Eyes wide shut--unusual two stage repair of pectus excavatum and annuloaortic ectasia in a 37 year old marfan patient: case report.

We report about a 37 year old male patient with a pectus excavatum. The patient was in NYHA functional class III. After performed computed tomography the symptoms were thought to be related to the severity of chest deformation. A Ravitch-procedure had been accomplished in a district hospital in 2009. The crack of a metal bar led to a reevaluation 2010, in which surprisingly the presence of an annuloaortic ectasia (root 73×74 mm) in direct neighborhood of the formerly implanted metal-bars was diagnosed. Echocardiography revealed a severe aortic valve regurgitation, the left ventricle was massively dilated presenting a reduced ejection fraction of 45%. A marfan syndrome was suspected and the patient underwent a valve sparing aortic root replacement (David procedure) in our institution with an uneventful postoperative course. A review of the literature in combination with discussion of our case suggests the application of stronger recommendations towards preoperative cardiovascular assessment in patients with pectus excavatum.

Is early antithrombotic therapy necessary after tissue mitral valve replacement?

BACKGROUND AND AIM OF THE STUDY: Patients with prosthetic heart valves have a higher risk of developing valve thrombosis and arterial thromboembolism. Antithrombotic therapy during the early postoperative period after biologic mitral valve replacement (MVR) is controversial. Hence, a retrospective study was conducted to investigate the efficacy of different antithrombotic therapies in patients after MVR with bioprostheses. METHODS: Between January 2000 and January 2006, a total of 99 patients presenting with preoperative sinus rhythm underwent isolated bioprosthetic MVR. Of these patients, 59 (58%) received a bovine pericardial xenograft, and 40 (42%) a porcine bioprosthesis. The postoperative antithrombotic therapy was prescribed according to the surgeon's preference. RESULTS: Fifty-one (51%) patients received acetylsalicylic acid (ASA group, 100 mg/day), 12 (13%) did not receive any specific antithrombotic therapy (NT group), and 36 (36%) received a vitamin K antagonist (VKA group, INR 2-3). The primary endpoints were the rate of cerebral ischemic events, bleeding events, and survival. The mean follow up was 23 months (range: 3-68 months). There were five early deaths (5%), and eight late deaths (8%). There were five episodes of cerebral ischemic events; these included three patients (8.3%) in the VKA group, one patient (2.0%) in ASA group, and one patient (8.3%) in the NT group (p = 0.351). Of these episodes, two occurred between 24 h and three months after surgery. Only one (2.8%) episode of major bleeding occurred (in the VKA group), due to poor anticoagulation management. CONCLUSION: Each of the antithrombotic therapies evaluated appeared to be safe. There was no evidence to suggest that any specific antithrombotic therapy would be superior in preventing valve thrombosis in patients undergoing bioprosthetic MVR.

Thoracoscopic pulmonary vein isolation in patients with atrial fibrillation and failed percutaneous ablation.

OBJECTIVE: Pulmonary vein isolation is indicated in patients with symptomatic isolated atrial fibrillation not controlled with antiarrhythmic therapy. We describe our surgical experience with thoracoscopic pulmonary vein isolation in patients in whom percutaneous ablation has failed. METHODS: Thirty-four adult patients with unsuccessful catheter ablations (range 1-4, mean 2 +/- 1) underwent thoracoscopic bipolar-radiofrequency pulmonary vein isolation. Seventeen patients had paroxysmal atrial fibrillation, 12 with persistent and 5 with long-standing persistent fibrillation, for a mean of 6 years (range 3-10 years), 13 years (5-25 years), and 9 years (3-15 years), respectively. RESULTS: There was no mortality during the procedure or follow-up (mean 16 +/- 11 months). Two patients needed conversion to thoracotomy owing to hemorrhage, and ablation could not be completed. Antiarrhythmic therapy was withdrawn 3 months postoperatively. Postoperative sinus rhythm was maintained in 82% of those with paroxysmal atrial fibrillation (13/15 at 6 months, 9/11 at 12 months), 60% had persistent atrial fibrillation (8/12 at 6 months and 6/10 at 12 months), and 20% had long-standing persistent atrial fibrillation (1/5 at 6 and 12 months). Preoperative left atrial diameter significantly differed between patients with paroxysmal fibrillation (mean 42 +/- 6 mm) and those with persistent and long-standing persistent fibrillation (means 50 +/- 4 and 47 +/- 2 mm). Left atrial size greater than 45 mm and atrial fibrillation type were preoperative factors that significantly influenced outcome in the univariate logistic regression analysis. CONCLUSIONS: Thoracoscopic pulmonary vein isolation in patients with previously unsuccessful catheter ablations demonstrates satisfactory sinus rhythm maintenance rates in paroxysmal and persistent atrial fibrillation, but not in long-standing persistent atrial fibrillation. As with other minimally invasive surgical techniques, there is an important learning curve.

