Using tissue mitral valves in younger patients: A word of caution.

BACKGROUND: The debate about the optimal mitral valve prosthesis continues. We aimed to compare the early and late outcomes, including stroke, bleeding, survival, and reoperation after isolated mitral valve replacement (MVR) using tissue versus mechanical valves. METHODS: This retrospective cohort study included 291 patients who had isolated MVR from 2005 to 2015. Patients were grouped into the tissue valve group (n = 140) and the mechanical valve group (n = 151). RESULTS: There were no differences in duration of mechanical ventilation, hospital stay, and hospital mortality between groups. Fifteen patients required cardiac rehospitalization, nine in the tissue valve group, and six in the mechanical valve group (p = .44). Stroke occurred in nine patients, five with tissue valves, and four with mechanical valves (p = .66). Bleeding occurred in 22 patients, seven patients with tissue valves, and 15 patients with mechanical valves (p = .09). Freedom from reoperation was 95%, 93%, 84%, 67% at 3, 5, 7, and 10 years for tissue valve and 97%, 96%, 96%, and 93% for mechanical valves, respectively (p˂ .001). The median follow-up was 84 months (Q1: Q3: 38-139). Survival at 3, 5, 7, and 10 years was 94%, 91%, 89%, 86% in tissue valves and 96%, 93%, 91%, 91% in mechanical valves, respectively (p = .49). CONCLUSIONS: Tissue valve degeneration is still an issue even in the new generations of mitral tissue valves. The significant risk of reoperation in patients with mitral tissue valves should be considered when using those valves in younger patients. Mechanical valves remain a valid option for all age groups.

Penetrating chest injury afflicting coronary artery fistula-A delayed and asymptomatic occurrence.

We present here a case of a symptomatic chest injury with a nail gun causing a delayed occurrence of coronary artery fistula to the left pulmonary artery presenting with unstable angina 4 years after the initial injury, three of which were symptom-free. The patient underwent successful surgical closure of the fistula and removal of the foreign body.

Population Pharmacokinetic Model for Vancomycin Used in Open Heart Surgery: Model-Based Evaluation of Standard Dosing Regimens.

The purpose of this study was to investigate the population pharmacokinetics of vancomycin in patients undergoing open heart surgery. In this observational pharmacokinetic study, multiple blood samples were drawn over a 48-h period of intravenous vancomycin in patients who were undergoing open heart surgery. Blood samples were analyzed using an Architect i4000SR immunoassay analyzer. Population pharmacokinetic models were developed using Monolix 4.4 software. Pharmacokinetic-pharmacodynamic (PK-PD) simulations were performed to explore the ability of different dosage regimens to achieve the pharmacodynamic targets. A total of 168 blood samples were analyzed from 28 patients. The pharmacokinetics of vancomycin are best described by a two-compartment model with between-subject variability in clearance (CL), the volume of distribution of the central compartment (V1), and volume of distribution of the peripheral compartment (V2). The CL and the V1 of vancomycin were related to creatinine CL (CLCR), body weight, and albumin concentration. Dosing simulations showed that standard dosing regimens of 1 and 1.5 g failed to achieve the PK-PD target of AUC0-24/MIC > 400 for an MIC of 1 mg/liter, while high weight-based dosing regimens were able to achieve the PK-PD target. In summary, the administration of standard doses of 1 and 1.5 g of vancomycin two times daily provided inadequate antibiotic prophylaxis in patients undergoing open heart surgery. The same findings were obtained when 15- and 20-mg/kg doses of vancomycin were administered. Achieving the PK-PD target required higher doses (25 and 30 mg/kg) of vancomycin.

Population Pharmacokinetic Model-Based Evaluation of Standard Dosing Regimens for Cefuroxime Used in Coronary Artery Bypass Graft Surgery with Cardiopulmonary Bypass.

