Primary cardiac leiomyosarcoma is not common but is lethal. Prompt surgery is mandatory for identifying the etiology while a comprehensive examination of pathology is crucial especially in the condition of two tumors with different etiologies. A 52-year-old man with medical history of systemic hypertension presented with chest discomfort and dyspnea. Echocardiography revealed the dilated right ventricle with a mass at right ventricular outlet tract (RVOT) (Figure 1A). It caused critical obstruction and resulted in severely pulmonary hypertension (estimated pulmonary systolic pressure up to 108mmHg). Cardiac magnetic resonance imaging confirmed a heterogeneous mass at RVOT with a high-intensity in T2 weighted image but failed to differentiate whether it is myxoma, metastasis or primary cardiac malignancy (Figure 1B). Given the exacerbating dyspnea, he received a prompt surgery which identified two tumors. One in the size of 9*4 cm originated from the RV dome extending to RVOT and pulmonary artery. The other smaller one (5*3 cm) mainly located within the RV (Figure 1C). The surgeon excised the smaller one for the frozen section while the immediate pathology reported that it was a benign lesion. Both tumors were removed. Surprisingly, post the operation the final pathology revealed that despite one tumor of benign degenerative tissues, the other of rare cardiac leiomyosarcoma at T1 stage. Immunohistochemical staining showed positive for smooth muscle actin and h-Caldesmon which is specific for leiomyosarcoma (Figure 1D). The patient subsequently received chemotherapies of Doxorubicin 75mg/m2 for 4 cycles.
Anomalous origin of the left circumflex artery (LCA) arising from the right coronary sinus was observed in a 45 year-old man with aortic root aneurysm. Valve-sparing aortic root replacement (VSARR) was decided despite the subannular course of the LCA. A modified Tirone David procedure was performed with specific consideration for distribution of the proximal suture line due to the peri-aortic and subannular course of the LCA. Due to the risk of LCA injury, a coronary artery bypass grafting was performed using the left internal thoracic artery to secure the perfusion of the LCA. The challenging association of aortic root aneurysm and anomalous origin and course of the LCA was managed successfully during VSARR.
On March 11, 2020, the World Health Organization (WHO) declared the SARS-CoV-2 outbreak a pandemic: it took a toll of more than 300.000 deaths and more than 4.5 million cases, worldwide. The initial data pointed out the tight bond between cardiovascular diseases and worse outcomes in COVID19-patients. Epidemiologically speaking, there is an overlap between the age-groups more affected by COVID-related death and the age-groups in which Cardiac Surgery has its usual base of patients. The Cardiac Surgery Departments have to think to a new normal: since the virus will remain endemic in the society, dedicated pathways or even dedicated Teams are pivotal to treat safely the patients, in respect of the safety of the health care workers. Moreover, we need a keen eye on deciding which pathologies have to be treated with priority: Coronary Artery Disease (CAD) showed a higher mortality rate in patients affected by COVID19, but it’s however reasonable to think that all the cardiac pathologies affecting the lung circulation - such as symptomatic severe mitral diseases or aortic stenosis - might deserve a priority access to treatment, in order to increase the survival rate in case of an acquired-Coronavirus infection later on.
This is a response to the Letter to Editor received regarding the article “The effect of patient obesity on extracorporeal membrane oxygenator outcomes and ventilator dependency.” We aim to address the authors’ comments regarding the relationship between BMI and survival after venoarterial extracorporeal membrane oxygenation (VA-ECMO).
The authors share their experience of managing the cardiac surgery services across London during the challenging Covid-19 pandemic. The Pan London Emergency Cardiac Surgery Service model could serve as a blueprint to design policies applicable to other surgical specialities and parts of the UK and worldwide.
Colonoscopy is generally considered a safe procedure, with a low rate of complications. Although rare, the migration of the colonoscope may represents a life-threating events, requiring emergency treatment. We herein describe the case of an elective colonoscopy complicated by an irretrievable colonoscope that migrated, through a previous traumatic diaphragmatic hernia, in the chest cavity. This hernia was likely a chronic complication of a previous abdominal trauma. Several attempts to retrieve the scope were unsuccessful. After further investigations and collegial discussion, a left thoracotomy was performed, with the aim to retrieve the colonoscope and to reduce the hernia.
The Coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is overwhelming healthcare resources and infrastructure worldwide. Cardiac surgical operating capacity during the COVID-19 pandemic is dramatically lower due to postponement or cancellation of elective or semi-urgent procedures. Earlier reports have demonstrated complicated post-operative courses and high fatality rates in patients undergoing emergent cardiothoracic surgery who were diagnosed post-operatively with COVID-19. These reports raise the possibility that active COVID-19 might precipitate a catastrophic pathophysiogical response to infection in the post-operative period and lead to unfavorable surgical outcomes. Hence, it is imperative to screen patients with SARS-CoV-2 infection prior to surgery and to carefully monitor them in the post-operative period to identify any early signs of active COVID-19. In this report, we present the successful outcome of coronary artery bypass grafting (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection presenting with an acute coronary syndrome and requiring urgent surgical intervention. We employed a meticulous strategy to identify subclinical COVID-19 disease, and after confirming the absence of active disease, proceeded with the CABG operation. The patient outcome was successful with the absence of any overt COVID-19 manifestations in the post-operative period.
Large osteochondroma arising from chest wall and sternum is uncommon and presentation with airway compression is further uncommon. Here we present a case of large chest wall osteochondroma as a part of Hereditary multiple exostoses in a 9 years old boy presented with a history of stridor and shortness of breath. The bony mass of the right chest wall was extending up to a suprasternal notch and compressing the trachea. The case was successfully managed by initial femoro-femoral cardiopulmonary bypass under local anesthesia prior to the induction of anesthesia to prevent respiratory collapse, followed by debulking surgery was done.
Iatrogenic aortocoronary dissection is a rare but potentially fatal complication of coronary catheterizations. Although the incidence is comparatively low, dissection often leads to procedure failure with increased risk of myocardial infarction and death. Iatrogenic aortocoronary dissection is principally caused by disruption of intima at the ostia of the right or left coronary artery during interventional procedures and appears as luminal filling defects, the persistence of contrast or intimal tear outside the coronary lumen. Dissection could propagate in the anterograde direction causing subtotal or total occlusion of the coronary lumen or extend in the retrograde direction into the sinus of Valsalva, ascending aorta, aortic arch or descending aorta resulting in hemodynamic instability. We present a case of Right Coronary Artery dissection leading to Type-A aortic dissection suffered during diagnostic coronary catheterization. This required emergency supracoronary replacement of the ascending aorta with an aortic interposition tube graft and venous grafts to coronary arteries
We report a case of intravenous drug use-associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-weeks gestation. Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement one week later. Both the patient and her infant were successfully managed through the perioperative period.
Stroke is a devastating complication following coronary artery bypass grafting, which thankfully occurs with low incidence. The role of preoperative carotid ultrasound remains unclear. Whilst it is a cheap and reliable way of diagnosing carotid stenosis, it is unclear if and how this knowledge should impact on subsequent patient management. The evidence overall suggests that patients with severe carotid stenosis are likely to have an increased incidence of postoperative stroke -- however, the prevalence of severe carotid stenosis is low, and even in this cohort of patients, the incidence is not particularly high. In screened patients identified to have severe carotid stenosis, there appears to be a generally low appetite for undertaking carotid intervention internationally either prior to or concurrently with the coronary artery bypass grafting. Putting this all together, the widespread screening of asymptomatic patients would appear to not be justified.
Title: Pasteurella Multiocida Infection Resulting in a Descending Thoracic Aorta Mycotic Pseudoaneurysm Objective: Highlight our management of a P. Multiocida infected descending thoracic aorta mycotic pseudoaneurysm Methods: Report a case of canine bite resulting in a P. Multiocida descending thoracic aorta mycotic pseudoaneurysm Results: We present a 61-year-old gentleman who was initially seen in an Emergency Department after a canine bite. He was admitted and treated with a course of IV antibiotics for P. Multiocida bacteremia and discharged. Three weeks post discharge, he continued to feel generalized malaise and work-up was significant for a descending thoracic aorta mycotic pseudoaneurysm. The patient underwent a low left posterior lateral thoracotomy and femoral-femoral cardiopulmonary bypass for complete resection and replacement with a 24 mm GelweaveTM graft (Terumo Cardiovascular Group, Ann Arbor, Michigan). Given purulence and gross infection we planned for a staged approach, with a secondary washout and omental flap for biologic coverage of the graft. The patient did well clinically and was discharged at 14 days to rehabilitation with six-week intravenous course of antibiotics. Conclusions: The patient’s clinical course with subsequent follow-up suggest that complete resection of the mycotic pseudoaneurysm, followed by omental flap coverage is a viable strategy to manage mycotic aortic infections with virulent organisms.
