Long-term survival after surgical treatment for post-infarction mechanical complications: results from the Caution study.

BACKGROUND AND AIMS: Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study early and long-term results of patients undergoing surgical treatment for post-AMI MCs. METHODS: Patients undergone surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centers worldwide were retrieved from the database of CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality. RESULTS: The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5 and 10 years was 54.0%, 48.1% and 41.0%, respectively. Older age (p < 0.001) and postoperative LCOS (p < 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significant higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022). CONCLUSIONS: Contemporary data from a multicenter cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate postoperative period is encouraging.Trial registration number: NCT03848429.

Extracorporeal life support in mitral papillary muscle rupture: Outcome of multicenter study.

BACKGROUND: Post-acute myocardial infarction papillary muscle rupture (post-AMI PMR) may present variable clinical scenarios and degree of emergency due to result of cardiogenic shock. Veno-arterial extracorporeal life support (V-A ECLS) has been proposed to improve extremely poor pre- or postoperative conditions. Information in this respect is scarce. METHODS: From the CAUTION (meChanical complicAtion of acUte myocardial infarcTion: an InternatiOnal multiceNter cohort study) database (16 different Centers, data from 2001 to 2018), we extracted adult patients who were surgically treated for post-AMI PMR and underwent pre- or/and postoperative V-A ECLS support. The end-points of this study were in-hospital survival and ECLS complications. RESULTS: From a total of 214 post-AMI PMR patients submitted to surgery, V-A ECLS was instituted in 23 (11%) patients. The median age was 61.7 years (range 46-81 years). Preoperatively, ECLS was commenced in 10 patients (43.5%), whereas intra/postoperative in the remaining 13. The most common V-A ECLS indication was post-cardiotomy shock, followed by preoperative cardiogenic shock and cardiac arrest. The median duration of V-A ECLS was 4 days. V-A ECLS complications occurred in more than half of the patients. Overall, in-hospital mortality was 39.2% (9/23), compared to 22% (42/219) for the non-ECLS group. CONCLUSIONS: In post-AMI PMR patients, V-A ECLS was used in almost 10% of the patients either to promote bridge to surgery or as postoperative support. Further investigations are required to better evaluate a potential for increased use and its effects of V-A ECLS in such a context based on the still high perioperative mortality.

Surgical treatment for post-infarction papillary muscle rupture: a multicentre study.

OBJECTIVES: Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS: Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS: A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07-6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02-15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00-1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16-0.92, P = 0.031). CONCLUSIONS: Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov: NCT03848429.

Surgical Treatment of Postinfarction Ventricular Septal Rupture.

Importance: Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic. Objectives: To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality. Design, Setting, and Participants: The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR. Exposures: Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting). Main Outcomes and Measures: The primary outcome was early mortality; secondary outcomes were postoperative complications. Results: Of the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery ≥7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [OR], 1.05; 95% CI, 1.02-1.08; P = .001), preoperative cardiac arrest (OR, 2.71; 95% CI, 1.18-6.27; P = .02) and percutaneous revascularization (OR, 1.63; 95% CI, 1.003-2.65; P = .048), and postoperative need for intra-aortic balloon pump (OR, 2.98; 95% CI, 1.46-6.09; P = .003) and extracorporeal membrane oxygenation (OR, 3.19; 95% CI, 1.30-7.38; P = .01) were independently associated with mortality. Conclusions and Relevance: In this study, surgical repair of postinfarction VSR was associated with a high risk of early mortality; this risk has remained unchanged during the last 2 decades. Delayed surgery seemed associated with better survival. Age, preoperative cardiac arrest and percutaneous revascularization, and postoperative need for intra-aortic balloon pump and extracorporeal membrane oxygenation were independently associated with early mortality. Further prospective studies addressing preoperative and perioperative patient management are warranted to hopefully improve the currently suboptimal outcome.

A Case Report of Giant Ascending Aortic Aneurysm: Role of Multimodality Imaging.

Giant ascending aortic aneurysm (AscAA >10 cm) is an uncommon entity with a variable presentation. The size of the aneurysm, rapid expansion, and calcification are associated with an increased risk of rupture. Atherosclerosis is the most common etiology of aortic aneurysm in the elderly population. Multimodality imaging can be wisely used for diagnosis, risk stratification, and follow-up. We herein report a case of successfully repaired giant calcified AscAA with a maximum diameter of 10 cm. We also provide a brief discussion on the role of multimodality imaging.

