Objective: Myomectomy is the cornerstone of therapy for hypertrophic obstructive cardiomyopathy (HOCM) in the presence of a high gradient. The importance of mechanical gradient across the left ventricle outflow track (LVOT) vs left ventricular diastolic dysfunction (LVDD) is debatable. Methods: We retrospectively analyzed data on 14 patients with HOCM who underwent myomectomy from 2007 to 2011 at our institution. All patients in this study were symptomatic. The purpose of this study was to assess the significance of immediate reduction of the gradient across the LVOT as well as improved LVDD and its correlation with hemodynamics. Results: A total of 14 patients with a mean age of 52.5 ± 19.0 years (male-female ratio of 5/8) were evaluated. The preoperative LVOT peak gradient was 76.9 ± 63.4 mmHg, the left atrial (LA) diameter was 41.9 ± 6.1 mm, and the septal thickness was 15.4 ± 3.2 mm. The relevant preoperative risk factors included DM (23.0%; n = 3), angina pectoris (15.4%; n = 2), cerebrovascular disease (CVD) (30.8%; n = 4), stroke (15.4%; n = 2), arrhythmias (30.8%; n = 4), and COPD (15.4%; n = 2). The concurrent procedures included mitral valve repair/ replacement (MVR) (30.8%; n = 4), aortic valve replacement (AVR) (23.0%; n = 3), coronary artery bypass grafting (CABG) (15.4%; n = 2), and modified MAZE procedure/ablation (15.4%; n = 2). The perioperative mortality was 7.7% (n = 1), and the long-term survival was 85.6% at a median follow up of 30 months. The postoperative LVOT gradient improved to 32.3 ± 24.4 mmHg and the septal thickness to 12.5 ± 3.8 mm. These differences were not statistically significant, likely due to small sample size. The postoperative complications included iatrogenic small VSD in one patient (who had myomectomy for a third time), atrial fibrillation (n = 4), cardiac arrest (7.7%; n = 1), neurologic adverse event (7.7%; n = 1), and new onset renal failure (7.7%; n = 1). We did not observe any new onset AV block. The length of stay (LOS) in the surgical critical care unit was 95.5 ± 112.7 hours. The overall hospital LOS was 15 ± 11.5 days. Conclusion: The septal myomectomy results showed an immediate reduction of the LVOT gradient, which translates into clinical and echocardiographic improvement.
Deliberate hypotension facilitates precise deployment of endovascular stent grafting in the thoracic aorta.We describe a practical technique using pulmonary artery catheter (PAC) guided transvenous rapid ventricular pacing via transjugular approach and delineate pertinent anesthetic considerations.Anesthesiologists performed PAC guided rapid ventricular pacing in thirty-nine (39) patients (27 men and 12 women, mean age 74 ± 11 years) undergoing thoracic endograft deployment for aneurysm repair.Patient characteristics, hemodynamic parameters, pacing rate, and number of pacing events were recorded.Post-operative complications were evaluated.PAC guided rapid ventricular pacing successfully provided controlled hypotension without technical complications.Mean pacing rate was 177 ± 17 beats/min with an average of 2.6 ± 2 pacing events/surgical procedure.Average pacing duration was 34 ± 29 seconds (MAP of 47 ± 5 mmHg).One intraoperative death occurred in a patient with severe valvular heart disease.In all other cases, recovery time to baseline hemodynamics was short.Postoperative complications included atrial fibrillation in five patients (12%), elevated troponin levels in eight (21%), and stroke in three (8%).No patients had PAC related complications.Pulmonary artery catheter guided rapid ventricular pacing allows for accurate deployment of thoracic aorta endovascular stent-grafts.Patients with severe valvular or ischemic heart disease are likely poor candidates for this technique.
Hypertrophic osteoarthropathy, a condition of osteitis of the long bones that manifests clinically with clubbing, is often secondary to a thoracic neoplasm, especially lung carcinoma in long-time smokers.We report an unusual case in which hypertrophic osteoarthropathy was the only manifestation of a benign pulmonary parenchymal leiomyoma.A 38year-old non-smoking man had bilateral clubbing of the fingers.Hypertrophic osteoarthropathy was diagnosed when radiography revealed thin lamellar deposits along the metatarsals and phalanges of the hands and similar osteal changes in the feet.Respiratory tests indicated normal lung functioning, but computed tomography revealed a 5x4 cm2 lobulated mass in the lower left lung which did not take up 18F-FDG on positron emission tomography.Exploratory thoracotomy revealed a pedunculated neoplasm which was removed by standard lobectomy.Histopathological diagnosis indicated the presence of smooth muscle spindle cells but absence of mitotic activity, nuclear atypia or necrosis, leading to a diagnosis of pulmonary parenchymal leiomyoma.Four months after surgery, the patient experienced a noticeable reduction in the finger clubbing.Hypertrophic osteoarthropathy may be the presenting characteristic of benign masses such as pulmonary leiomyoma.