Abstract The posterior rupture of the left ventricle has been a complication recognized since the beginning of mitral valve surgery and, despite advances in cardiac surgery, the outcome of the rupture of the left ventricle has remained tragic. During mitral valve surgery, care must be taken not to traumatize the free wall of the left ventricle. On the other side, septal Myectomy is performed on hypertrophied septums to address the left ventricular outflow tract obstruction. In this article I have presented a theory that could give a part of the explanation of the resistance of the interventricular septum of surgical trauma unlike the ventricular wall.
Heart-Lung transplant (HLT) is a widely accepted modality for certain patients with advanced and refractory cardiopulmonary disease. Some of these patients are critically ill on the transplant waiting list, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be used as a bridge to transplantation. Although the experience with ECMO as a bridge to lung transplant is promising, there is limited evidence to use ECMO as a bridge to HLT. Femoral cannulation remains a concern for ambulation given the risk of bleeding and cannula complications despite studies reporting its safety. We present a case of a 56-year-old male with interstitial lung disease (ILD) and severe secondary pulmonary hypertension, who was successfully bridged to HLT with ambulatory femoral VA-ECMO.
Background: Infective endocarditis (IE) remains an expressive health problem with high morbimortali-ty rates. Despite its importance, epidemiological and microbiological data remain scarce, especially in developing countries. Aim: This study aims to describe IE epidemiological, clinical, and microbiological profile in a tertiary university center in South America, and to identify in-hospital mortality rate and predictors. Methods: Observational, retrospective study of 167 patients, who fulfilled modified Duke’s criteria during a six-year enrollment period, from January 2010 to December 2015. Primary outcome was de-fined as in-hospital mortality analyzed according to treatment received (clinical vs. surgical). Multivari-ate analysis identified mortality predictors. Results: Median age was 60years (Q1-Q3 50-71), and 66% were male. Echocardiogram demonstrated vegetations in 90.4%. An infective agent was identified in 76.6%, being Staphylococcus aureus (19%), Enterococcus (12%), Coagulase-negative staphylococci (10%), and Streptococcus viridans (9.6%) the most prevalent. Overall in-hospital mortality was 41.9%, varying from 49.4% to 34.1%, in clinical and surgical patients, respectively (p=0.047). On multivariate analysis, diabetes mellitus (OR 2.5), previous structural heart disease (OR 3.1), and mitral valve infection (OR 2.1) were all-cause death predictors. Surgical treatment was the only variable related to better outcome (OR 0.45; 95%IC 0.2-0.9). Conclusion: This study presents IE profile and all-cause mortality in a large patient’s cohort, compris-ing a 6-years’ time window, a rare initiative in developing countries. Elderly and male patients predom-inated, while Staphylococcus aureus was the main microbiological agent. Patients conservatively treated presented higher mortality than surgically managed ones. Epidemiological studies from developing countries are essential to increase IE understanding.
We want to thank Dr. Raveenthiran and Dr. Harky for their interest in our paper and in the topic of Marfans in the setting of pregnancy. Certainly, the reduction of adverse outcomes would be improved with early knowledge of Marfans syndrome in the mother which would aid in preparation and clinical consideration during the perioperative period, and, prior to pregnancy.
Infectious complications following left ventricular assist device implantation can carry significant morbidity and mortality. The main tenet of treatment is source control which entails local wound care, intravenous antimicrobial therapy, surgical debridement, and at times, soft tissue flap coverage. The mode of therapy depends on the severity, etiology, and location of infection as well as the clinical status of the patient. We describe a case of a 46 year old male who underwent left ventricular assist device placement complicated by pump thrombosis, recurrent infection, and hardware exposure who was successfully treated with a novel method of staged, soft tissue reconstruction.