Asian Cardiovascular and Thoracic Annals current issue

[ELECTRONIC CASE STUDIES] Intimal Sarcoma of Aortic Arch Treated with Proton Therapy Following Surgery

Ishigami, Suzuki, Takahashi, Neyatani, Bashar, Kazui — 2008-04-01

Management of a rare case of intimal sarcoma of the aortic arch is reported, which was diagnosed unexpectedly after total arch replacement for pseudoaneurysm. The prognosis for this condition is poor, with death usually within a few months from diagnosis. The newly developed proton-beam radiation therapy was applied to treat a local recurrence of the sarcoma following surgery. Positron-emission tomography/computed tomography revealed complete remission of the lesion.

[ELECTRONIC CASE STUDIES] Mycotic Pseudoaneurysm of the Ascending Aorta at Site of Aortic Cannulation

Gabbieri, Dohmen, Linneweber, Lembcke, von Heymann, Konertz — 2008-04-01

Reoperation for pseudoaneurysm of the ascending aorta presents a surgical challenge. Instituting femorofemoral bypass and establishing hypothermic circulatory arrest is a well-known strategy, although not free from complications. We report a case of mycotic pseudoaneurysm after coronary artery bypass in a 53-year-old man, at the site of previous aortic cannulation, and review the surgical strategies proposed to manage this pathologic entity.

[ELECTRONIC CASE STUDIES] Double Outlet Right Ventricle with Anomalous Left Pulmonary Artery

Bockeria, Makhachev, Sobolev, Plakhova, Gorbachevsky, Zaets — 2008-04-01

We describe a rare case of anomalous origin of the left pulmonary artery from the ascending aorta with concomitant double-outlet right ventricle in a 2-year-old boy. He underwent successful 2-stage surgical treatment with transluminal balloon pulmonary valvuloplasty, followed by complete repair. A follow-up examination at 4 years after the operation showed good results.

[ELECTRONIC CASE STUDIES] Chylous Pericardial Effusion after Aortic Valve Replacement

Chaloob, Brown, Stuklis — 2008-04-01

Chylous pericardial effusion after open-heart surgery is a rare complication. We report a case of chylous pericardial effusion following aortic valve replacement, which presented as cardiac tamponade, and its subsequent management.

[EDITORIAL] From Vision to Mission in Myocardial Restoration

Kofidis, Lee — 2008-04-01

[ORIGINAL CONTRIBUTIONS] Procedural Outcome and Midterm Result of Carotid Stenting in High-Risk Patients

Kojuri, Ostovan, Zamiri, Zolghadr Asli, Bani Hashemi, Borhani Haghighi — 2008-04-01

Carotid endarterectomy is the standard treatment for carotid stenosis, but carotid artery stenting has emerged as a potential alternative. Elective carotid artery stenting was performed in 42 patients aged 42 to 79 years (mean, 67.05 ± 8.67 years) after ultrasonography, computed tomography, magnetic resonance angiography and a neurological evaluation. There was bilateral carotid stenosis in 23 patients (55%), with > 90% stenosis in 18 vessels. All patients had significant associated coronary lesions. An emboli protection device and self-expanding stents were used. One year later, the patients were evaluated by Doppler sonography and selective angiography. Technical success was achieved in all procedures. During follow-up, 1 (2.4%) patient died from myocardial infarction, 1 underwent coronary artery bypass and 14 (40%) had minor complaints including occasional dizziness. No other neurological events were noted. Restenosis was found in one case, but selective angiography ruled out a significant lesion. One patient suffered embolization, but recovered completely within 24 hours. In 7 (17%) patients with type C arch interruption and a tortuous carotid course, stenting was successful and they had no embolization or restenosis. Carotid artery stenting is recommended in high-risk patients.

[ORIGINAL CONTRIBUTIONS] Cardiac Troponin I vs EuroSCORE: Myocardial Infarction and Hospital Mortality

Simon, Capuano, Roscitano, Benedetto, Comito, Sinatra — 2008-04-01

Perioperative myocardial infarction is the most common cause of morbidity and mortality in cardiac surgery. It occurs in 8% to 35% of patients. The primary aim of this prospective study was to determine the level of cardiac troponin I that indicates perioperative myocardial infarction in patients undergoing coronary artery bypass. A secondary goal was to establish the best independent predictor of hospital death. There were 180 consecutive patients undergoing isolated coronary artery bypass surgery enrolled in this study. Values of cardiac troponin I > 12.9 ng·mL^–1 at 8 hours postoperatively predicted perioperative myocardial infarction with a sensitivity of 100% and a specificity of 93.2%. Compared to patients who survived, those who suffered hospital death were significantly older (74 ± 7 vs 63 ± 10 years), had significantly higher levels of cardiac troponin I at 24 hours (9 ± 17 vs 27.3 ± 16 ng·mL^–1) and 48 hours (6.9 ± 19 vs 30.3 ± 24 ng·mL^–1) postoperatively, and a significantly higher EuroSCORE (9 ± 2 vs 4 ± 3). At 8 hours postoperatively, cardiac troponin I led to an earlier diagnosis of perioperative myocardial infarction, while EuroSCORE was the strongest independent predictor of hospital death.