Objectives: Sympathetic overactivity and vagal withdrawal are cardinal presentations in patients with heart failure that predisposes them to malignant arrhythmias and sudden cardiac death. To develop therapy to enhance vagal tone and regain autonomic balance we conducted stimulation recruitment tests at three locations along the cardiac vagal pathway. Materials and Methodology: In anesthetized canines, small electrodes were placed against the vagus nerve (n=4) or in epicardial fat containing the sinoatrial or ventricular cardiac ganglia (n=8). Results: Stimulation of the vagus nerve induced vocal cord evoked potentials at 0.5 mA and increases in heart rate at 1.3 ± 0.3 mA. Higher currents were needed to induce parasympathetic effects of decreased heart rate and blood pressure, 3.7 ± 1.0 mA. Stimulation of the sinoatrial node ganglia decreased heart rate at a threshold current of 4.4 ± 2.1 mA. Stimulation of the ventricular ganglia, produced sympathetic effects at 9.3 ± 0.7 mA of current and ventricular arrhythmias or pacing at 10.7 ± 0.7 mA; using small wire electrodes unwanted sympathetic and ventricular pacing effects occurred at even lower stimulating currents. Conclusion: Our results show that the effects of stimulation are highly dependent upon the site of stimulation and stimulation currents. Further, given the significant side effects of whole nerve stimulation an important need exists for more selective vagal and cardiac ganglia stimulation technology as offered by microelectrode arrays.
Aim: Stages I and II malignant pleural mesothelioma (MPM) can be satisfactorily treated with extended extrapleural pneumonectomy (EPP). We modified our diagnostic methods and surgical techniques to improve outcome. Methods: 74 patients were treated with EPP, 33 from 1988 to May 2000 (first group), and 41 from June 2000 to 2010 (second group) and all underwent thoracoscopy without mediastinoscopy or laparoscopy prior to EPP. We began to make changes in surgical management in group 2 (2000-2010). Staging was improved using 3D CT scan and Standard Uptake Values (SUV) provided by 2-(Fluorine-18)fluro-2-deoxy-D-glucose positron emission tomography (FDG PET) scan. Talc pleurodesis was used preoperatively in 15 cases. Double unilateral thoracotomy, performed on 24 patients, facilitated dissection of the diaphragm and made alterations in the reconstructive phase possible. Polytetrafluoroethylene (PTFE) prostheses were used instead of biological materials. In 10 cases the pericardium was not reconstructed on the left side after the previous negative experience of functional pericardial concretio that needed the prosthesis removal (Table 1). Topical thrombin was used to reduce postoperative complications whereas posterior prosthetic packing was used to prevent paraprosthetic evisceration and reduce postoperative bleeding. Results: Patients of group 2 experienced less morbidity. Fourteen of the 71 patients who survived beyond the immediate postoperative period lived at least 3 years. Potential positive prognostic factors were identified at follow-up. Conclusions: The innovations we adopted, especially the reconstruction procedures, improved the outcome for our series of patients who underwent extended EPP for MPM. Follow-up results suggest that the MIB-1 index, stage 1 disease, prosthetic diaphragmatic replacement, adjuvant radiotherapy and control are important positive prognostic factors.
Acquired esophagobronchial fistula (EBF) is a rare condition and its surgical remediation is challenging. Management depends on the cause and degree of the injury. Corrosive substances can be alkaline or acidic in nature. Alkali ingestion commonly causes esophageal injury while acid ingestion most often damages the stomach. However, it is not always clear which gastrointestinal site will be injured. We present two cases of tracheoesophageal fistula with different etiology but similar complication: one due to alkaline ingestion, and one due to acidic ingestion. Both patients had successful surgical management.
We present a case of acute decompensated heart failure in a patient with congenitally corrected transposition of great arteries treated with levosimendan, an agent with positive inotropic and vasodilatory effects. Levosimendan infusion resulted in symptomatic and functional improvement, improvement of the subpulmonary left ventricular systolic function and amelioration of the diastolic but not the systolic function of the systemic right ventricle. A number of factors may account for the poor response of the systemic right ventricle to levosimendan, such as altered myofibrillar structure and coronary flow together with the particular loading conditions of the systemic right ventricle.
Bleeding is a well described complication of percutaneous extracorporeal membrane oxygenation support (ECMO). In an effort to prevent ongoing percutaneous-cannula blood loss, we tried multiple methods to achieve hemostasis and obtained the best results with QuikClot ® Combat Gauze TM (Z-Medica Corp, Wallingford, CT). This product is made of kaolin, white alumina silicate clay, which initiates activation of the intrinsic clotting cascade. We reviewed our experience in 21 ECMO patients and found 5 patients who required 17 applications of QuikClot ® Combat Gauze TM to percutaneous catheter insertion sites and demonstrated a significant reduction in both localized bleeding complications and the need for blood transfusion. QuikClot Combat Gauze TM , used for the dual purpose of a dressing and hemostatic agent, is a simple valuable method to control pericatheter bleeding in the ECMO population with demonstrated cost savings and clinical utility.