The purpose of this study was to investigate the population pharmacokinetics (PK) of cefuroxime in patients undergoing coronary artery bypass graft (CABG) surgery. In this observational pharmacokinetic study, multiple blood samples were collected over a 48-h interval of intravenous cefuroxime administration. The samples were analyzed by using a validated high-performance liquid chromatography (HPLC) method. Population pharmacokinetic models were developed using Monolix (version 4.4) software. Pharmacokinetic-pharmacodynamic (PD) simulations were performed to explore the ability of different dosage regimens to achieve the pharmacodynamic targets. A total of 468 blood samples from 78 patients were analyzed. The PK for cefuroxime were best described by a two-compartment model with between-subject variability on clearance, the volume of distribution of the central compartment, and the volume of distribution of the peripheral compartment. The clearance of cefuroxime was related to creatinine clearance (CLCR). Dosing simulations showed that standard dosing regimens of 1.5 g could achieve the PK-PD target of the percentage of the time that the free concentration is maintained above the MIC during a dosing interval (fTMIC) of 65% for an MIC of 8 mg/liter in patients with a CLCR of 30, 60, or 90 ml/min, whereas this dosing regimen failed to achieve the PK-PD target in patients with a CLCR of ≥125 ml/min. In conclusion, administration of standard doses of 1.5 g three times daily provided adequate antibiotic prophylaxis in patients undergoing CABG surgery. Lower doses failed to achieve the PK-PD target. Patients with high CLCR values required either higher doses or shorter intervals of cefuroxime dosing. On the other hand, lower doses (1 g three times daily) produced adequate target attainment for patients with low CLCR values (≤30 ml/min).

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery.

OBJECTIVES: The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery. DESIGN: Prospective observational study. SETTING: Tertiary university hospital. PARTICIPANTS: The study comprised 51 patients aged 18 years or older presenting for cardiac surgery. INTERVENTIONS: Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points. MEASUREMENTS AND MAIN RESULTS: Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01). CONCLUSIONS: Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

Thrombocytopenia associated with Perceval sutureless aortic valve replacement in elderly patients: a word of caution.

OBJECTIVE: The aim of this study was to report for the first time the phenomenon of thrombocytopenia associated with the use of sutureless aortic valve replacements (AVR), and try to find an explanation for its occurrence. METHODS: The data was collected retrospectively for all patients who had sutureless AVR (7 patients) and was compared to patients who underwent sutured AVR (22 patients) by the same surgeon between February 2012 and November 2013.  RESULTS: Cardiopulmonary bypass and cross-clamp durations were shorter in the sutureless group (96.4 min, 70.6 min) compared to the sutured group (128.3 min, 97.3 min), (P = .04, P = .003) respectively. Mean transvalvular gradients were lower in the sutureless group (mean = 9.6 mmHg) compared to the sutured group (mean = 17.3 mmHg). Platelet levels were significantly lower in the Perceval patients compared to the Enable patients and sutured valves. Platelet transfusion was higher for sutureless valves (6.5 units versus 5.4 units for the sutured group, P = .63), especially the Perceval valve (7.6 units versus 5.3 for the Enable valve, P = .35), but was not statistically significant. Packed red blood cells (PRBCs) transfusion was significantly higher in the sutureless group (6 units versus 3.1 for the sutured group, P = .002).  CONCLUSION: The implantation of sutureless aortic valves, especially the Perceval valve, was associated with a significant drop in platelet count postoperatively with slow recovery and higher PRBCs transfusion requirements. Extreme caution should be taken before the routine use of these valves in elderly patients who are already at risk of thrombocytopenia postoperatively.

Should routine pulmonary function tests be performed in patients with left ventricular dysfunction and/or congestive heart failure undergoing cardiac surgery?

