Custodiol cardioplegia for temporary mechanical circulatory support.

Several patients requiring biventricular mechanical circulatory support in the acute setting will not be candidates for less invasive advanced heart failure therapies not requiring median sternotomy. Temporary biventricular assist device may provide reliable short term support bridging patients to recovery or further advanced treatments. However, this exposes patients to increased risk of reoperation due to bleeding and further exposure to blood products. This article outlines the practical details necessary in performing this technique while minimizing potential complications.

Hemi-Cabrol Aortic Root Replacement in Complex Aortic Reconstructions.

The Cabrol aortic root replacement with subsequent modifications remains an extremely useful technique within the armamentarium of the aortic surgeon. The technical considerations detailed here allow for the uncompromised creation of a hemi-Cabrol anastomosis in complex aortic reconstructions.

Secondary syphilis presenting with aortitis and coronary ostial occlusion.

Aortitis is an established manifestation of tertiary syphilis. We report a rare case of aortitis with ostial occlusion and left ventricular failure in secondary syphilis. Her management required a true multidisciplinary approach from multiple specialities due to complications of concomitant psychosis and a history of anaphylaxis to penicillin. This case illustrates the complexities of diagnosing and managing a rare presentation of this increasingly prevalent infection.

Homograft Aortic Root Replacement with Saphenous Vein Graft Hemi-Cabrol for Prosthetic Aortic Valve Endocarditis.

A 44-year-old female presented with prosthetic valve endocarditis with periannular abscess involving the left coronary ostium. We describe cryopreserved aortic homograft root replacement with hemi-Cabrol reimplantation of the left coronary ostium using the long saphenous vein.

Endograft failure in an adult patient with coarctation and bicuspid aortic valve.

A 25-year-old man presented with associated bicuspid aortic valve and coarctation of the aorta. Following aortic valve replacement, he underwent endovascular stenting of his native coarctation. We describe early failure of the latter procedure that necessitated definitive surgical correction.

Scrotal distension after endoscopic harvesting of the saphenous vein in patients with inguinal hernia.

The great saphenous vein remains the most commonly used conduit for coronary artery bypass grafting. The endoscopic vein harvesting technique is widely used due to reduced postoperative complications. We present the case of 5 patients with a history of inguinal hernia undergoing coronary artery bypass grafting, which resulted in CO2 infiltration through the deep inguinal ring and into the scrotum leading to acute scrotal enlargement. Due to the risk of impediment of vascular blood supply and necrosis, endoscopic vein harvesting was withdrawn, and the vein was harvested by using the bridging technique. Postoperatively, severe contusion, inflammation, and erythematous vesicular eruption resulted in a lengthened hospital stay.

Conventional aortic valve replacement for high-risk aortic stenosis patients not suitable for trans-catheter aortic valve implantation: feasibility and outcome.

OBJECTIVE: High-risk patients with aortic stenosis are increasingly referred to specialist multidisciplinary teams (MDTs) for consideration of trans-catheter aortic valve implantation (TAVI). A subgroup of these cases is unsuitable for TAVI, and high-risk conventional aortic valve replacement (AVR) is undertaken. We have studied our outcomes in this cohort. METHODS: Data prospectively collected between March 2008 and November 2009 for patients (n = 28, nine male) undergoing high-risk AVR were analysed. The mean age was 78.4 ± 9.2 years. The mean additive EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 10.0 ± 3.6 and mean logistic EuroSCORE was 19.9 ± 18.8. Three patients had undergone previous coronary artery bypass grafting (CABG). RESULTS: The mean ejection fraction was 51 ± 16%, mean valve area 0.56 ± 0.19 cm², and mean peak gradient 91 ± 27 mm Hg. Ascending aortic, right axillary artery and femoral artery cannulation was used in 64%, 29% and 7% of cases, respectively. Median cross-clamp and cardiopulmonary bypass times were 84 (68-143) min and 111 (94-223) min. The median (range) inserted valve size was 21 (19-25) mm. Median intensive care and overall hospital stay were 5 (2-37) and 11 (5-44) days, respectively. In-hospital mortality was 4% (one patient). Postoperative complications included re-operation for bleeding (7%), renal failure (21%), tracheostomy (14%), sternal wound infection (7%), atrial fibrillation (25%) and permanent pacemaker implantation (7%). Kaplan-Meier survival at median follow-up of 359 (148-744) days was 81% (one further death of non-cardiac aetiology). Quality-of-life assessment at follow-up also yielded satisfactory results. CONCLUSIONS: MDT assessment of high-risk aortic stenosis in the era of TAVI has increased the number of referrals. Conventional open surgery remains a valid option for these patients, with acceptable in-hospital mortality and early/midterm outcomes but high in-hospital morbidity.

Apolipoprotein E alleles and bicuspid aortic valve stenosis in monozygotic twins.

Aortic valve disease is a common valvular heart disease but the underlying pathology that leads to the severe dysfunction of the aortic valve is unclear. There is increasing interest in the role of hypercholesterolaemia in the causation and progression of aortic valve disease. Apolipoprotein E is an essential component of cholesterol and previous studies have reported conflicting results on the association between various apolipoprotein E alleles and aortic valve disease. We report two interesting cases of severe dysfunction of bicuspid aortic valves in twin brothers who presented to us at the same time.

Primary cardiac sarcoma: reports of two cases and a review of current literature.