[Mortality and morbidity in HIV-infected patients undergoing coronary artery bypass surgery: a case control study]. / Morbimortalidad en pacientes con infección por el virus de la inmunodeficiencia humana que reciben cirugía de revascularización miocárdica: estudio de casos y controles.

The use of highly active antiretroviral therapy (HAART) in patients with HIV infection has improved survival. This improvement combined with the metabolic effects of treatment has increased cardiovascular risk and the need for cardiac surgery in these patients. We compared morbidity and mortality in HIV-infected patients (cases, n=7) and non-HIV-infected patients (controls, n=21) who underwent isolated coronary artery surgery between 1997 and 2004. The durations of extracorporeal circulation and aortic cross-clamping were shorter in HIV-infected patients (P=.002 and P=.014, respectively). The percentage of patients who experienced complications was similar, at 57.1% in both groups, but there was a slightly higher number of complications per patient in non-HIV-infected individuals. The mean length of total hospitalization was greater in HIV-infected patients (27.1 [13.3] versus 8.8 [5.3] days; P=.003), as was that of postoperative hospitalization (18.2 [15.4] vs 7.9 [4.2] days; P=.08). No HIV-infected patient died or needed a repeat cardiac operation. No progression of the HIV infection was observed. Isolated coronary artery surgery in HIV-infected patients produces good results, and there is no increase in morbidity or mortality. Extracorporeal circulation did not influence disease progression.

Hemolysis in mechanical bileaflet prostheses: experience with the Bicarbon valve.

BACKGROUND: Normal functioning mechanical heart valve prostheses are designed to have a certain degree of intrinsic structural regurgitation as a washout mechanism to avoid prosthetic thrombosis. However, intrinsic regurgitation leads to blood cell trauma and hemolysis. Information on hemolysis associated with mechanical bileaflet prostheses is scarce. This study evaluated factors influencing hemolysis in 197 Bicarbon mechanical bileaflet prostheses implanted in 164 patients. METHODS: Serial office interviews, laboratory studies, and echocardiography evaluations were done in the surviving patients. An assay for measuring lactate dehydrogenase activity was developed, and the presence and severity of subclinical hemolysis was determined using reported criteria and analyzed at 1 and 2 years. RESULTS: Hospital mortality was 5.5%. Follow-up was 98.1% complete. No patient had clinically significant or severe subclinical hemolysis. Serum lactate dehydrogenase levels were significantly higher when a paravalvular leak was documented (282 +/- 85 U/L versus 242 +/- 64 U/L; p = 0.0026). Subclinical hemolysis was significantly more frequent after mitral valve (p = 0.001) and double valve replacement (p = 0.001) than after aortic valve replacement, and was unrelated to prosthetic size or to geometric area index, even in those cases with effective orifice area index equal to or less than 0.85 cm2/m2 (p = 0.298). CONCLUSIONS: Mild subclinical hemolysis is frequently associated with normal functioning Bicarbon heart valves. Subclinical hemolysis was significantly influenced by valve position but not by valve size or effective orifice area index and remained stable through time. The magnitude of hemolysis in Bicarbon prostheses compared favorably with that reported for other bileaflet heart valve prostheses.

Morbimortalidad en pacientes con infección por el virus de la inmunodeficiencia humana que reciben cirugía de revascularización miocárdica: estudio de casos y controles / Mortality and morbidity in HIV-infected patients undergoing coronary artery bypass surgery: a case control study

La mayor supervivencia y los efectos metabólicos del tratamiento antirretroviral han aumentado el riesgo cardiovascular y la necesidad de cirugía coronaria en individuos positivos para el virus de la inmunodeficiencia humana (VIH). Comparamos la morbimortalidad entre pacientes VIH-positivos (casos, n = 7) y negativos (controles, n = 21) que recibieron cirugía de revascularización miocárdica (CRM) entre 1997 y 2004. Los tiempos de circulación extracorpórea (CEC) y oclusión aórtica fueron inferiores en pacientes VIH-positivos (p = 0,002 y p = 0,014, respectivamente). La incidencia de complicaciones fue similar (el 57,1% en ambos grupos), aunque el número de complicaciones por paciente fue ligeramente superior en los VIH-negativos. Los pacientes VIH-positivos precisaron mayor estancia hospitalaria total (27,1 ± 13,3 y 8,8 ± 5,3 días; p = 0,003) y postoperatoria (18,2 ± 15,4 y 7,9 ± 4,2 días; p = 0,08). Ningún paciente VIH-positivo falleció, precisó una nueva CRM ni mostró progresión de la enfermedad. La CRM aislada obtiene buenos resultados en la infección por el VIH, sin incrementar la morbimortalidad. La CEC no influyó en la progresión de la infección