[ORIGINAL CONTRIBUTIONS] Differentiation of Ischemic and Dilated Cardiomyopathy on Electrocardiograms

Aghasadeghi, Aslani — 2008-04-01

Differentiating coronary artery disease with left ventricular dysfunction from dilated cardiomyopathy is important prognostically and therapeutically. To provide a diagnostic algorithm to distinguish these conditions using a standard 12-lead electrocardiogram, all 105 patients with left ventricular ejection fraction < 50% who underwent angiography between January 2004 and December 2006 were studied prospectively. Coronary artery disease was defined as ≥ 50% stenosis of the left main coronary artery or ≥ 70% stenosis of 1 or more of the 3 major epicardial arteries. Normal coronary angiography findings with left ventricular ejection fraction < 50% was defined as dilated cardiomyopathy. The most specific finding for differentiation of these diseases was pathologic Q waves in lead II, aVF, V3 or V4. The most sensitive parameter was a ratio ≥ 5 of R-wave amplitudes in lead V6 and lead III (94% sensitive). The 12-lead electrocardiogram provides a useful noninvasive method for differentiation of dilated cardiomyopathy from coronary artery disease with left ventricular systolic dysfunction.

[ORIGINAL CONTRIBUTIONS] Valvuloplasty in the Treatment of Rheumatic Tricuspid Disease

Pande, Agarwal, Majumdar, Kapoor, Kale, Kundu — 2008-04-01

Organic involvement of the tricuspid valve is uncommon. Valve repair is preferred over replacement as it results in a low gradient across the valve and obviates the risk of prosthesis-related complications. From October 2002 to October 2004, 37 patients who required tricuspid valve repair for organic involvement were included in this study. They were divided into 2 groups depending on the surgical procedure for valve repair: 20 patients in group 1 had tricuspid commissurotomy and De Vega annuloplasty; 17 in group 2 had tricuspid commissurotomy only. There were significant reductions in peak and mean tricuspid gradients and right ventricular systolic pressure in both groups. Annular shortening was similar in both groups (median, 23% in group 1, 21% in group 2), but the ratio of the tricuspid regurgitation jet area to right atrial area was greater in group 2 (median, 0.40 in group 2, 0.19 in group 1). There was no postoperative death. We recommend supporting the tricuspid annulus with annuloplasty in patients with organic tricuspid valve disease and no dilatation of the annulus, if annular shortening is < 30%.

[ORIGINAL CONTRIBUTIONS] Abscess of Residual Lobe After Pulmonary Resection for Lung Cancer

Ligabue, Voltolini, Ghiribelli, Luzzi, Rapicetta, Gotti — 2008-04-01

Abscess of the residual lobe after lobectomy is a rare but potentially lethal complication. Between January 1975 and December 2006, 1,460 patients underwent elective pulmonary lobectomy for non-small-cell lung cancer at our institution. Abscess of the residual lung parenchyma occurred in 5 (0.3%) cases (4 bilobectomies and 1 lobectomy). Postoperative chest radiography showed incomplete expansion and consolidation of residual lung parenchyma. Flexible bronchoscopy revealed persistent bronchial occlusion from purulent secretions and/or bronchial collapse. Computed tomography in 3 patients demonstrated lung abscess foci. Surgical treatment included completion right pneumonectomy in 3 patients and a middle lobectomy in one. Complications after repeat thoracotomy comprised contralateral pneumonia and sepsis in 1 patient. Residual lobar abscess after lobectomy should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy and bronchoscopy. Computed tomography is mandatory for early diagnosis. Surgical resection of the affected lobe is recommended.

