Severe bilateral isolated coronary ostial lesions as a rare manifestation of radiation-induced cardiac disease A case report.

RATIONALE: With advances in contemporary radiotherapy techniques, and as cancer survival improves, severe isolated coronary ostial disease may develop many years following mediastinal radiotherapy, even in the absence of classical cardiovascular risk factors. PATIENT CONCERNS: We describe the case of a 73-year-old woman with previous chest radiotherapy for breast cancer who underwent coronary artery bypass graft surgery for severe bilateral coronary ostial lesions. DIAGNOSES: Coronary angiography demonstrated severe, isolated bilateral coronary ostial lesions. INTERVENTIONS: The patient underwent urgent coronary artery bypass graft surgery to treat her critical coronary artery disease. OUTCOMES: Intra-operatively, internal mammary arteries were not amenable to harvesting due to very dense mediastinal adhesions. Therefore, saphenous vein grafts were performed to the left anterior descending, distal left circumflex, obtuse marginal and distal right coronary arteries. The patient made a satisfactory in-hospital recovery, and was subsequently discharged back to her local hospital for rehabilitation. LESSONS: Patients successfully treated with mediastinal radiotherapy require careful long-term follow-up for the assessment of radiation-induced coronary artery disease. Importantly, mediastinal irradiation may preclude internal mammary artery utilization, and thus alter the strategy for surgical myocardial revascularization.

Analysis of aortic area/height ratio in patients with thoracic aortic aneurysm and Type A dissection.

OBJECTIVES: Significant proportions of aortic dissections occur at aortic diameters <5.5 cm. By indexing aortic area to height and correlating with absolute aortic diameter, we sought to identify those aneurysm patients with aortic diameters <5.5 cm who do not meet current size thresholds for surgery, yet with corresponding abnormal indexed aortic areas (IAAs) >10 cm2/m, are at increased risk of aortic complications. METHODS: IAAs were calculated at 3 aortic locations in 187 aneurysm and 66 dissection patients operated on between 2010 and 2016 at our tertiary aortic centre. Proportions of patients with IAA >10 cm2/m, mean IAAs corresponding to aortic diameters <4.0 cm, 4.0-4.5 cm, 4.5-5.0 cm, 5.0-5.5 cm and >5.5 cm, and mean aortic diameters corresponding to IAAs 10-12 cm2/m, 12-14 cm2/m and >14 cm2/m were determined. RESULTS: Proportions of patients with abnormal IAAs were similar in both groups. In all, 49.1% of aneurysm patients with aortic diameters 4.5-5.0 cm, and 98.5% with aortic diameters 5.0-5.5 cm had abnormal IAAs. Out of 200 separate aneurysms with IAAs >10 cm2/m between the mid-sinus and mid-ascending aorta, 139 (69.5%) would not warrant surgery according to existing guidelines. CONCLUSIONS: Using the IAA, we identified a significant proportion of patients with thoracic aortic aneurysms who are at increased risk of aortic complications, despite current aortic guidelines not endorsing surgical intervention in this group. Our data suggests the IAA may be useful in preoperative risk evaluation and as a criterion for surgery.

Rapid resolution of Ortner's syndrome with giant left atrium after double-valve replacement surgery.

Hoarseness of voice due to recurrent laryngeal nerve palsy is an uncommon manifestation of cardiothoracic disease. Ortner's syndrome is hoarseness attributed to mechanical compression of the left recurrent laryngeal nerve in association with several cardiopulmonary disease states. We here describe a rare case of Ortner's syndrome developing in a 60-year-old woman with a giant left atrium in the context of rheumatic mitral valve stenosis. The remarkable resolution of her voice hoarseness within 1 week of valve replacement surgery has not been reported in similar cases to date.

Technical Considerations of Giant Right Coronary Artery Aneurysm Exclusion.

Giant coronary artery aneurysms are rare clinical entities. We report the case of a 49-year-old man who presented with dyspnoea and exertional chest pain. Investigations confirmed an aneurysmal right coronary artery measuring 4 cm with a fistulous communication to the right atrium. Following right atriotomy, the fistula was oversewn and the aneurysmal right coronary artery ligated at its origin and at several points along its course. A saphenous vein graft was anastomosed to the posterior descending artery. Persistent ventricular fibrillation occurred upon chest closure, attributed to ischaemia following ligation of the aneurysmal coronary artery. Emergent resternotomy and internal defibrillation were successfully performed. The sternum was stented open to reduce right ventricular strain and closed the following day. The patient made an unremarkable recovery. We here address the technical challenges associated with surgical repair of right coronary aneurysms and the physiology and management of potential complications.

A Simple and Effective Technique for Anatomical Approximation of the Upper Pericardium Using Hemostatic Clips.

Closure of the pericardium is important to protect bypass grafts, the great vessels, and the heart from injury due to sternal dehiscence. Furthermore, it is reported to reduce the formation of pericardial adhesions and thus facilitate entry into the chest at resternotomy. We here describe a simple, reproducible, and effective technique for tension-free approximation of the upper pericardium by applying small hemostatic clips to the preserved thymic fascia overlying the pericardium.

Tracheal Lobular Capillary Haemangioma: A Rare Benign Cause of Recurrent Haemoptysis.

Lobular capillary haemangioma (LCH), previously known as pyogenic granuloma, is a benign vascular lesion commonly found within the oral and nasal cavity. However, it is rarely encountered within the trachea, where presenting features include recurrent haemoptysis, cough, and wheeze. We here describe a case of a 7 mm tracheal LCH in a 56-year-old woman, which was successfully resected at interventional bronchoscopy using biopsy forceps. Clinicians should be aware of tracheal LCH in the differential diagnosis for recurrent haemoptysis.

