Left atrial appendage perforation with Watchman device implantation: Strategies for surgical repair.

Percutaneous occlusion of the left atrial appendage is increasingly being used as an alternative for stroke prevention in patients with non-valvular atrial fibrillation at high risk of complications from long term anticoagulation. We describe a case of left atrial appendage perforation during Watchman device implantation requiring emergency repair of the left atrium using sternotomy and cardiopulmonary bypass. Technical considerations for surgical decision making are discussed; in hemodynamically unstable patients as well as those at high risk for embolization.

Collateral damage of COVID-19 pandemic: Delayed medical care.

During the COVID-19 pandemic, emergency room visits have drastically decreased for non-COVID conditions such as appendicitis, heart attack, and stroke. Patients may be avoiding seeking medical attention for fear of catching the deadly condition or as an unintended consequence of stay-at-home orders. This delay in seeking care can lead to increased morbidity and mortality, which has not been figured in the assessment of the extent of damage caused by this pandemic. This case illustrates an example of "collateral damage" caused by the COVID-19 pandemic. What would have been a standard ST-elevation myocardial infarction treated with timely and successful stenting of a dominant right coronary artery occlusion, became a much more dangerous postinfarction ventricular septal defect; all because of a 2-day delay in seeking medical attention by an unsuspecting patient.

Left atrial angiosarcoma: an unusual presentation and location.

Primary sarcomas are aggressive tumors with a predilection for the right side of the heart. The case is reported of a patient with a highly aggressive angiosarcoma occupying the entire left atrium, who presented with a rapidly progressive history of dyspnea. The tumor was resected surgically and found to be invading the left pulmonary veins. Unfortunately, the patient had a recurrence within three months of surgery and died one year after the first presentation. A brief review of the relevant literature is also provided.

Complex repair of a Barlow's valve using the Da Vinci robotic surgical system.

Robotic mitral valve repair is increasingly being used for mitral valve repair. However, the repair of a bileaflet prolapse (especially Barlow's type) is difficult and not often considered suitable for a robotic-assisted approach. The case is reported of a successful robotic-assisted repair of a Barlow's valve, including posterior leaflet resection, chordal transfer, cleft repair, construction of Gore-Tex neo-chords, bilateral commissuroplasties, and a flexible/partial annuloplasty. The total cardiopulmonary bypass and cross-clamp times were 231 and 183 min, respectively. The patient was discharged home on the third postoperative day and is doing well one year later, with no residual mitral regurgitation.

Meta-Analysis Comparing Multiple Arterial Grafts Versus Single Arterial Graft for Coronary-Artery Bypass Grafting.

Observational studies and randomized controlled trials (RCTs) have shown conflicting outcomes for multiple arterial graft (MAG) coronary artery bypass graft surgery compared with single arterial grafts (SAGs). The predominant evidence supporting the use of MAGs is observational. The aim of this meta-analysis of RCTs is to compare outcomes following MAG and SAG. We searched multiple databases for RCTs comparing MAG versus SAG. The clinical outcomes studied were all-cause mortality, cardiac mortality, myocardial infarction (MI), revascularization, stroke, sternal wound complications, and major bleeding. We used hazard ratio (HR), relative risk (RR), and corresponding 95% confidence interval (CI) for measuring outcomes. Ten RCTs (6392 patients) were included. The average follow-up in the studies was 4.2 years. The average age of the patients in the studies ranged from 56.3 years to 74.6. No significant difference was seen between MAG and SAG groups for all-cause mortality (11.8% vs 12.7%, HR 0.94, 95% CI 0.81 to 1.09, p 0.36), cardiac mortality (4.1% vs 4.5%, HR 0.96 95% CI 0.74 to 1.26, p 0.77), MI (3.5% vs 5.1%, HR 0.87 95% CI 0.67 to 1.12, p 0.28), and major bleeding (3.3% vs 4.9%, RR 0.85 95% CI 0.64 to 1.13, p 0.26). Repeat revascularization in MAG showed a lower RR than SAG when one of the confounding studies was excluded (RR 0.63, 95% CI 0.4 to 0.99, p 0.04). The incidence of stroke was lower in MAG than SAG (2.9% vs 3.9%, RR 0.74 95% CI 0.56 to 0.98, p 0.03). MAG had higher incidence of sternal wound complications than SAG (2.9% vs 1.7%, RR 1.75 95% CI 1.19 to 2.55, p 0.004). In conclusion, MAG does not have a survival advantage compared with SAG but is better in revascularization and risk of stroke. This benefit may be set off by a higher incidence of sternal wound complications in MAG.

Supravalvular aortic membrane with severe aortic regurgitation: an unusual presentation in adults.