The use of highly active antiretroviral therapy (HAART) in patients with HIV infection has improved survival. This improvement combined with the metabolic effects of treatment has increased cardiovascular risk and the need for cardiac surgery in these patients. We compared morbidity and mortality in HIV-infected patients (cases, n=7) and non-HIV-infected patients (controls, n=21) who underwent isolated coronary artery surgery between 1997 and 2004. The durations of extracorporeal circulation and aortic cross-clamping were shorter in HIV-infected patients (P=.002 and P=.014, respectively). The percentage of patients who experienced complications was similar, at 57.1% in both groups, but there was a slightly higher number of complications per patient in non-HIV-infected individuals. The mean length of total hospitalization was greater in HIV-infected patients (27.1 [13.3] versus 8.8 [5.3] days; P=.003), as was that of postoperative hospitalization (18.2 [15.4] vs 7.9 [4.2] days; P=.08). No HIV-infected patient died or needed a repeat cardiac operation. No progression of the HIV infection was observed. Isolated coronary artery surgery in HIV-infected patients produces good results, and there is no increase in morbidity or mortality. Extracorporeal circulation did not influence disease progression

Acute limb ischemia due to embolization of biological glue after repair of type A aortic dissection.

OBJECTIVE: We present two cases of type A aortic dissection repaired with the help of biological glue, that were followed by acute limb ischemia due to embolism of glue. METHODS AND RESULTS: A 30-year-old man was diagnosed with aortic dissection from left coronary sinus to right subclavian artery. Under deep hypothermic circulatory arrest (DHCA), distal aortic anastomotic site was reconstructed with injection of Bioglue between dissected layers, and a valve sparing inclusion technique was performed using a straight dacron graft. On postoperative day 14, he presented acute limb ischemia due to femoral artery glue embolism that required surgery. A 76-year-old woman with the diagnosis of type A dissection ending proximal to the celiac trunk was operated under cardiopulmonary bypass and DHCA. The ascending aorta was replaced with a straight dacron tube, with resuspension of aortic valve and reinforcement of proximal and distal anastomosis with Bioglue between the diseased layers. Absence of previously patent radial pulse was detected intraoperatively, solved with humeral thromboembolectomy. CONCLUSIONS: Management of the diseased aortic wall in acute dissections is a surgical challenge for the cardiac surgeon. Despite our group having a positive experience with biological glue in type A aortic dissection, this report reminds us that the use of bioadhesives to reinforce anastomotic sites may be an important tool but it is not free of problems.

Estudio prospectivo, comparativo entre implantes de marcapasos realizados en el laboratorio de electrofisiología y en el quirófano / Comparative prospective study between pacemaker implantation in the electrophysiology laboratory and at the operating room

Introducción y objetivos. El implante de marcapasos permanentes es realizado por diversos especialistas con entrenamiento quirúrgico o clínico. El objetivo del estudio fue analizar si existían diferencias en los parámetros de implante y complicaciones entre los implantes realizados por cardiólogos en el laboratorio de electrofisiología y cirujanos cardíacos en el quirófano. Material y métodos. Se recogieron prospectivamente datos de los primoimplantes de marcapasos realizados durante 1998 por cirugía cardiovascular y electrofisiología. Se recolectaron datos demográficos, diagnóstico que motivó el implante, tiempo de procedimiento, complicaciones del mismo, umbrales de estimulación y detección y tipo de estimulación. Resultados. Se implantaron 216 marcapasos, 101 por cirugía cardiovascular y 115 por electrofisiología. El 56 por ciento de los pacientes eran varones. La edad promedio del grupo de cirugía cardiovascular fue 74 ñ 9 años y 72 ñ 12,3 años para el de electrofisiología (p = NS). Los principales diagnósticos fueron bloqueos AV completos en el 32,9 por ciento de los pacientes, bloqueos AV de segundo grado en el 16,4 por ciento, disfunción sinusal en el 12,2 por ciento, ablación del nodo AV en el 12,2 por ciento. La tasa de complicaciones del procedimiento fue del 4 por ciento para cirugía cardiovascular y 1,7 por ciento para electrofisiología (p = NS). Hubo más implantes de marcapasos bicamerales en electrofisiología, y mínimas diferencias sin significación clínica en los parámetros de implante. Conclusiones. El implante de marcapasos por cardiólogos en el laboratorio de electrofisiología se puede realizar de manera segura y sin más complicaciones que en los implantes realizados por cirujanos. Esto permite optimizar los recursos hospitalarios y disminuir los días de estancia (AU)