Complications Following Percutaneous Mitral Valve Edge-to-Edge Repair Using MitraClip.

Percutaneous mitral valve edge-to-edge repair with MitraClip (Abbott, Abbott Park, Illinois) has emerged as an effective and safe treatment for symptomatic mitral regurgitation in suitable patients. The safety of the MitraClip procedure is well established, and the rate of major complications is 4.35%. We present 4 cases of mitral regurgitation in patients who had complications following the MitraClip procedure. (Level of Difficulty: Intermediate.).

Surgical Treatment of Post-Infarction Left Ventricular Free-Wall Rupture: A Multicenter Study.

BACKGROUND: Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. METHODS: Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post-acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality. RESULTS: The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P < .001), cardiac arrest at presentation (P = .011), female sex (P = .044), and the need for preoperative extracorporeal life support (P = .003) were independent predictors for operative mortality. CONCLUSIONS: Surgical repair of post-infarction LVFWR carries a high operative mortality. Female sex, preoperative left ventricular ejection fraction, cardiac arrest, and extracorporeal life support are predictors of early mortality.

A case report of Adult-onset Still's disease as a cause of severe mitral regurgitation.

BACKGROUND: Adult-onset Still's disease (AOSD) is an uncommon systemic inflammatory disease, causing spiking fever, skin rash, and arthritis. Pericarditis and myocarditis are the most common cardiac manifestation of AOSD but valvular involvement is rarely reported. CASE SUMMARY: An 18-year-old boy presented with gradually worsening shortness of breath for 6 months. There was a history of low-grade intermittent fever and polyarthralgia affecting ankles, knees, and elbows. He was in heart failure with cardiogenic and septic shock. He was managed initially with antibiotics, inotropes, and diuretics. Echocardiography showed flail anterior mitral leaflet with severe mitral regurgitation. He remained febrile with persistent negative blood cultures. Intravenous antibiotics led to neutropenia without any response to fever and clinical status. On further workup, he was diagnosed to have AOSD, and he responded dramatically to oral steroid therapy. Later his mitral valve was replaced surgically. On follow-up, he was stable with mild exertional dyspnoea. His international normalized ratio was in therapeutic range and his follow-up echocardiography showed normally functioning mitral prosthesis. He is following rheumatology and currently on the maintenance dose of steroids. DISCUSSION: Adult-onset Still's disease is a systemic illness with diagnosis is based on clinical features and exclusion of other illnesses. Adult-onset Still's disease should be considered as a differential diagnosis in culture-negative endocarditis, especially in those with systemic features and non-responders to antibiotics.

Low Grade Primary Leiomyosarcoma of the Right Atrium: Promising Survival with Complete Surgical Resection.

Primary cardiac leiomyosarcoma has an extremely low incidence with overall median survival of approximately 6 months. Here, We report the case of a 60-year-old man who underwent complete surgical excision of right atrial mass. Histologic examination revealed leiomyosarcoma. The patient made a full recovery with no evidence of recurrence at 24 months. To the best of our knowledge, this is the first reported case or primary cardiac leiomyosarcoma in the Middle East.

Post-myocardial infarction ventricular septal rupture in a patient with large secundum atrial septal defect: a case report.

BACKGROUND: Ventricular septal rupture (VSR) is an uncommon but potentially fatal complication of acute myocardial infarction (AMI). The management of VSR is challenging, and its surgical correction is associated with the highest mortality among all cardiac surgery procedures. CASE SUMMARY: A 57-year-old man with a history of smoking presented with AMI with a large apical VSR in addition to a large secundum atrial septal defect (ASD). His left ventricular ejection fraction was 30%, and the right ventricle was moderately dilated with normal systolic function. Cardiac catheterization revealed that the left anterior descending artery was diffusely diseased with total mid occlusion, whereas other coronary arteries had non-obstructive disease. This unique combination resulted in distinctive presentation with paradoxically better outcomes. After stabilization, the patient's interventricular septum was reconstructed, and the ASD was closed with a pericardial patch. The post-operative period was uneventful, and the patient was discharged 1 week after surgery. A follow-up echocardiography revealed no residual shunt. DISCUSSION: Post-myocardial infarction VSR presents differently in patients with pre-existing right ventricular volume overload. In such cases, the absence of significant cardiogenic shock at presentation may result in better surgical outcomes.

Long-term clinical outcomes of drug-eluting stents in diabetic patients with small vessels compared to larger vessel-7 years clinical follow-up.