[ORIGINAL CONTRIBUTIONS] Survival after Surgery with Cardiopulmonary Bypass in Low Weight Patients

Miyamoto, Sinzobahamvya, Photiadis, Brecher, Asfour — 2008-04-01

To evaluate risk factors for hospital death in patients weighing < 2.5 kg undergoing open-heart surgery, records of 34 consecutive low-weight patients operated on between December 1997 and November 2004 were reviewed. Mean weight was 2.152 ± 0.237 kg (range, 1.600 to 2.460 kg). Biventricular repair was achieved in 28 patients. The most frequent procedures were the arterial switch operation in 9 children, ventricular septal defect closure in 6, repair of total anomalous pulmonary venous connection in 5 and truncus arteriosus repair in 5. There were 8 early deaths. Mortality was strongly associated with the Comprehensive Aristotle Complexity Score: mortality was low (2/27; 7.4%) with a score < 19, and high (6/7; 85.7%) with a score ≥ 19. Higher mortality was encountered after univentricular repair (4/6; 67%). Hyperlactatemia at the end of cardiopulmonary bypass was also associated with poor survival. A Comprehensive Aristotle score < 19 was the strongest predictor of survival in low-weight patients undergoing open-heart surgery. Biventricular repair, when feasible, should be promoted to improve outcome.

[ORIGINAL CONTRIBUTIONS] Management of Malignant Pleural Effusion Associated with Trapped Lung Syndrome

Qureshi, Collinson, Powell, Froeschle, Berrisford — 2008-04-01

Management of recurrent malignant pleural effusion associated with trapped lung syndrome remains problematic. An alternative treatment using a pleural catheter has been advocated. Between August 1999 and August 2002, 127 patients underwent thoracoscopy for malignant pleural effusion. Of these, 52 (41%) with trapped lung were managed by insertion of a pleural catheter. Mean age was 66 years (range, 42–89 years). The most frequent diagnosis was breast cancer. Spontaneous pleurodesis (drainage < 10 mL) occurred in 25 (48%) patients whose catheter was removed after 30 to 255 days (mean, 93.8 days). Symptomatic relief was achieved in 49 (94%) patients. Mean dyspnea score improved significantly from 3.0 to 1.9. Complications comprised catheter blockage, surgical emphysema, cellulitis, and loculated effusion in 2 patients each. Mean length of hospital stay was 3 days (range, 1–16 days). Median survival was 126 days (range, 10–175 days). We conclude that long-term placement of a pleural catheter provides effective palliation for malignant pleural effusion associated with trapped lung syndrome.

[ORIGINAL CONTRIBUTIONS] Potential Role of Adipocytokine Leptin in Acute Coronary Syndrome

Dubey, Zeng, Wang, Liu — 2008-04-01

By activating immune cells or a direct action on the vascular wall, leptin may affect the initiation and progression of atherosclerosis. We investigated whether plasma leptin concentration is associated with coronary artery disease, with particular focus on the relationship between plasma leptin and the development of an acute coronary syndrome. Plasma leptin, interleukin-6 and high-sensitivity C-reactive protein were measured in 34 patients with acute coronary syndrome and 21 with stable angina. Their results were compared with those of 21 normal controls. Plasma leptin levels were significantly higher in the acute coronary syndrome group (13.36 ± 5.02 ng·mL^–1) compared to the stable angina group (8.97 ± 4.06 ng·mL^–1) or normal controls (5.14 ± 2.75 ng·mL^–1). Interleukin-6 and high-sensitivity C-reactive protein were also higher in the acute coronary syndrome group, and leptin correlated positively with interleukin-6 and high-sensitivity C-reactive protein. These findings suggest that plasma leptin levels may be a useful marker of systemic inflammation, and measurement of plasma leptin may be helpful in assessing the risk of developing coronary heart disease.

[ORIGINAL CONTRIBUTIONS] Valve Repair in Rheumatic Heart Disease in Pediatric Age Group

Reddy, Dharmapuram, Swain, Ramdoss, Raghavan, Murthy — 2008-04-01

Valve repair in children is technically demanding but more desirable than valve replacement. From April 2004 to September 2005, 1 boy and 8 girls with rheumatic heart disease, aged 2–13 years (median, 9 years), underwent valve repair for isolated mitral regurgitation in 5, combined mitral and aortic regurgitation in 2, mitral stenosis in 1, and mitral regurgitation associated with atrial septal defect in 1. Chordal shortening in 7, annular plication in 6, commissurotomy in 1, reconstruction of commissural leaflets in 7 were performed for mitral valve disease. Plication and reattachment of the aortic cusps was carried out in 2 patients. Annuloplasty rings were not used. All patients survived the operation, 8 had trivial or mild residual mitral regurgitation, and 1 had trivial aortic regurgitation. Mean left atrial pressure decreased from 14 to 7 mm Hg postoperatively. During follow-up of 3–18 months, all children were asymptomatic and enjoyed normal activity. None required reoperation. In addition to chordal shortening and annular plication, reconstruction of the commissural leaflets is considered the most important aspect of valve repair. It can be achieved without annuloplasty rings, giving good early and midterm results.