Aortic stenosis due to supravalvular membrane usually presents in children. It may be associated with fusion of the left coronary leaflet and the supravalvular membrane, causing obstruction of the left coronary ostium, and resulting in myocardial ischemia. Despite the immobilization of the left coronary leaflet, these patients present in childhood with aortic stenosis and not regurgitation, with or without accompanying myocardial ischemia. The case is described of an adult patient with supravalvular aortic membrane presenting with severe aortic regurgitation and myocardial infarction due to fusion of the left coronary leaflet with the supravalvular membrane.

Beating heart video-assisted mitral valve surgery: a useful technique for high-risk patients.

BACKGROUND: Beating-heart valve surgery through a sternotomy has been used as an excellent myocardial protection strategy in high risk patients. Minimally invasive approaches have reduced the trauma and enhanced the recovery of patients undergoing heart surgery. We hypothesized that high-risk patients undergoing mitral valve surgery will benefit from a combination of these two approaches. METHODS: A 52-year-old male with dilated cardiomyopathy and left ventricular function of 15% was referred for surgery because of congestive heart failure. RESULTS: Using a 4-cm right minithoracotomy and femoral cannulation for cardiopulmonary bypass, successful beating-heart video-assisted mitral valve repair was performed. The adequacy of myocardial protection was confirmed by absence of ischemic electrophysiologic changes. The patient was discharged home on the 6(th) postoperative day. CONCLUSION: Beating-heart strategy can be combined with a minimally invasive approach in patients with severely reduced ventricular function, who require mitral valve surgery.

Hybrid percutaneous coronary intervention and minimally invasive reoperative mitral valve surgery.

We report a complex case of peripheral vascular disease (PVD), coronary artery disease (CAD), and three prosthetic heart valves, who developed severe mitral regurgitation (MR) due to healed endocarditis. She was successfully managed with a hybrid approach utilizing percutaneous coronary intervention (PCI) followed by minimally invasive mitral valve surgery (MIMVS) through right minithoracotomy. This was the patient's fifth cardiac surgery and she was discharged home on the fourth postoperative day (POD).

Managing the Left Atrial Appendage in Atrial Fibrillation: Current State of the Art.

BACKGROUND: Patients with atrial fibrillation are at increased risk for thromboembolic stroke originating predominantly in the left atrial appendage. To reduce the risk, the standard of care is anticoagulation. In addition, several devices for exclusion of the left atrial appendage have been developed. METHODS: PubMed was searched for articles relevant to left atrial appendage management. The resulting articles were reviewed as were relevant articles in their bibliographies. Relevant journals were manually searched for sources. RESULTS: Devices are being used for left atrial appendage exclusion by percutaneous and surgical approaches. Their indications, limitations, and outcomes are reviewed. CONCLUSIONS: Excision and exclusion of the left atrial appendage is safe and as effective as medical management of atrial fibrillation for stroke prevention. The choice of treatment should be made based on patients' anatomy, history, and preference informed by an appropriate left atrial appendage management team.

Initial Experience With Minimally Invasive Surgical Exclusion of the Left Atrial Appendage With an Epicardial Clip.

OBJECTIVE: Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic stroke. Atrial fibrillation affects 2.7 million people with a stroke rate of 3.5% per year. Most of the emboli in patients with nonvalvular AF originate in the left atrial appendage (LAA). Surgical exclusion of the LAA decreases the yearly risk of stroke to 0.7% when combined with a Maze procedure. Traditional oversewing the LAA from inside the left atrium is associated with a significant number of recanalizations of LAA. An alternate technique is epicardial clipping, which has been approved through sternotomy for permanent exclusion of LAA. We present our initial experience of epicardial clipping of the LAA using a minimally invasive approach. METHODS: Between May 2012 and December 2015, a total of 24 consecutive patients underwent minimally invasive, echo-guided epicardial clipping. Indications for the procedure were persistent (n = 12) or paroxysmal (n = 12) AF in patients who could not tolerate full anticoagulation because of a combination of gastrointestinal bleeding (n = 7), hemorrhagic stroke (n = 5), ischemic stroke (n = 5), intramuscular bleeding (n = 3), falls (n = 2), urinary tract bleeding (n = 2), subdural hematoma (n = 1), traumatic aortic intramural hematoma (n = 1), and lifestyle and career practices inconsistent with anticoagulation (n = 1). The clipping was performed through three 5-mm ports in the left seventh intercostal space (n = 22) or a 5-cm incision in the fifth intercostal space (n = 2). Echocardiography was performed to exclude the presence of LAA thrombus and to confirm exclusion of LAA before final deployment of the clip. RESULTS: The mean age was 73.6 years. The mean CHA2DS2VASC score was 4.7 and the mean HAS-BLED score was 3.8. The mean postoperative length of stay was 6.4 days. One patient died of stroke-related complications 10 days after successful clipping, and two patients required thoracentesis to drain recurrent pleural effusions. All patients had successful exclusion of LAA defined as residual sac of less than 1 cm. CONCLUSIONS: Isolated epicardial left atrial clipping is a safe treatment option in high-risk patients with AF. Long-term success in preventing stroke is still to be determined, but short-term results are very encouraging.