Transcatheter aortic valve implantation with pre-existing mitral valve prosthesis using cardiopulmonary bypass: A case report.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is rarely performed in patients with a pre-existing mitral valve prosthesis, which was excluded from the Placement of Aortic Transcatheter Valve trial. Cardiopulmonary bypass (CPB) can provide sufficient hemodynamic stability to facilitate safe implantation; specifically, we prefer using normothermic femoro-femoral CPB. Careful attention should be paid to determine the positional relationship between the two valves in such patients. PRESENTATION OF CASE: We present a case of transfemoral TAVI using femoro-femoral CPB in a 90-year-old female patient with a pre-existing bioprosthetic mitral valve. Baseline echocardiography revealed severe aortic valve stenosis; hence, emergency balloon valvuloplasty was performed. Three months later, elective TAVI was performed; subsequently, left ventricular ejection fraction reached 63 % without mitral valve regurgitation or stenosis. DISCUSSION: Despite the safety of TAVI using CPB in older patients, cannula insertion into peripheral vessels carries a high risk. CONCLUSION: As CPB can increase tissue invasion for a short duration, the safety of this procedure needs further validation.

[Re-operative Cardiac Surgery in Patients with Patent In Situ Coronary Artery Bypass Grafts].

BACKGROUND: Re-operative cardiac surgery after prior coronary artery bypass grafting( CABG), using in situ graft is a challenge. Technical difficulties regarding this procedure include risks of graft injury and myocardial protection. The conventional strategy involves re-sternotomy, dissection, and temporary occlusion of the in situ graft to prevent cardioplegia washout. However, the problem with this procedure is that injury to the in situ graft can result in catastrophic complications. METHODS: We reviewed 25 redo cases of patients who had prior CABG with patent in situ grafts. The in situ grafts were dissected and clamped in 18 (group C) patients, whereas in 7 (group U) patients, the in situ grafts were not dissected or clamped. All patients underwent re-sternotomy, aortic cross clamping and cardiac arrest with cardioplegia. Besides, myocardial protection was obtained using moderate hypothermia and systemic potassium injection in group U. RESULTS: There were no injuries to the in situ grafts in either group. The peak creatine kinase-MB values were not significantly different between the two groups. Postoperative ejection fraction was preserved in both groups. CONCLUSIONS: The simplified approach of no-clamping technique yielded safety and effectiveness for myocardial protection in redo cases for patients with prior CABG in the presence of patent in situ grafts.

[Concomitant Transapical Transcatheter Aortic Valve Implantation and Coronary Artery Bypass Grafting via the Left Thoracotomy].

A 79-year-old man presented with progressive congestive heart failure symptom as a result of severe aortic stenosis. A rescue balloon aortic valvuloplasty was performed. After a transient improvement, computed tomographic scan revealed a porcelain aorta, and it showed a high risk for a surgical aortic valve replacement. Routine preoperative coronary angiography revealed tight stenosis of a proximal left anterior descending coronary artery. Percutaneous coronary intervention was performed unsuccessfully due to the severe calcification of the coronary artery. Therefore, a concomitant transapical transcatheter aortic valve implantation and coronary artery bypass grafting via the left thoracotomy was indicated. Under a veno-arterial extracorporeal circulatory support, we performed the transcatheter aortic valve implantation (TAVI) and coronary artery bypass grafting (CABG) successfully via a left thoracotomy. Even though the approach for TAVI is from fifth and CABG is from forth intercostal space respectively, it could be manipulated using the same skin incision. Concomitant TAVI and CABG via the left thoracotomy might be a reasonable and feasible option for the patients presented with severe aortic stenosis and coronary artery disease who are not eligible for conventional surgical solutions.

[Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis with Preexisting Mitral Prosthesis;Report of a Case].

An 81-year-old woman presented with progressive congestive heart failure. Seventeen years before, she had undergone mitral valve replacement with a mechanical prosthesis. Echocardiography revealed severe aortic stenosis with a depressed left ventricular ejection fraction of 32%.At first, rescue balloon aortic valvuloplasty (BAV) was performed. After transient improvement of symptoms, she was readmitted 2 months later with recurrence of severe congestive heart failure. Transcatheter aortic valve implantation (TAVI) with an Edwards Sapien valve was performed. During the procedure, BAV was performed to confirm that the balloon did not interfere the movement of the mechanical valve. Moreover, supported by a veno-arterial extracorporeal membrane oxygenation, we could prevent myocardial ischemia during rapid pacing and slowly deploy the valve in a precise position. TAVI can be safely and successfully performed in patients with a preexisting mechanical mitral prosthesis.

Bronchogenic cyst of the interatrial septum.

Although bronchogenic cysts are the most common primary mediastinal cysts, intracardiac bronchogenic cysts are extremely rare. We report a case of a bronchogenic cyst of the interatrial septum in a 42-year-old woman who presented with recent onset of dyspnea on exertion. Cardiac investigations including transthoracic echocardiography and computed tomography revealed a cystic homogeneous mass in the interatrial septum. The patient underwent surgical resection, and the resultant atrial septal defect was repaired using an autologous pericardial patch. Histopathological examination of the resected specimen revealed findings consistent with a benign bronchogenic cyst. Although bronchogenic cysts are extremely rare, they should be considered in the differential diagnoses of intracardiac tumors. Complete resection of bronchogenic cysts is recommended primarily for diagnostic and potentially therapeutic purposes.