[ORIGINAL CONTRIBUTIONS] Endoscopic vs Conventional Vein Harvesting: a Prospective Analysis

Vaidyanathan, Sankar, Cherian — 2008-04-01

Minimally invasive vein harvesting is associated with better leg wound healing and a lower incidence of wound infections. We analyzed our experience in 2 prospectively enrolled groups of non-randomized patients undergoing elective coronary artery bypass grafting. Group 1 was 81 patients who had endoscopic vein harvesting; group 2 was 80 who had conventional open vein harvesting. The time taken for endoscopic harvest (skin incision to skin closure) was significantly less than that for open harvest (51.07 vs 75.94 min). The number of cases to reach a plateau on the learning curve for endoscopic vein harvest was 20 for 2 lengths of vein and 35 for 3 lengths of vein. Significantly more suture repairs per vein were required in group 1 (1.32) than group 2 (0.38). The incidence of wound infection was 1.2% in group 1 vs 8.8% in group 2. Endoscopic vein harvesting is not difficult to learn and it should be preferred over open vein harvest, given its benefits in wound healing.

[ORIGINAL CONTRIBUTIONS] Solitary Benign Fibrous Tumors of the Pleura

Regal, Al Rubaish, Al Ghoneimy, Hammad — 2008-04-01

Solitary benign fibrous tumors of the pleura are very rare. Seven patients (mean age, 52 years) who presented between 1995 and 2005 were studied retrospectively. They had nonspecific chest symptoms and no history of asbestos exposure or smoking. Chest radiography showed a large opacity occupying most of the affected hemithorax, with clear costophrenic angles. Computed tomography of the chest showed a large well-delineated heterogeneous mass directly related to the lateral chest wall. Needle biopsy suggested the benign nature of the lesion. Surgery was performed through a posterolateral thoracotomy. Five tumors arose from visceral pleura, and 2 from parietal pleura. The mean tumor diameter was 7.5 cm (range, 8–14 cm). Complete surgical excision was carried out in all cases. Histopathology and immunohistochemical staining confirmed the benign nature of the tumors. There was no mortality or major complication. The mean follow-up period was 4 years (range, 1–10 years). All patients remained tumor-free during follow-up. Wide local excision, including pulmonary and pleural resection, is recommended as the best therapeutic option.

[ORIGINAL CONTRIBUTIONS] Intramyocardial Angiogenic Cell Precursor Injection for Cardiomyopathy

Arom, Ruengsakulrach, Jotisakulratana — 2008-04-01

Stem cell therapy for heart failure is a rapidly progressing field. The objective of this study was to assess the safety, and short-term results of thoracoscopic direct injection of angiogenic cell precursors into patients with endstage cardiomyopathy. Cells were obtained from the patient’s own blood, avoiding immunological concerns. The number of cells prior to injection was 29.1 ± 18.9 x10⁶. Forty-one patients with cardiomyopathy (mean age, 58.5 ± 14.3 years) underwent stem cell injection; 21 had dilated cardiomyopathy and 20 had ischemic cardiomyopathy. Overall ejection fraction improved significantly by 4.8% ± 7.5% at 149 ± 98 days postoperatively. It increased from 25.9% ± 8.6% to 28.7% ± 9.8% in dilated cardiomyopathy, and from 26.6% ± 5.8% to 33.6% ± 7.8% in ischemic cardiomyopathy. New York Heart Association functional class was significantly better at 2 months in both groups. It was concluded that thoracoscopic intramyocardial angiogenic cell precursor injection is feasible and safe in patients with cardiomyopathy. The early results are good, and phase II trials are in progress.

[CASE STUDIES] Late Presentation of Cor Triatriatum with Persistent Levoatrial Cardinal Vein

Feltri, Crawley, Peart, Pozzi, Corno — 2008-04-01

An asymptomatic 10-year-old boy presented with reduced exercise tolerance and an echocardiographic diagnosis of cor triatriatum. Transthoracic and transesophageal echocardiography failed to reveal the persistent levoatrial cardinal vein discovered at surgery. In patients with late presentation of cor triatriatum with severe mitral inflow obstruction and a small patent foramen ovale, an alternative communication between the posterior collecting chamber and the systemic venous circulation should be sought with alternative imaging techniques.