BACKGROUND: It is controversial whether pulmonary function testing should be performed routinely in cardiac surgery patients. The aim of our study was to focus on patients who have congestive heart failure, caused by left ventricular dysfunction or left-sided heart valve disease, and study the prognostic value of performing preoperative pulmonary function testing on their postoperative outcomes. METHODS: This is a retrospective propensity score matched study that included 366 patients with congestive heart failure who underwent cardiac surgery and had preoperative pulmonary function test. The patients were divided into two groups: Group 1 who had a normal or mild reduction in pulmonary function tests and group 2 who had moderate to severe reduction in pulmonary function tests. The postoperative outcomes, including pulmonary complications, were compared between the two groups. RESULTS: Pulmonary function tests were normal or mildly reduced in 190 patients (group 1) and moderately to severely reduced in 176 patients (group 2). Propensity matching identified 111 matched pairs in each group with balanced preoperative and operative characteristics. Compared to group 1, Group 2 had longer duration of mechanical ventilation [12 (7.5-16) vs. 9 (6.5-13) hours, p < 0.001], higher postoperative Creatinine [111 (90-142) vs. 105 (81-128) µmol/dl, p = 0.02] and higher hospital mortality (6.31% vs. 0%, p = 0.02). CONCLUSION: Routine Pulmonary Function Testing should be performed in patients with Left ventricular dysfunction and/or congestive heart failure undergoing cardiac surgery since moderate to severe reduction in those patients was associated with longer duration of mechanical ventilation and higher hospital mortality.

Saudi Heart Association/National Heart Center/Saudi Arabian Cardiac Interventional Society/Saudi Society for Cardiac Surgeons/Saudi Cardiac Imaging Group 2023 TAVI Guidelines.

Saudi Arabia has seen a significant improvement in its healthcare system over the past four decades resulting in an increase in life-expectancy. Transcatheter aortic valve implantation (TAVI) has spread widely in Saudi Arabia and has become a routine procedure in many centers. The expanding clinical indications and the availability of the technology have made it possible for many large and intermediate centers all over the country to commence their own TAVI programs. So, the aim of this document is to standardize TAVI practices in different Saudi Arabian centers through reasonable guidelines based on the evaluation and summarization of the best available evidence. The review committee, composed of different experts in several aspects of the management of patient undergoing TAVI, based their recommendations on the reviewed and analyzed evidence and the class and level of recommendations were discussed until a consensus was reached by the panel.

Bentall procedure for an adult patient with supravalvular aortic stenosis and coronary aneurysms.

We describe the surgical management of a 35-year-old male with multiple coronary aneurysms and a diffuse form of supravalvular aortic stenosis who presented with acute myocardial infarction and left ventricular dysfunction. The patient underwent a Bentall procedure with left internal mammary artery to left anterior descending artery bypass grafting with the use of cardiopulmonary bypass utilizing the right axillary artery for arterial cannulation.

Mechanical Tricuspid Valves Have Higher Rate of Reintervention: A Single Center Experience.

PURPOSE: We compared the composite outcome of tricuspid valve (TV) reintervention or heart failure (HF) admission in patients who underwent tricuspid valve replacement (TVR) with tissue vs. mechanical valves. PATIENTS AND METHODS: The study included 159 patients who underwent TVR from 2009 to 2019. We grouped the patients according to the valve's type into tissue valve group (n = 139) and mechanical valve group (n = 20). RESULTS: The mean age of patients was 52.4 ± 12.8 years, and 117 patients were females (73.6%). Hospital mortality occurred in 20 patients (12.6%); all of them were in the tissue valve group. The composite outcome of reintervention and HF readmission occurred in 8 patients with mechanical valves (40%) vs. 24 patients with tissue valves (17.3%), (P = 0.018). Predictors of reintervention and HF admission were female (subdistributional hazard ratio [SHR]: 1.38-34.3, P = 0.019), stroke (SHR: 1.25-8.76, P = 0.016), hypertension (SHR: 1.13-5.36, P = 0.024), and mechanical valves (SHR: 1.6-10.7, P = 0.003). In post hoc analysis, the difference in the composite outcome was derived from the difference in the reintervention rate that was higher in mechanical valves. Survival did not differ significantly between groups (P = 0.12). CONCLUSION: Mechanical TVs have a higher rate of composite outcome of reintervention or HF readmission than tissue TVs that are related mainly to higher rate of reintervention.

Does preoperative screening with computed tomography of the chest decrease risk of stroke in patients undergoing coronary artery bypass grafting.