OBJECTIVES: The aim of this study was to analyze the effectiveness of drug-eluting stents (DES) in small vessels in patients with non-insulin-dependent (NIDDM) and insulin-dependent diabetes mellitus (IDDM). BACKGROUND: Several randomized trials have shown DES to significantly reduce the angiographic and clinical events in diabetic patients. However, there is insufficient data on similar outcomes in diabetics with small vessels. METHODS: We studied 258 consecutive diabetic patients (173 NIDDM and 85 IDDM) who underwent coronary stenting with DES, divided into 2 cohorts: group A (vessels<2.7mm): 163 patients, and group B (vessels≥2.7mm): 95 patients. We analyzed the major adverse cardiac events (MACE) [death, nonfatal myocardial infarction MI, and target lesion revascularization (TVR)] over a mean follow-up of 78.4±14.8months. RESULTS: Group A patients had: smaller reference diameter (2.4±0.31 versus 3.14±0.2mm, p=0.0001), longer lesions (19.3±9.5 versus 16.7±7.1mm, p=0.023), more complex lesions: (B2/C) (80.7 versus 52.6%, p<0.033), bifurcation lesions (25.8 versus 11.6%, p=0.007), diffuse disease (42.9 versus 26.3%, p=0.008), multivessel (32.5 versus 18.9%, p=0.019), eccentric lesions (57.1 versus 43.2%, p=0.031), more stents implanted (1.99±1.6 versus 1.7±1.3, p<0.0001), more overlapping stents (29.4 versus 13.7%, p=0.004) and more stents length (25.7±4.9 versus 20.2±2.6, p<0.003). During the follow-up, both groups had overall similar MACE (10.4 versus 11.7%, p=0.9) with insignificant higher restenosis (9.2 versus 8.4%, p=0.832) and TVR (7.4 versus 6.4%, p=0.75) in group A. There was no difference in death (p=0.111) or MI (p=0.858). Both groups had similar stent thrombosis rate (1.2 versus 1.1%, p=0.899), angina events (10.4 versus 16.8%, p=0.137), abnormal stress thallium (14.1 versus 14.7%, p=0.890), and hospital days (2.91 versus 3.57, p=0.886). CONCLUSION: Despite complex angiographic characteristics, the use of DES in diabetic patients with small vessels showed favorable clinical outcomes and similar low TVR compared to those with large vessels.

Influence of time of placement of investments for burnout and the type of rings being used on the casting accuracy.

The sole objective of casting procedure is to provide a metallic duplication of missing tooth structure, with as great accuracy as possible. The ability to produce well fitting castings require strict adherence to certain fundamentals. A study was undertaken to comparatively evaluate the effect on casting accuracy by subjecting the invested wax patterns to burnout after different time intervals. The effect on casting accuracy using metal ring into a pre heated burnout furnace and using split ring was also carried. The readings obtained were tabulated and subjected to statistical analysis.

Radical resection of pleuropulmonary blastoma.

Pleuropulmonary blastoma (PPB) is a rare intrathoracic neoplasm of early childhood that occurs in the lung or visceral pleura. We present a case of a 5-year-old boy with a cough, left-sided chest pain and progressive dyspnea on exertion. The patient had had an operation for a congenital lung cyst of the left lower lobe, six months prior to the present admission. A CT showed a heterogeneously enhancing mass lesion filling the left hemithorax. CT-guided fine needle aspiration cytology of the mass was inconclusive. En bloc resection of the mass along with left lower lobe, the involved ribs and left diaphragm was performed. The diaphragmatic defect was repaired using prolene mesh. Histopathology of the resected specimen showed solid and cystic areas consistent with type II PPB. The patient received adjuvent chemotherapy and was doing well 23 months after surgery. Radical resection of the tumor followed by adjuvent chemotherapy provides the only hope of salvaging cases of type II or type III PPB.

Traumatic diaphragmatic rupture, a diagnostic dilemma in the presence of eventration: a case report.

Eventration of the diaphragm is the condition where the muscle is permanently elevated, but retains its continuity and attachments to the costal margins. Traumatic diaphragmatic rupture is a recognized consequence of high velocity blunt trauma to the abdomen usually a result of motor vehicle accident. Multi-slice CT and Magnetic Resonance Imaging in the pre-operative evaluation of trauma patients, diaphragmatic rupture can be still overlooked if not evaluated with the fair degree of clinical suspicion, more so if it is associated with an eventration of diaphragm - as was in our case.

