Survival After Mitral Valve Replacement for Leaflet Escape in a Contemporary On-X Mechanical Valve.

Leaflet escape in contemporary mechanical valves is an extremely rare and potentially lethal condition. We report the case of a 77-year-old man who presented with embolization of a leaflet from an On-X mitral valve (CryoLife, Kennesaw, GA) with Conform-X Sewing Ring prosthesis (CryoLife) after exercise. The patient recovered completely 6 months after surgery, and he is currently asymptomatic.

Unexpected entrapment during surgery of anomalous circumflex coronary artery arising from right coronary artery.

A patient with advanced rheumatic heart valve disease underwent aortic and mitral valve replacement with tricuspid ring annuloplasty. There was an anomalous left circumflex coronary artery (LCCA) arising from the right coronary artery (RCA) running along the anterior surface of an enlarged right ventricle (RV). During the immediate postoperative course, signs of inferior and lateral myocardial ischemia developed. An emergent coronary angiography revealed LCCA entrapment. An additional suture placed in the RV outflow tract used to optimize exposition of the aortic root during the aortotomy was determined to be the origin of the coronary entrapment. No similar case of LCCA occlusion has previously been reported. This is a description of successful management of this complication.

Veno-arterial extracorporeal membrane oxygenation as a bridge for enabling surgery in a patient under cardiogenic shock due to acute mitral prosthesis dysfunction.

A 52-year-old male patient, who underwent mitral replacement with a mechanical prosthesis as a child, sustained a cardiac arrest which was successfully resuscitated. Further investigation showed prosthesis malfunction with significant regurgitation in the context of multi-organ failure. In such a life-threatening condition, veno-arterial extracorporeal membrane oxygenation was considered as a rescue procedure to achieve optimisation of clinical status to allow definitive surgical treatment. An unusual complete fracture of the prosthesis was subsequently identified as the cause of acute dysfunction.

The hemostatic power of fat: An effective, inexpensive, and biocompatible method to achieve hemostasis in cardiac surgery.

Postoperative bleeding with its important socioeconomic cost is associated with an increased morbidity and mortality. It causes hemodynamic instability, increases blood loss, and multiplies the number of transfusions required. Especially in vascular or aortic surgery, postoperative bleeding can become a life-threatening complication due to anticoagulant or antiaggregation preoperative status or postoperative coagulation dysfunction after a high level of heparinization. Presently described is the case of a patient who underwent an aortic valve and ascending aorta replacement. A simple but effective method to achieve hemostasis, designed particularly for aortic surgery and the use of Dacron grafts, is presented. No residual adherence or contraindications exist, and it can potentially be applied to any kind of surgical process. This method offers a cheap, biocompatible, and highly effective means to achieve complete hemostasis without the use of extra sutures, or expensive synthetic or allogeneic hemostatic agents or sealants.

Mutilating Purpura Fulminans in an Adult with Meningococcal Sepsis.

We report a dramatic case of meningococcal sepsis manifesting as purpura fulminans in an elderly diabetic woman. Hemodynamic instability and severe bilateral cutaneous lesions involving her hands and feet developed rapidly. Specific antibiotic therapy and the administration of inotropic and vasopressor drugs were initiated. The severity and extension of the cutaneous lesions (attributed to purpura fulminans) worsened because of the need for vasoconstrictors for the treatment of septic shock. Bilateral transmetatarsal and metacarpal amputations were required to stabilize the patient.

Wrapping of the ascending aorta revisited-is there any role left for conservative treatment of ascending aortic aneurysm?

Dilatation of the ascending aorta (AA) is a common finding in patients with aortic valve disease. The clinical practice guidelines recommend replacing the AA whenever the diameter exceeds 45 mm. However, no consensus has been reached regarding the approach when the aorta is only moderately dilated. Although the risk in aorta replacement is generally low, it may be higher when associated with other complex surgical procedures or it is carried out in elderly patients or patients with significant comorbidity. This would justify the use of alternative surgical techniques, which reduce surgical risk and guarantee a durable correction of the aortic pathology. Conservative treatment of aneurysms of the AA via wrapping with different synthetic materials has been implemented for many years. The most commonly used technical variant is wrapping the dilated aorta with a vascular prosthesis with a predetermined diameter. When this technique is adequately applied, it immediately reduces the diameter of the AA and, to a lesser degree, the diameter of the aortic root and arch, while at the same time it reinforces the weak aortic wall. These effects lead to a drop-in wall shear stress and in the risk of aortic dissection and rupture, and persist over time. Although the low elasticity of the external support causes significant changes in the histologic structure of the aortic wall, mainly atrophy and alterations typical of a foreign body-induced reaction, this does not seem to involve a higher risk of complications. In some selected patients, this technique may be used in cases other than post-stenotic aortopathy, and also in aortas with a larger diameter.