Surgical resection of a huge ruptured mature mediastinal teratoma.

Usually slow-growing and benign, mature mediastinal teratomas are rare clinical entities. They may be complicated by rupture into the pleural or pericardial spaces, lungs, or bronchi. Complete surgical resection is the treatment of choice and is usually curative. We report the unusual case of a 24-year-old woman presenting 15 weeks postpartum with a huge ruptured mature mediastinal teratoma superinfected with Mycobacterium avium Catastrophic bleeding from the superior vena cava was encountered on mobilization of adhesions attached to it, requiring extracorporeal membrane oxygenator support for control. Histopathological examination confirmed a 12.0 × 7.8 × 4.5-cm differentiated teratoma without malignant transformation.

Uniportal thoracoscopic management of middle lobe torsion after upper lobectomy.

Lobar torsion is a rare but potentially life-threatening complication following pulmonary resection. Surgical management usually entails an exploratory thoracotomy and resection of the involved lobe if nonviable. We present the case of a 67-year-old woman diagnosed with right middle lobe torsion 5 days after thoracotomy and right upper lobectomy for squamous carcinoma of the lung. A thoracoscopic right middle lobectomy was successfully performed utilizing a single 4-cm port placed along the midaxillary line in the 5th intercostal space.

Poorly-differentiated signet-ring cell carcinoma of the ampulla of Vater: report of a rare malignancy.

CONTEXT: Signet-ring cell carcinoma (SRCC) of the ampulla of Vater is a very rare clinical entity, which is infrequently reported in medical literature. CASE REPORT: A 78-year-old woman was admitted with jaundice, pruritus and postprandial vomiting. Abdominal ultrasound and computed tomography scanning demonstrated gross dilatation of the common bile and pancreatic ducts with gallbladder calculi. Endoscopic retrograde cholangiopancreatography suggested a duodenal tumour at the ampulla. The patient underwent Whipple's procedure with cholecystectomy. Immunohistopathological examination confirmed poorly-differentiated SRCC of the ampulla of Vater. The tumour had infiltrated the duodenal muscularis propria and pancreatic parenchyma, but local lymph nodes were clear (T3N0M0). The patient was disease-free at 6-month follow-up. CONCLUSIONS: We here report a case of poorly-differentiated SRCC of the Ampulla of Vater. The majority of patients with such tumours undergo pancreaticoduodenectomy, which affords good outcomes in early disease. However, owing to the rarity of cases, the exact prognosis of ampullary SRCC remains as yet undetermined.

Is totally endoscopic coronary artery bypass safe, feasible and effective?

A best evidence topic was written according to a structured protocol. The question addressed was whether totally endoscopic coronary artery bypass (TECAB) is safe, effective and feasible. A total of 171 papers were found, of which eight represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The da Vinci robotic system was utilized in seven retrospective studies and one multicentre prospective trial, comprising 724 patients undergoing TECAB. Patient-related outcomes, including the incidence of major adverse cardiac events, graft patency and survival, were investigated. From the studies evaluated, TECAB appears to be safe operation with low complication rates and excellent early- and mid-term graft patencies. The incidence of internal thoracic artery injury was documented in four studies and ranged from 0 to 10%. Re-exploration for bleeding was necessary in 1-15% of patients. Conversion to open techniques was performed in 0-24% of cases. There was no in-hospital mortality in the majority of studies, but this reached 2.1% in a large series of 228 patients. Target-vessel reintervention rates varied between 0 and 12.1% according to the institutional experience. Pre- and post-discharge graft patencies were excellent at 93-100 and 92-100%, respectively. Intraoperative variables, such as time taken for internal thoracic artery harvest, anastomosis, cross-clamp, cardiopulmonary bypass (CPB) and the overall operation were as follows: internal thoracic artery harvest time (range 5-187 min), anastomosis time (range 6-82 min), cross-clamp time (range 30-223 min), CPB time (range 41-268 min) and operative time (range 84-600 min). TECAB is a technically demanding and time-consuming procedure associated with a significant learning curve. Proctoring and structured training programmes are currently supported by European and international societies to encourage wider uptake of the procedure. In conclusion, TECAB represents a feasible alternative to conventional coronary artery bypass in selected patients. It is associated with low morbidity and excellent mid-term graft patency. Larger, prospective and multicentre trials are required to assess the long-term and patient-reported outcomes of TECAB.

What is the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device?

A best evidence topic was written according to a structured protocol. The question addressed was what the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device (LVAD) is. A total of 373 papers were found, of which 11 represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Eight retrospective and two prospective studies, including one randomized controlled trial (RCT), were identified. Although highly variable, the prophylactic antibiotic protocols employed in these studies generally favour the use of vancomycin, a cephalosporin, beta-lactam and quinolone, with the option of additional fluconazole and mupirocin. However, the lack of standardized definitions for infection, and variations in the choice, timing and duration of prophylactic antibiotics complicates the interpretation of reported infection rates. Driveline and pocket infections comprised the majority of infectious complications, and were principally attributed to Gram-positive organisms, such as Staphylococcus, as well as Pseudomonas species. We conclude that a beta-lactam be used for primary prophylaxis, with vancomycin where the risk of MRSA is high. Topical mupirocin and an anti-fungal are also recommended. Prophylaxis should commence prior to device insertion, and be continued into the peri- and post-operative period. Large-scale RCTs are necessary to assess the impact of different antibiotic regimens on infection within LVAD recipients.