We read with great interest the article by Khashkhusha TR et al “ACE inhibitors and COVID-19: We don’t know yet”. The authors discuss whether the use of angiotensin-converting enzyme (ACE) inhibitors (ACEIs) in novel coronavirus disease‐19 (COVID‐19) patients is beneficial or harmful. ACEIs and angiotensin receptor antagonists (ARBs) both upregulate ACE2 levels. We believe that ARBs should be preferred since, unlike ARBs, ACEIs may increase angiotensin II through the chymase pathway. We would like to discuss potential harms ACEI may cause through secondary bradykinin-chymase pathways.
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.
Background Displacement of Impella 5.0 secondary to patient movement or transportation is a well known complication. Typically, repositioning of an Impella across the aortic valve is attempted over a guidewire. We present the first case, to our knowledge, of repositioning a dislodged Impella 5.0 without a guidewire under transesophageal echocardiography (TEE) guidance, by inducing rapid ventricular pacing to cross the aortic valve. Case presentation: A 70-year-old man with low left ventricular ejection fraction underwent off-pump coronary artery bypass grafting (OPCABG). On 2nd postoperative day a low cardiac output state developed with increasing lactate levels and consequently the patient was taken to the cardiac catheterization laboratory for insertion of an Impella 5.0. Suddenly the Impella system failed with a rapid hemodynamic deterioration and it was successfully bedside repositioned inducing rapid ventricular pacing. Conclusions: In case of accidental Impella dislodgement and fast deterioration of patient’s hemodynamic status, rapid pacing may be an option to “open” the aortic valve thus aiding quick replacement of Impella 5.0 through the aortic valve into the left ventricle under TEE guidance.
We present the clinical case of a 60-year-old woman complained of dyspnea on exertion. Echocardiogram showed a giant mass in right ventricle (RV) with obstruction to the outflow tract. Thorax CT confirmed a mass of >60 mm infiltrating RV and causing severe stenosis in pulmonary artery, with severe pericardial effusion. Cardiac surgery was performed for tumor resection and pulmonary root replacement with a biological valved conduit. Histological analysis diagnosed a poorly differentiated large-cell neuroendocrine carcinoma. The patient had no immediate postoperative complications and has completed radiotherapy at 6-month follow-up.
Objectives We aimed to investigate whether uncomplicated type A intramural hematoma (IMHA) patients with type 2 diabetes mellitus (DM) who underwent a “wait-and-watch strategy” and tight glycemic control had similar clinical outcomes as patients without DM who received the same treatment strategy. Methods Between January 2010 and December 2016, uncomplicated IMHA patients with and without diabetes mellitus were included and were propensity score matched to improve balance between the two groups. Cox proportional hazard models were constructed to identify the specific factors associated with aorta-related mortality. The Fine-Gray model for the competing risk analysis was used to estimate the aorta-related and non-aorta-related mortality in different groups during the follow-up period. Results 109 IMHA patients were included in this study, and 66 patients were included after matching. Patients without DM experienced significantly more aorta-related adverse events (51.6% vs 13.3%, P=0.001) and reinterventions than patients in the DM group (29.0% vs 6.7%, P=0.023). Cox regression analysis revealed that a higher matrix metalloproteinase-9 level (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.39-2.09, P<0.001) and larger maximum aortic diameter (HR, 1.41; 95% CI, 1.11-1.80, P=0.005) were associated with higher aorta-related mortality. The competing risk analysis revealed a significantly higher aorta-related mortality during the follow-up period in the no DM group than in the DM group (36.4%; 95% CI, 11.6%-82.3%, P=0.0294). Conclusions Uncomplicated IMHA patients with DM (receiving the “wait-and-watch strategy” and tight glycemic control) may have a lower aorta-related mortality, and rates of aorta-related adverse events and reinterventions than the no DM group.
