus (DM) is associated with a considerable risk of cardiovascular and renal diseases, including heart failure. Sodium-glucose co-transporter 2 (SGLT2) inhibitors have demonstrated unprecedented cardiorenal protective effects in large-scale clinical trials of patients with or without diabetes and either established cardiovascular disease (CV) or multiple CV risk factors. OBJECTIVE: Herein we aim to focus on the role of SGLT2 inhibitors regarding the improvement in heart failure outcomes and the proposed mechanisms of action by which these drugs confer their beneficial effect. METHODS: PubMed, Embase, and Google Scholar databases were searched to identify eligible articles that are comprehensively summarized and discussed in this study. RESULTS: The most commonly discussed mechanisms of action are diuresis and natriuresis, reduction in preload, afterload, and ventricular mass, as well as stimulation of erythropoietin production and improved myocardial energetics. SGLT2 inhibitors improve outcomes in patients with established heart failure (HF) and reduce the risk of death and HF admissions in patients with established chronic HF with reduced ejection fraction (HFrEF), either with or without diabetes. CONCLUSION: Potential key mechanisms that may explain the notable cardioprotective benefits of SGLT2 inhibitors have been outlined. These agents have recently received class Ia recommendation in specific groups of people with DM to lower the risk of hospitalization for HF and risk of death, while these benefits may also extend to people without diabetes. It remains to be seen whether they will also emerge as treatment approaches in the acute phase of CV episodes.

Right Anterior Mini-Thoracotomy for Discrete Fibromembranous Subaortic Stenosis.

Discrete fibromembranous subaortic stenosis is a common type of subaortic stenosis causing clinically significant left ventricular outflow obstruction. Surgery for discrete subaortic stenosis is most often performed through a typical midline sternotomy. Herein, we present our experience with an adult patient who underwent a right mini-thoracotomy for subaortic membrane resection with central cannulation under direct operative vision.

The aberrant subclavian artery: approach to management.

PURPOSE OF REVIEW: Aberrant subclavian artery (ASCA) represents one of the most common congenital vascular anomalies of the aortic arch. The majority of ASCAs are associated with an aneurysm which occurs at their origin from the descending thoracic aorta, namely, the Kommerell's diverticulum. In this review, we discuss recent data with regards to indications of treatment and surgical management of these anatomical variants. RECENT FINDINGS: Various surgical methods have been described for the repair of ASCA and Kommerell's diverticulum. Traditionally, treatment included open surgery; however, recent studies describe a shift of conventional treatment to more hybrid or endovascular approaches. The heterogeneity in the anatomy and presentation of these clinical entities as well as patient-related factors have prevented conduction of randomized trials for the best available modality of treatment. This dearth of literature is well depicted in the current guidelines. SUMMARY: The optimal surgical procedure has to be tailored to every patient according to the presentation, individual anatomy, and patient's risk profile. Conventional surgery for ASCA and Kommerell's diverticulum has acceptable mortality and complication rates, whereas hybrid repairs report encouraging results. Further studies are required to provide sufficient evidence which will formulate a clear frame of treatment indications and optimal surgical methods, as well as evaluate long-term results following hybrid repair.

Discharge of thoracic patients on portable digital suction: Is it cost-effective?

OBJECTIVES: A portable suction drainage device for patients undergoing thoracic surgical procedures was introduced into our service in January 2010. Patients who met strict discharge criteria were allowed to continue their treatment at home with the device. They were monitored in a designated follow-up clinic. Data were collected to identify the impact of this service in relation to the duration of follow-up required, bed-days saved, and potential cost/benefits. METHODS: All patients who underwent a thoracic procedure from March 2012 to April 2014 and required suction postoperatively for air leak were included in the study. Patients were identified as suitable according to the discharge criteria. Data regarding patient demographics were collected prospectively on the thoracic database, and data on the drainage device were logged in a specific data sheet. Visits to the follow-up clinic were also recorded. RESULTS: During the study period, 50 patients stayed a total 1125 days on the portable suction system. Twenty were discharged home, equating to 772 bed-days saved (GBP 270,000 cost-saving). Clinic attendance totalled 162 visits (GBP 24,300 cost reimbursement for attendance). Six (30%) patients were readmitted on 9 occasions due to device malfunction or inability to cope at home. CONCLUSION: Careful identification of patients suitable for discharge with a portable suction device achieved a significant cost-saving and freed hospital beds, thus allowing increased surgical activity. Patients were also able to be cared for within their home environment and maintain their quality of life.

Large monophasic synovial sarcoma of the mediastinum in a 15-year old boy.

We present the interesting case of a 15-year old boy with a monophasic synovial sarcoma (MSS) of the mediastinum, which was infiltrating the right heart chambers and the inferior vena cava (IVC). A radical excision was performed, with extensive reconstruction of the heart, under deep hypothermic circulatory arrest. Radical surgical excision is considered to be the treatment of choice for these lesions, as chemotherapy and radiotherapy have little effect. Unfortunately, the patient and his parents refused any further consultation with an oncologist and, although there was no recurrence at 12 months following the procedure, at 24 months we were informed of his death due to the tumour appearing on the left cardiac chambers with subsequent multi-organ failure.

Massive hemothorax secondary to metastatic renal carcinoma.

We present the case of a 78-year-old man with a past history of nephrectomy for renal cell carcinoma who was brought to the emergency room in hypovolemic shock after suddenly collapsing at home. A chest roentgenogram taken on admission showed a large pleural effusion on the right with a mediastinal shift to the left. A contrast computed tomographic scan of his chest excluded aortic dissection. An emergency right thoracotomy was performed, which revealed a chest wall tumor that was bleeding profusely. The tumor was biopsied after the bleeding was controlled. The histologic report revealed metastatic renal cell carcinoma, which is a rare cause for a spontaneous massive hemothorax.