Surgeon and human immunodeficiency virus infection.

HIV infection has attained extraordinary attention among surgeons and other health care workers as a potential source of occupational infection. Disease is usually blood-borne and transmissible, and due to the nature of surgical work, surgical community has become involved and is developing sterile surgical barriers, and improved surgical techniques and procedures.

Impact of atrial fibrillation on immediate and long-term results of mitral balloon valvuloplasty in 531 consecutive patients.

BACKGROUND AND AIM OF THE STUDY: Conflicting evidence exists regarding the impact of atrial fibrillation (AF) on the immediate and long-term outcome of mitral balloon valvuloplasty (MBV). The study aim was to investigate such outcome in 531 consecutive patients. METHODS: The immediate and long-term (up to 18 years) clinical and echocardiographic results of MBV of 71 patients with AF at baseline were prospectively collected and compared with those of 460 patients in normal sinus rhythm (NSR). RESULTS: Typically, patients in AF were older (42 +/- 12 years versus 30 +/- 10 years; p <0.0001) and had higher echocardiographic scores (8.45 +/- 1.14 versus 7.95 +/- 1.0; p = 0.005) than those in NSR. In patients with AF, MBV resulted in inferior immediate and long-term results, as reflected by a smaller immediate mitral valve area (MVA) (1.89 +/- 0.23 versus 2.0 +/- 0.3 cm2; p = 0.005), smaller MVA at follow up (1.49 +/- 0.39 versus 1.6 +/- 0.4 cm2; p = 0.037), and a higher restenosis rate (44% versus 30%; p = 0.012). Actuarial freedom from restenosis at 10 years was 67 +/- 6% for AF patients versus 77 +/- 2% for NSR patients (p = 0.11); values at 15 years were 34 +/- 8% and 46 +/- 4%, respectively (p = 0.18). An echo score >8 (p < 0.0001) and previous surgery (p = 0.043) were identified as predictors of restenosis. Actuarial survival at 15 years was lower in AF patients (72 +/- 11% versus 96 +/- 1%; p = 0.029). Likewise, event-free survival was lower in AF patients after 10 years (72 +/- 1% versus 89 +/- 1%; p <0.0001) and 15 years (40 +/- 9% versus 55 +/- 4%; p = 0.128). An echocardiography score > 8 (p < 0.0001) and baseline AF (p = 0.03) were identified as predictors of combined events (p < 0.0001) at follow up. CONCLUSION: AF has a negative impact on the immediate and long-term outcome after MBV. In addition, the presence of AF is a marker of clinical and morphological features associated with inferior results after MBV.

Atrial myxoma: trends in management.

Myxomas are the most common type of cardiac tumours in all age groups accounting for one-third to one-half of cases at postmortum and for about three quarter of tumours treated surgically. Most atrial myxomas, whether left or right, arise from the atrial septum. About 10% have other sites of origin, particularly posterior wall, anterior wall and the appendages (in order of frequency). Myxomas are frequently located in left atrium and produce symptoms when they fragment and cause systemic emboli or when they interfere with cardiac valvular function and cause pulmonary congestion. Careful surgical management of these lesions should be curative with minimal early and late morbidity and mortality. Recurrence of atrial myxomas can occur most likely in about 3% of patients. However, extensive resection of the myxoma attached to atrial septum or atrial wall can reduce the likelihood of recurrence to a greater extent. Long term clinical and echocardiographic follow-up is mandatory.

Popliteal artery injuries: the Kashmir experience.

BACKGROUND: Popliteal artery injuries pose a serious threat to limb survival. Blunt trauma appears to be associated with a higher amputation rate than penetrating trauma, probably because of the more extensive nature of the injuries. METHODS: Two hundred seventy-two cases of popliteal artery injury were studied retrospectively from 1989 to 2001, a warlike period in Kashmir. Preoperative angiography was not performed. Thirty-two percent of patients had associated venous injury and 24.6% of patients had associated bone fracture. RESULTS: Overall morbidity was 55%, with the most common complication being infection (24%). Secondary amputation had to be performed in 16 patients (5.5%). The amputation rate was not influenced by cause of injury and type of repair or the presence of venous injury, but associated bone fracture significantly increased the risk of amputation (p < 0.05). The patients who underwent repair more than 12 hours after sustaining injury had a significantly greater amputation rate (p < 0.05). CONCLUSION: Prompt resuscitation, vascularization, and proper technique appear to be the only correctable factors that improve limb salvage.