In recent years, the use of bioprosthetic valve (BPV) has increased significantly with both surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) due to reasons such as the advantage of not using anticoagulants. Nevertheless major disadvantage of all BPV is the risk of early structural valve deterioration, leading to valve dysfunction, and requires reoperation, which significantly increases the risk of mortality or major morbidity especially after SAVR. There are a limited number of TAV-in-TAV case reports due to TAVI BPV degeneration. In our knowledge this is the second report of TAV-in-TAV implantation wherein a previously implanted transfemoral 25-mm nonmetallic Direct Flow SVD valve treated with ViV TAVI via Edwards Sapien XT.
Background Fractional flow reserve (FFR) is a well-established method for the evaluation of coronary artery stenosis before PCI. However, whether FFR assessment should be routinely used before CABG remains unclear. Our aim was to compare the outcomes of using FFR with that of conventional CAG (coronary angiography) in guiding CABG. Method This systematic review and meta-analysis was performed according to the PRISMA guidelines. Six studies were included, of which four were double-arm (two prospectively randomised) and two single-arm, reporting data on 1931 patients. A meta-analysis was done for double-arm studies, comparing rates of overall death, MACCE, target vessel revascularisation, spontaneous MI and graft patency. The data of all six studies were entered in a pooled analysis for the endpoints of overall death, spontaneous MI and target vessel revascularisation. Results Meta-analysis demonstrated significantly lower death rates in the FFR-guided than the CAG-guided group (p=0.03) and no significant differences in the rates of MACCE, target vessel revascularisation, spontaneous MI and graft patency. In pooled analysis, FFR-guided group was linked with lower rates of overall death and spontaneous MI. Graft occlusion rate was significantly lower after FFR in one retrospective study, however, this difference was lost in meta-analysis (p=0.24). Conclusion In this meta-analysis, FFR-guided CABG was associated with lower overall death rate and was, at least, non-inferior in the endpoints of MACCE, target vessel revascularisation, spontaneous MI and graft patency than CAG-guided CABG. Further randomized trials are needed to define the role of FFR in guiding CABG surgery.
During the COVID-19 pandemic, ER 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 COVID-19 pandemic. What would have been a standard STEMI treated with timely and successful stenting of a dominant right coronary artery occlusion, became a much more dangerous post-infarction VSD; all because of a 2-day delay in seeking medical attention by an unsuspecting patient.
Objectives: To elucidate the impact of regulation of tricuspid regurgitation (TR) using tricuspid annuloplasty on postoperative changes in right ventricular (RV) systolic and diastolic functions. Methods: We enrolled 69 patients who underwent aortic or mitral valve surgery between July 2016 to March 2018 without recurrence. Patients with concomitant coronary artery bypass grafting or a history of previous cardiovascular surgery were excluded, remaining 45 patients enrolled. Patients were divided into 2 groups according to concomitant tricuspid annuloplasty (T: n=12 vs non-T: n=33). RV global longitudinal strain (RVGLS), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) and early tricuspid inflow velocity/early diastolic tricuspid annular velocity ratio (tricuspid E/e’) were assessed as functional indices at preoperative, postoperative and 1-year follow-up periods. Results: RVFAC deteriorated postoperatively but recovered at follow-up in group T, whereas that in group non-T showed gradual deterioration overtime. RVGLS and TAPSE showed similar temporary deterioration and recovery between groups. Tricuspid E in group T increased postoperatively and showed significant difference, which was kept until follow-up period. Tricuspid e’ decreased postoperatively, and recovered slightly in both groups. As a result, postoperative RV diastolic function (tricuspid E/e’) showed significant difference between groups. This difference was maintained until follow-up. Conclusions: RV systolic function deteriorated postoperatively, but there was a tendency to improve at follow-up regardless of tricuspid annuloplasty. RV diastolic function may potentially be impaired when TR was regulated by tricuspid annuloplasty.
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.