Background: Stroke is one of the most feared complications post coronary artery bypass with aortic calcifications being the commonest source of embolic stroke. The aim of our study was to determine the clinical impact and usefulness of routine use of plain chest computerised tomography to screen for aortic calcification on incidence of postoperative stroke in coronary artery bypass grafting (CABG) patients. Methods: This is a retrospective case-control study that included four hundred and five patients who underwent primary isolated CABG and had preoperative plain chest computerised tomography as a screening for aortic calcification. Aortic calcification was classified according to the area involved (ascending, arch, arch vessels and descending aorta) and the pattern of calcification. Patients were divided into two groups according to the incidence of postoperative stroke and the aortic calcification distribution was compared between the two groups. Stroke predictors were studies using univariate and multivariate regression analysis. Results: Fourteen patients (3.5%) developed postoperative stroke. There was no difference in preoperative and operative characteristics between patients who developed postoperative stroke and those who did not, except for the history of preoperative stroke or transient ischemic attack (TIA) that was higher in the group who developed postoperative stroke (50.00% vs. 6.19%, P<0.001). Patients who developed postoperative stroke had higher percentage of aortic root calcification (78.57% vs. 64.18%), ascending aortic calcification (28.57% vs. 19.07%) and descending aortic calcification (85.71% vs. 73.71%) but none of them reached statistical significance. History of preoperative stroke or TIA was the only significant predictor of postoperative stroke using both univariate and multivariate regression models. Conclusions: Our study showed the importance of preoperative computed tomography (CT) scan of the chest as a screening tool as it detected a high prevalence of aortic calcification in our patients. However, its impact on prevention of postoperative stroke needs to be investigated further in future prospective studies.

Hybrid Thoracic Aortic Repair and Aortic Valve-In-Valve Replacement for Chronic Type A Dissection.

We describe a case of hybrid total thoracic aortic repair and valve-in-valve transcatheter aortic valve replacement in a high-risk patient with complicated chronic type A dissection and severe prosthetic aortic stenosis. The patient underwent a three-stage-procedure including aortic arch debranching, thoracic endovascular aortic repair of the ascending aorta, aortic arch and descending thoracic aorta, and direct aortic valve-in-valve replacement using transcatheter heart valve. The details of the procedures are described with a discussion of the challenges and the decision-making process.

Surgical management of right aortic arch with tailored surgical approach.

BACKGROUND AND AIM OF STUDY: Right-sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques. METHODS: We retrospectively reviewed 17 patients undergoing right-sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach. RESULTS: Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In-hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months. CONCLUSION: The surgical treatment for right-sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention.

Results of Surgical Ablation for Atrial Fibrillation in Patients with Rheumatic Heart Disease.

Background: There is conflicting evidence regarding the success of the Maze procedure to restore sinus rhythm in patients with rheumatic heart disease. Hence, the aim of our study was to describe the results of surgical ablation for atrial fibrillation in patients with rheumatic heart disease undergoing cardiac surgery. Methods: This is a retrospective study that included adult patients with rheumatic heart disease who underwent surgical ablation for atrial fibrillation. The ablation lesions were performed using monopolar radiofrequency ablation in all patients. Results: Fifty-seven consecutive patients were included in the study. Cox Maze IV was performed in 44 patients (77%), while left-sided surgical ablation was performed in 10 patients (17%) and pulmonary vein isolation in 3 patients (5%). The percentage of patients who were in sinus rhythm on discharge, at 1-month, at 3-months, 6-months and 12-months follow up were 56%, 54%, 52%, 56% and 46% respectively. Complete heart block occurred in 21 patients (44%), but only 15 of them (26%) required permanent pacemaker insertion. Freedom from composite endpoint of death, stroke, and readmission for heart failure was 78% at one-year follow up. Conclusion: Despite the suboptimal rates of sinus rhythm at the intermediate and long term follow up, surgical ablation of atrial fibrillation in patients with rheumatic heart disease should continue to be performed. Continuation of Class III antiarrhythmic medications and early intervention for recurrent atrial fibrillation is crucial to the success of this procedure and for maintenance of higher rates of sinus rhythm at intermediate and long-term follow up.