Primary cardiac sarcomas are rare tumors with an unfavourable prognosis. Complete surgical resection is currently the only mode of therapy proven to show any benefit. We report the cases of two patients presenting with features of obstruction and embolism and a presumed diagnosis of left atrial myxoma. At operation they were unexpectedly found to have large tumours raising strong suspicions of malignancy. Due to the extensive involvement of intracardiac structures with little possibility of reconstruction together with poor general condition of the patient, debulking was deemed to be the only viable option. Subsequent histology confirmed the diagnosis of sarcoma in both patients. Surgery produced immediate and effective symptom relief. The first patient died four months after the operation and second patient is still alive at 12 months after her operation. A brief review of literature on cardiac sarcoma is presented.

Aortic arch replacement using a trifurcated graft: simple, versatile, and safe.

BACKGROUND: Hypothermic selective antegrade cerebral perfusion during aortic arch replacement may prevent adverse neurologic sequelae. It can be provided via balloon-tipped catheters or a branched graft sewn to the brachiocephalic vessels. We report a consecutive series of total arch replacement using a trifurcated graft. METHODS: From September 1999 through October 2004, 109 patients underwent nonemergent total arch replacement using this technique. The graft, placed during a period of hypothermic circulatory arrest, was used for selective cerebral perfusion during the arch reconstruction. RESULTS: Adverse outcomes were seen in 9 (8.3%) patients: hospital death in 5 (4.6%), and stroke in 5 (4.6%). Transient neurologic dysfunction was noted in 6 (5.5%) patients. Mean duration of hypothermic circulatory arrest was 31.2 +/- 6.6 minutes and selective cerebral perfusion was 65.3 +/- 20.9 minutes. Reoperation for bleeding was required in 3 (2.8%) patients and prolonged intubation in 15 (13.8%). Median intensive care unit stay was 3 days (interquartile range 2-4; range, 1 to 108) and hospital stay was 9 (interquartile range 8-15; range, 5 to 108). CONCLUSIONS: The trifurcated graft technique results in low rates of perioperative mortality, temporary neurologic dysfunction, and stroke. It may reduce cerebral embolization as it requires no instrumentation of the aortic arch to establish selective cerebral perfusion and, although it mandates hypothermic circulatory arrest to place the graft, this interval is reliably brief enough to fall within accepted safe limits. This strategy leaves no residual arch tissue behind, and allows placement of an elephant trunk proximal to one or more arch vessels if anatomically indicated.

Recurrent acute rheumatic fever: a forgotten diagnosis?

The incidence of acute rheumatic fever has seen a dramatic decline over the last 15 to 20 years in most developed countries and treatment of this disease has changed little since. The ease of travel and immigration and the cosmopolitan nature of many cities mean that occasionally the disease will come to the attention of clinicians not familiar with its presentation, resulting in delayed diagnosis and treatment. We present a case of recurrent acute rheumatic fever in a patient who was initially thought to be suffering from acute bacterial endocarditis on her previously diseased rheumatic aortic valve. This culminated in her undergoing urgent aortic valve replacement during a phase of the illness that should have been treated with high dose anti-inflammatory medication. Therefore, clinicians should be aware of this condition and include it in their differential diagnosis of the febrile patient with a previous history of rheumatic fever. We briefly discuss the diagnostic dilemma of patients suffering from this condition and in differentiating it from acute endocarditis.

Comparison of exercise and dobutamine echocardiography in the haemodynamic assessment of small size mechanical aortic valve prostheses.

OBJECTIVE: Doppler echocardiographic evaluation of prosthetic heart valve function is usually performed at rest although this situation is not representative of patients' daily activities. Following aortic valve replacement, patients most likely to remain symptomatic are those with a small aortic root and dobutamine or exercise echocardiography has been proposed to elicit the presence of abnormal haemodynamics or persistently elevated transvalvular gradients in these patients. This study was carried out to compare dobutamine echocardiography with a symptom limited treadmill exercise echocardiography in patients following aortic valve replacement with a small size (19 mm) St. Jude Mechanical valve prosthesis. METHODS: The study population consisted of ten unselected patients following aortic valve replacement. Dobutamine was infused intravenously starting at 5 microg/kg/min and increasing by 5 microg/kg/min at 15 min interval up to 20 microg/kg/min. Heart rate, blood pressure, cardiac output (CO), peak and mean gradients as well as effective orifice area (EOA) were measured. These parameters were also measured following a symptom limited treadmill exercise. RESULTS: Dobutamine stress increased heart rate (HR) and CO by 50 and 74%, respectively (both P<0.0002), and mean transvalvular gradient from 22+/-4.1 mmHg at rest to 40.0+/-10 mmHg at maximum stress (P<0.001). With exercise, HR and CO increased by 48 and 70%, respectively while mean transvalvular gradient increased from 22+/-3.1 mmHg at rest to 38.0+/-6.4 mmHg (P<0.0001). The maximum increase in HR, CO and mean transvalvular gradient with dobutamine and exercise were similar however. There was no significant change in the EOA with either dobutamine or exercise. CONCLUSION: The result suggests that both treadmill exercise and dobutamine stress echocardiography are equally effective for the hemodynamic evaluation of small aortic valve prosthesis.

Congenital unilateral pulmonary artery agenesis and aspergilloma.

Isolated unilateral pulmonary artery agenesis is a rare condition, which in most patients is asymptomatic. Occasionally patients present with symptoms that are nonspecific and not necessarily attributable to disease of the respiratory system. In these individuals the clue to the diagnosis is found in a plain chest roentgenogram, often revealing a hyperlucent contracted hemithorax. We present an unusual case of isolated unilateral pulmonary artery agenesis associated with the opportunistic organism Mycobacterium kansasii and Aspergillus fumigatus in which the diagnosis was made 10 years after initial presentation. Clinicians should be aware of this condition and include it in their differential diagnosis of a hyperlucent lung field on the chest roentgenogram.