Introduction: In adult congenital patients with transposition of the great arteries originally treated with the Mustard (atrial switch) procedure, the most common reason for re-intervention is baffle stenosis. This may be exacerbated by permanent transvenous pacemaker lead placement across the baffle. Case Report: A 47-year-old female status post Mustard procedure performed at 15 months old presented with a high-grade stenosis of the superior vena cava (SVC) baffle from the SVC to the left atrium, with a nonfunctional permanent pacemaker lead passing through the baffle. A mechanical rotating dilator sheath was used for attempted lead extraction, relieving the baffle stenosis almost completely as a secondary effect, prior to the placement of a 10 x 27 mm Visipro balloon expandable stent in the SVC baffle. Conclusions: Use of the mechanical rotating dilator sheath is an evolving treatment strategy in adult congenital heart disease to minimize the risk of bleeding, trauma to surrounding structures, and death. Its ability to fully alleviate baffle stenosis even when full lead extraction is not feasible or is associated with significant procedural risk further demonstrates its expanded role in this patient population. A multidisciplinary approach and great diligence must be employed to avoid potential complications.
Although a Kommerell diverticulum (KD) and aberrant subclavian artery (ASA) are a common congenital anomaly, a KD and ASA with two thoracic aortic aneurysms are rarely reported. We describe a case of a KD with a right ASA and two thoracic saccular aortic aneurysms, which were treated with a total arch replacement, frozen elephant trunk technique, and thoracic endovascular aortic repair.
Background. Unroofed coronary sinus syndrome (UCSS) is rare and often associated with Left superior vena cava (LSVC). We report our experience in 159 patients with UCSS during a 20-year period in terms of clinical features, diagnosis, associated anomalies, surgical procedures and late outcomes. Methods. Between May 1998 and May 2019, 159 patients with UCSS were treated surgically and followed up. UCSS was confirmed by preoperative echocardiography or CT scan in 97 patients and by the surgeons during surgery in 62. LSVC directly drained into the left atrium (LA) was found in 100 cases. In these patients, 8 cases of LSVC were ligated, 59 cases were reconstructed the intracardiac tunnel to drain LSVC to right atrium (RA), and the extracardiac procedure was constructed to lead the LSVC draining to RA in 2. The associated cardiac lesions were corrected concomitantly. Results There were 5 hospital deaths. We followed up 143 early survivors, and there was no death. Except for one case of avulsion of the patch in which LSVC was drained by internal tunnel, there were no serious complications in other follow-up patients. Conclusion. UCSS is often misdiagnosed in the preoperative evaluation of congenital heart diseases. Preoperative transthoracic echocardiography (TTE) is still the most important method in the diagnosis of UCSS. When associated with LSVC, UCSS should be considered as a possible additional finding．We performed different surgical approaches to deal with the different types of UCSS with LSVC with a good result.
We report herein successful treatment of a case of acute type A aortic dissection complicated by cardiac tamponade and mesenteric malperfusion. The patient was a 60-year-old man, with back and abdominal pain and in shock, who was transported to our hospital 2 hours after symptom onset. Computed tomography revealed DeBakey type I dissection with massive hemopericardium and obstruction of both the celiac artery and superior mesenteric artery. After emergency pericardiotomy and removal of the hematoma, superior mesenteric artery-external iliac artery bypass was constructed with a vein graft, and this restored mesenteric perfusion. Open distal hemiarch replacement was then performed. The postoperative course was uneventful. Superior mesenteric artery revascularization achieved immediately after release of the cardiac tamponade prevented further mesenteric ischemia and paved the way for the aortic repair.
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.
Patient selection and cannulation arguably represent the key steps for the successful implementation of Extracorporeal Membrane Oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real-time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients’ critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite. Therefore, with the objective of avoiding delay with initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation. In the current pandemic, this strategy may have additional benefits for the care of patients with refractory acute respiratory distress syndrome (ARDS) due to COVID-19 decreasing risk of healthcare worker or other patients exposure to the novel SARS-CoV-2 virus occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation.
Congenital superior vena cava (SVC) stenosis is a very rare anomaly especially in pediatric population. Co-existence with obstructed supracardiac total anomalous pulmonary venous connection (TAPVC) has never been reported. Clinical examination should prompt detailed and focused evaluation for this treatable etiology. SVC stenosis, although causing SVC syndrome, may decrease the severity of pulmonary venous hypertension by limiting the amount of blood in obstructed common chamber. Pericardial patch augmentation can cure SVC stenosis, and may allow for growth potential as well. We describe a case of congenital SVC stenosis in a case of obstructed supra-cardiac TAPVC in a 3 month old infant, managed successfully.