[CASE STUDIES] Fibrin Sealant for Left Ventricular Rupture after Mitral Valve Replacement

Garcia-Villarreal, Casillas-Covarrubias — 2008-04-01

Despite safer surgical procedures, left ventricular rupture remains a rare but potentially lethal complication of mitral valve replacement. The use of fibrin sealant has substantially improved the outcome of many difficult bleeding episodes after cardiac surgery. We describe a case of left ventricular rupture successfully treated with fibrin sealant combined with external Teflon-pledgeted sutures.

[CASE STUDIES] Angiosarcoma Presenting as Syncope

Nayar, Nayar, Cherian — 2008-04-01

A 31-year-old lady presented with anemia and syncope. Echocardiography revealed massive pericardial effusion with a right atrial mass. Transesophageal echocardiography, computed tomography and magnetic resonance imaging scans confirmed presence of a right atrial mass. Histopathology revealed a high grade angiosarcoma. Complete resection was done and the patient was referred to an oncology unit for further management. After three months the patient had extensive metastasis and succumbed to the disease. This case report highlights the clinical presentation, rapid and aggressive course of cardiac angiosarcomas.

[CASE STUDIES] Hancock Valve Deterioration in Tricuspid Position for Ebstein's Anomaly

Sughimoto, Nakano, Gomi, Nakatani, Nakamura, Sato — 2008-04-01

A 65-year-old woman with a Hancock valve implanted 25 years earlier for Ebstein’s anomaly underwent a successful second tricuspid valve replacement with a Mosaic valve because of significant tricuspid regurgitation. At surgery, it was found that the Hancock valve had a cylinder-shaped hole and had lost its entire structure. Tricuspid valve dysfunction may be tolerated for a long time before surgery is contemplated.

[HOW TO DO IT] Left Heart Pump-Assisted Beating Heart Coronary Surgery in High-Risk Patients

Pepino, Oliviero, Petteruti, di Tommaso, Monaco, Stassano — 2008-04-01

A simple technique of left ventricular assistance, offering the advantages of both cardiopulmonary bypass and off-pump revascularization, was adopted for high-risk patients. It was used in 56 patients with critical left main stenosis and occluded right coronary artery, severely reduced ejection fraction and/or unstable angina. All patients underwent complete and successful myocardial revascularization (3.4 grafts per patient). Weaning from the pump was uncomplicated, and none required conversion to full cardiopulmonary bypass.

[HOW TO DO IT] Easy Technique for Placing Anchoring Sutures for Aortic Root Reimplantation

Ogino, Minatoya, Matsuda, Sasaki — 2008-04-01

In the aortic valve-sparing reimplantation technique, insertion of the anchoring sutures beneath the valve is a crucial but difficult step because the spared aortic cusps obscure the field of view. We present a novel and easy method of placing these anchoring stitches with good exposure of the subvalvular tissue.

[REVIEW PAPER] Current Status of Off-pump Coronary Artery Bypass Surgery

Raja, Dreyfus — 2008-04-01

The expanding indications for angioplasty coupled with the successful short and mid-term results of randomized controlled trials of drug-eluting stents have already had an unquestionable impact on the practice of coronary revascularization operations. However, coronary artery bypass grafting remains a major mode of therapy for coronary artery disease. It is likely that surgery will continue to be preferred for more complex subsets and that surgeons will have to continue to maintain good results in patients with more complex problems. Concerns regarding morbidity associated with conventional surgical myocardial revascularization on cardiopulmonary bypass have led to a resurgence of interest in off-pump bypass surgery during the last decade, with the expectation that it would be safer if cardiopulmonary bypass could be avoided. This review summarizes the impact of off-pump bypass surgery in reducing the morbidity and mortality associated with conventional coronary artery bypass on cardiopulmonary bypass by evaluating the current best-available evidence from randomized controlled trials and meta-analyses comparing off-pump surgery with conventional bypass grafting.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Postinfarction Giant Pseudoaneurysm in the Inferior Wall of the Left Ventricle

Ogawa, Doi, Koushi, Itoh, Nishimura, Yaku — 2008-04-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] A Large Horse Shoe-shaped Leiomyoma of the Thoracic Esophagus

Dahabreh, Dountsis, Vasilikos, Zisis — 2008-04-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Right Ventricular Perforation Induced by Trans Venous Pacing Lead

Sai Krishna, Ramesh Babu, Ram Mohan, Panigrahi, Naresh Kumar — 2008-04-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Bilateral Common Carotid Artery Aneurysm in Takayasu's Arteritis

Tochii, Ando, Yamashita, Hattori, Hoshino, Akita — 2008-04-01