Protamine Induced Anaphylactic Shock after Peripheral Vascular Surgery.

Anaphylactic reactions to protamine are quite rare and almost exclusively reported during cardiac surgery. In this report, we illustrate a rare case of protamine reaction after peripheral vascular surgery a couple of months after cardiac surgery and how the patient survived this critical complication.

Endovascular treatment of atherosclerotic lesions in the superficial femoral artery and proximal popliteal artery using the sinus-SuperFlex-635 stent: twelve-month results from the HERO Registry.

BACKGROUND: The aim of this study was to evaluate the safety and performance of the sinus-SuperFlex-635 self-expandable nitinol stent (Optimed GmbH) for the treatment of steno-occlusive lesions in the superficial femoral artery (SFA) and proximal popliteal artery (PPA). METHODS: The prospective, multicenter, observational HERO study recruited 117 eligible patients (83 men; mean age 69.4±9.7y) from 7 centers in Belgium. RESULTS: A total of 129 stents were successfully deployed in 121 lesions in 117 patients (100%). The patients presented with symptomatic ≥50% stenosis or chronic total occlusion (CTO) (30.6%). Mean lesion length was 71.4±56.3 mm. Moderate to severe calcification was present in 82.6% of the lesions. Acute lesion success (<30% residual stenosis) was achieved in 96.0%. There were no in-hospital serious adverse events. Duplex ultrasound-driven primary patency at 12 months was recorded in 84 of 107 (78.5%) lesions. The overall target lesion revascularization (TLR) rate was 8.4% at 12 months; the target extremity revascularization (TER) rate was 4.7%. Clinical assessment at 12 months demonstrated improvement by at least 1 Rutherford class, without the need for TLR (i.e. primary sustained clinical improvement) in 83.9% of patients and with the need for TLR in 90.6% of patients (i.e. secondary sustained clinical improvement). CONCLUSIONS: Based on the high primary patency, low stent fracture rate and significant clinical improvement, combined with refined stent design and long stent availability, the sinus-SuperFlex-635 self-expandable nitinol stent proves its value in the treatment of complex femoropopliteal lesions.

From Bone Marrow to Cardiac Atrial Appendage Stem Cells for Cardiac Repair: A Review.

Traditionally the heart is considered a terminally differentiated organ. However, at the beginning of this century increased mitotic activity was reported in ischemic and idiopathic dilated cardiomyopathy hearts, compared to healthy controls, underscoring the potential of regeneration after injury. Due to the presence of adult stem cells in bone marrow and their purported ability to differentiate into other cell lineages, this cell population was soon estimated to be the most suited candidate for cardiac regeneration. Clinical trials with autologous bone marrow-derived mononuclear cells, using either an intracoronary or direct intramyocardial injection approach consistently showed only minor improvement in global left ventricular ejection fraction. This was explained by their limited cardiomyogenic differentiation potential. To obtain more convincing improvement in cardiac function, based on true myocardial regeneration, the focus of research has shifted towards resident cardiac progenitor cells. Several isolation procedures have been described: the c-kit surface marker was the first to be used, however experimental research has clearly shown that c-kit+ cells only marginally contribute to regeneration post myocardial infarction. Sphere formation was used to isolate the so-called cardiosphere derived cells (CDC), and also in this cell population cardiomyogenic differentiation is a rare event. Recently a new type of stem cells derived from atrial tissue (cardiac atrial stem cells - CASCs) was identified, based on the presence of the enzyme aldehyde dehydrogenase (ALDH). Those cells significantly improve both regional and global LV ejection fraction, based on substantial engraftment and consistent differentiation into mature cardiomyocytes (98%).

Midterm follow-up after off-pump versus on-pump coronary artery bypass grafting. Results from a case-matched study.

OBJECTIVE: Early survival in off-pump coronary artery bypass (OPCAB) patients is reported to be as good as that of conventional coronary artery bypass grafting (CABG). However, it remains unknown whether midterm cardiac outcome after off-pump surgery is similar to that for the on-pump procedure. METHODS AND RESULTS: One hundred OPCAB patients (67.8 (9.3) y) were compared to a case-matched contemporary group of CABG patients (69.4 (8.8) y). In-hospital and midterm outcome data are presented. Follow-up was 100% complete. The mean number of distal anastomoses per patient was 1.9 (0.8) and 2.4 (1.0) in the OPCAB and CABG group, respectively. Grafting according to treatment plan was 100% in both groups. Peak creatine kinase muscle-brain and cardiac troponin I (cTnI) release were similar in the overall groups, but the cTnI release in the 25 most recently operated patients was significantly lower in the OPCAB group (4.8 (9.1) ng/ml vs. 14.0 (20.5) ng/ml, p = 0.04). Duration of mechanical ventilation, ICU stay and hospital stay were shorter in the OPCAB group. The incidence of atrial fibrillation was similar. There were no differences in in-hospital complications. The actuarial survival at 1, 3 and 5 years was 88% (C.I. 81.6 to 94.3), 78% (C.I. 66.1 to 90.2) and 78% (C.I. 66.1 to 90.2) in the OPCAB and 90% (C.I. 84.0 to 95.9), 84% (C.I. 74.6 to 92.5) and 68% (C.I. 44.7 to 90.6) in the CABG group (log rank p-value = 0.96). Event-free survival at 1, 3, 5 years was 85% (C.I. 77.8 to 91.9), 71 % (C.I. 57.4 to 84.2) and 71 % (C.I. 57.4 to 84.2) in the OPCAB and 85% (C.I. 77.8 to 91.9), 72% (C.I. 61.1 to 82.7) and 58% (C.I. 37.2 to 78.8) in the CABG group (log rank p-value = 0.63). Recurrence of angina (3%) and need for reintervention (2%) in the OPCAB group were low. CONCLUSIONS: OPCAB surgery is a safe and reproducible technique, yielding short-and midterm outcomes comparable to conventional CABG.

Acute thrombosis of an abdominal aortic aneurysm following intra-aortic balloon pumping.

Acute thrombosis of an abdominal aortic aneurysm is a rare but devastating surgical emergency. We present the first case of a patient with sudden thrombosis of an AAA delayed (more than 24 h) after removal of an intra-aortic balloon pump. Treatment options include open surgical repair, axillobifemoral grafting or endovascular aortic repair. The patient received an aorto-bifemoral graft. The associations between intra-aortic balloon pump counter-pulsation and abdominal aortic thrombosis are discussed.

Penetrating pediatric cardiac trauma caused by fall on a pencil with normal echocardiography.

A toddler, age 2, presented with a penetrating cardiac trauma caused by a fall on a pencil. This case showed a normal echocardiography. However, during removal of the pencil, signs of cardiac tamponade were noticeable. Thus, a normal echocardiography is no guarantee to exclude a possible penetrating cardiac injury.