Atherosclerotic carotid artery disease is estimated to represent the etiology for one quarter of all strokes. Carotid magnetic resonance imaging and magnetic resonance angiography are promising tools in the evaluation of carotid atherosclerotic vascular disease. In this study, we evaluate the reliability of high resolution carotid wall magnetic resonance (MR) imaging by investigating the inter-observer, intra-observer, and inter-scan variability in measurements of carotid vessel total lumen area and mean wall thickness. This HIPAA compliant study received IRB approval and all subjects gave written informed consent. Nineteen subjects were imaged on a 3T MRI scanner with custom-built 4-element receive-only phased-array coils optimized for carotid anatomy. Three observers manually drew regions of interest around the lumen and outer wall for both left and right carotid arteries. Intraclass correlation coefficients (ICC) showed excellent agreement between Observer 1 and the others (>0.92). A two- way analysis of variance (ANOVA) found no significant difference between observers (p>0.05). Intra-observer variability for Observer 1 was measured by coefficient of variation (CV) with 0.03 for total lumen area and 0.03 for mean wall thickness. Similarly, the inter-scan variability of Observer 1 was found by CV to be 0.05±0.02 for total lumen area and 0.04±0.03 for mean wall thickness. Our results demonstrate that the MR measurements of total lumen area and mean wall thickness are highly reproducible and provide a reliable foundation for the evaluation of carotid atherosclerotic vascular disease.
This report highlights the utility of three dimensional (3D)-CT angiography, in conjunction with combined endovascular and open surgical management, to treat a degenerative subclavian artery aneurysm. The patient presented with an incidentally discovered right subclavian artery aneurysm and underwent surgical reconstruction without complication. Although a variety of case reports in the literature document repair of various subclavian artery pathologies including those associated with aberrant subclavian artery anatomy (Kommerel's diverticulum), iatrogenic pseudoaneurysm, and thoracic outlet compression with post-stenotic dilatation, post-inflammatory and infectious aneurysms; true fusiform degenerative aneurysms of the subclavian artery remain a rare clinical entity. These lesions present with variable anatomic configurations, which can be clearly defined with pre-operative CT or MR angiography. Defining the anatomy with 3D imaging can facilitate clinical decision- making and allow potential application of hybrid approaches to surgical management.
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Objectives: A prospective randomized study designed to compare results of intra-operative applications of povidone-iodine with those of hydrogen peroxide during surgery for hydatid cysts. Methods: This study includes 160 patients with pulmonary and/or hepatic univesicular hydatid cysts. Group A consisted of 80 patients for whom we used hydrogen peroxide; Group B consisted of 80 patients for whom we used povidone- iodine. Each cyst was examined both macroscopically and microscopically to identify effects of the used scolicidal agent on the wall. Post-operatively, patients received Albendazole as a scolicidal drug for one year. Follow up times ranged between 48 and 84 months. Chest x-rays and abdominal ultrasound examinations were performed every six months to detect any recurrences. Results: There was no peri-operative mortality in either of the two groups. Group A: one case of postoperative prolonged air-leak and two cases of wound infection. No recurrences were reported. Mean hospital stay was 5.5 ± 1.1 days. Group B: two cases of prolonged air leak, three cases of persistent cough and hemoptysis, one developing broncho-pleural fistula that healed (air leak ceased after 19 days), two cases of wound infection, one had subphrenic abscess, nine cases of recurrences, one on the diaphragmatic pleura, two with deep chest wall cysts at sites of thoracostomy tubes, four intraperitonial recurrences, two in the same liver lobe. Recurrences occurred in 11% of the subjects (9/80; p value = 0.028). Mean hospital stay was 9.6 ± 1.5 days. On histologic examination of Group A, the cyst wall lost its integrity, luster and viability and became friable. In Group B the cyst wall maintained most of its luster, integrity, viability and did not become friable. Conclusions: Hydrogen peroxide is a more effective and safer scolicidal drug than povidone-iodine as shown by the differences in mean duration of hospital stay and postoperative recurrence rate significance.