Budget impact analysis of a bioprosthetic valve with a novel tissue versus mechanical aortic valve replacement in patients older than 65 years with aortic stenosis in Saudi Arabia.

AIMS: A budget impact analysis (BIA) comparing bioprosthetic valves with RESILIA tissue and mechanical valves in aortic stenosis (AS) patients > 65 years in the public and private sectors of Saudi Arabia. MATERIALS AND METHODS: A decision-tree with a partitioned survival model was adapted to estimate the financial consequences of either a RESILIA tissue valve or a mechanical valve in aortic valve replacement (AVR) procedures up to 5 years. The budget impact of resource consumption for both valve types was compared and included disabling strokes, reoperations, minor thromboembolic events, major bleeding, endocarditis, anticoagulation treatment and monitoring, and echocardiogram assessments. One-way sensitivity analyses (OWSA) were performed on cost and probability inputs. RESULTS: RESILIA tissue valves versus mechanical valves are overall budget saving commencing in Year 1 and savings gradually increase year-on-year. The higher costs of the initial procedure, reoperation, and additional monitoring (echocardiogram tests and visits) associated with RESILIA tissue valves are offset by savings in warfarin use, disabling strokes, major bleeding, and anticoagulation complications. The cost per initial procedure per patient is SAR795 higher for a RESILIA tissue valve reflecting the higher valve acquisition cost, which is partially offset by a shorter hospital stay. The OWSA suggests that total procedure costs of each valve, including the hospital stay, are the main cost drivers in the model. LIMITATIONS: The variability of cost inputs and the presence of multiple payers with multiple costing data is a key challenge in Saudi Arabia. Budget impact results may, therefore, change if repeated per AVR center and may also be impacted by the long-term durability of RESILIA tissue valves. CONCLUSIONS: An AVR in patients > 65 years with a RESILIA tissue valve is budget-saving from the first year in Saudi Arabia. Patients, payers, providers and policymakers may benefit economically from increased implantation of RESILIA tissue valves.

Serum level of prophylactic antibiotics in cardiac surgery and its implication on surgical site infection (SSI).

BACKGROUND: Surgical site infection in cardiac surgery is still common despite applying preoperative antibiotic prophylaxis as per guidelines. Therefore, the aim of our study was to assess the relationship between perioperative antibiotics serum levels and the incidence of surgical site infection. METHODS: This is a prospective study that included all adult patients who underwent elective coronary artery bypass grafting between June and December 2018. The serum antibiotics levels were measured at 4 different time points. The patients were divided into two groups: The group who developed surgical site infection and the group who did not develop surgical site infection. The serum antibiotics levels were compared between the two groups. RESULTS: Eighty-seven consecutive patients were enrolled in the study. The overall rate of infection was 17.95% (14/78 patients). High pre-operative HbA1C levels were associated with a higher rate of SSI (SSI 8.46 ± 2.23 vs no SSI 7.28 ± 1.82, P = 0.04). Patients who developed surgical site infection had longer intervals between administration of prophylactic antibiotics and different parts of the procedure than those who did not develop infection T2 (SSI 3.09 ± 1.12 vs no SSI 2.32 ± 0.98, P = 0.004), T3 (SSI 5.74 ± 1.69 vs no SSI 4.68 ± 1.83, P = 0.024) and T4 (SSI 7.35 ± 1.97 vs no SSI 6.01 ± 2.11, P = 0.015). CONCLUSION: Prolonging different parts of cardiac surgery procedures could lead to higher risk of infection and better timing of intra-operative re-dosing of prophylactic antibiotics could be guided by measuring intra-operative serum concentrations of these antibiotics.

Ischemic cardiomyopathy versus non-ischemic cardiomyopathy in diabetic patients: clinical characteristics, management, and long-term outcomes.

BACKGROUND: Diabetes mellitus causes ischemic heart disease (IHD) through macrovascular or microvascular involvement. Diabetes-associated hypertension, dyslipidemia, and obesity further increase coronary artery disease risk and can cause left ventricular hypertrophy leading to heart failure with preserved ejection fraction independent of IHD. This study was undertaken to evaluate the differences in demographics, clinical characteristics, Echocardiographic parameters, management, and outcomes between non-ischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM) patients in cohort of diabetes patients. METHODS: This retrospective study included diabetes patients with reduced ejection fraction (≤40) who were hospitalized with heart failure between January 2014 and February 2020. Patients were divided into two groups: group 1; ICM and group 2; NICM. Data obtained on above mentioned features including mortality and heart failure readmissions were compared between the two groups. RESULTS: A total of 612 diabetes patients admitted with acute heart failure were screened of which 442 were included. Group 1 (ICM) had 361 patients (81.7%) and group 2 (NICM) had 81 patients (18.3%). Patients in group 1 were older, predominantly males and with higher prevalence of hypertension, smoking and insulin dependent Diabetes while group 2 patients had higher BMI and higher prevalence of cardiac rhythm problems. No significant difference was detected in 5-year-mortality between the two groups (P=0.165). However, heart failure associated hospitalizations were higher in group 2 though it was not statistically significant (P=0.062). CONCLUSION: There was no difference in 5-years mortality between ICM and NICM in diabetes patients. However, NICM patients had higher prevalence of obesity and rhythm problems.

Paramedic Ability in Interpreting Electrocardiogram with ST-segment Elevation Myocardial Infarction (STEMI) in Saudi Arabia.

Objective: To evaluate paramedic ability in recognizing 12-lead Electrocardiogram (ECG) with ST-segment Elevation myocardial infarction (STEMI) in Saudi Arabia. Methods: This is a quantitative exploratory cross-sectional study using an electronic survey of paramedics was conducted between June and September 2021. The survey included demographics, educational and clinical experiences, and multiple 12-lead ECG strip questions to assess participants' ability to recognize STEMI. We reported the overall sensitivity, specificity, and correct proportions with 95% Confidence Intervals (CI). Results: Eighty-four paramedics completed the survey, and 65% of them were between 24 and 29 years old, with a median, of three years of field experience. Overall sensitivity and specificity were 58.39% (95% CI, 50.4% to 66.1%) and 29.01% (95% CI, 25.15% to 33.1%), respectively. In total, 67.1% correctly identified inferior STEMI, whereas only 50% correctly identified lateral STEMI. Both STEMIs were correctly identified by 41%, and the majority misinterpreted STEMI mimics (ECG rhythms with similar ECG morphology to STEMI). The proportion who correctly recognized left bundle branch block was 14.8%, pericarditis was 10.9%, and ventricular pacing was 1.4%. However, almost third of participants correctly identified right bundle branch block (32.9%) and left ventricle hypertrophy (30.7%). Overall, there was no correlation between the correct ECG interpretation of STEMIs and educational and clinical experiences. Conclusion: Paramedics were able to identify STEMI events in prehospital settings with moderate sensitivity and low specificity with limited ability to differentiate between STEMI and STEMI mimics. Therefore, additional training in ECG interpretation could improve their clinical decision-making, and to ensure that proper care and treatment is provided. Further research on a large, representative sample of paramedics across the country could provide more definitive evidence to establish a greater degree of accuracy in detecting STEMI in prehospital settings.

Successful management of a posterior saccular coronary artery aneurysm at the left main coronary artery bifurcation.

Left main coronary artery aneurysm is a rare condition that presents as a potential surgical challenge due to its location. We present a case of successful repair of a posterior saccular aneurysm of the left main coronary artery by aneurysm exclusion, afferent and efferent ligation with coronary artery bypass grafting.

Bartonella infective endocarditis of a prosthetic aortic valve with a subvalvular abscess.

A patient with a prosthetic aortic valve, and culture negative endocarditis caused by Bartonella henselae presented with nonspecific constitutional symptoms, skin rash, and then later developed acute renal failure. The patient underwent redo sternotomy, aortic root, and ascending aorta replacement with a homograft, which resolved his symptoms and the renal failure.