Introduction: Most of the patients undergoing heart operation are discharged from the intensive care unit the day after their operation. The aim of this study was to evaluate preoperative, intraoperative and early postoperative risk factors for prolonged intensive care unit length of stay (intensive care unit stay greater than 1 day) in cardiac surgery patients. Materials and Methodology: This retrospective study examines the determinants of prolonged intensive care unit length of stay in 2182 consecutive surgical patients. Univariate and multivariate analyses have been performed. Results: 46.76% of all patients had a prolonged intensive care unit length of stay. Multivariate analysis revealed the following independent predictors for prolonged intensive care unit length of stay: Preoperative: Age (p = 0.001), chronic obstructive pulmonary disease (p = 0.049), serum creatinine (p = 0.003), serum total bilirubin (p = 0.048), chronic renal failure requiring dialysis (P = 0.040), intravenous infusion of nitrates (p = 0.014), NYHA class � 3 (p = 0.032), left ventricular ejection fraction (p = 0.006). Intraoperative: aortic cross-clamping time (p = 0.04), CPB duration (P < 0.0001), lowest hematocrit on CPB (p < 0.0001), type of operation (p = 0.012), high doses of catecholamine therapy after CPB (p = 0.001). Postoperative: re-exploration (p < 0.0001), massive transfusions (p < 0.0001), arterial pH at ICU admission (p = 0.024). Conclusion: Due to the increasing number of high-risk patients needing cardiac surgery, it is important to identify risk factors for a prolonged intensive care unit length of stay. This can be applied for scheduling patients for cardiac surgery as well as in optimizing intensive care unit resource planning when resources are limited.
Inflammatory bowel disease is a complex entity that involves not only intestinal but also systemic manifestations. Several studies describing cardiovascular complications, such as coronary atherosclerosis, aortic aneurysms, vasculitis and pericarditis, have been published. However, the presence of coronary artery aneurysms has not been previously associated with this disease. In this report, we describe a 76-year-old patient with history of ulcerative colitis and coronary artery disease with a coronary angiography revealing the presence of several coronary aneurysms. Since endothelial dysfunction and destruction of elastic fibers due to inflammation could conceivably lead to coronary artery dilatation and aneurysms, we suggest that the inflammatory response in ulcerative colitis may play an important role in the development of some of the aforementioned cardiac complications.
Pseudoaneurysms are rare complications occurring after prosthetic ascending or aortic arch replacement for the treatment of dissections, aneurysms and aortic dilatation with or without aortic valve pathology, and are a consequence of suture line weakness and increased tissue fragility. However, in cases of thoracic aorta reconstructive surgery, the occurrence of false aneurysms or dissections originating from suture lines between grafts and the aorta varies greatly. Suture line disruption is a life threatening complication after thoracic aortic surgery that always requires reoperation. This case emphasises the potential role of CT scanning in the follow-up of patients after aortic surgery.
A greater number of people with spinal cord injury is always submitted to surgical operations. Some pathologies associated to the medullary damage as the autonomic dysreflexia, the muscular spasm and the respiratory inadequacy can increase perioperative complications. Manifold early studies have shown that the multimodal approach in complex elective surgery can reduce perioperative morbility and mortality. We describe the case of a 77 year-old patient tetraparetic scheduled for open abdominal aortic aneurismectomy using multimodal approach that consists in minimal invasive surgery (subcostal incision), thoracic epidural anesthesia with light sedation and postoperative forced rehabilitation. This approach has allowed the decrease of perioperatorie complications and the improvement of postoperative outcome.
High operative mortality of infected thoracoabdominal aortic aneurysms (ITAA) is partly attributable to ischemic injury during aortic clamping. We report a 62-year-old man with biliary cirrhosis, who developed a rapidly enlarging ITAA secondary to thoracolumbar osteomyelitis. Additional infectious foci were found in the pubic and ischial bones and in the left lung. Blood cultures gave growth of streptococcus pneumoniae. The aneurysm was repaired through a thoracoabdominal incision with a Dacron prosthesis. Prior to aneurysm repair, a prosthetic shunt was anastomosed end - to- side to the aortic prosthesis and to the descending aorta using a side-biting clamp. The shunt allowed perfusion of the lower body and of renal and visceral vessels after 45 minutes, the time needed to resect infected tissue and complete the distal anastomosis. The proximal anastomosis and orthopedic treatment of the spinal osteomyelitis could be performed, while the lower body and visceral organs were perfused. Postoperatively, the patient developed hypotension and increasing lactacidosis. Laparotomy revealed intestinal infarction, and gut resection was performed. Following a temporary improvement, he developed multiorgan failure and candida sepsis and died after 32 days. No atheroemboli were found in arteries of resected intestines. Portal hypertension most likely was present and it could be calculated that minimum intestinal perfusion pressure the night after the operation could have been in the range of 30-37 mm Hg, which probably was not enough to maintain aerobic metabolism. In the presence of aortic atheromas it may be advisable to divert blood to the shunt from an axillary artery.
We have recently shown that ventricular unloading with an implantable left ventricular assist device (LVAD) leads to improved calcium handling and membrane integrity and redistribution of alpha adrenoreceptors (AARs) and betaadrenoreceptors (BARs).Here, we used fluorescence deconvolution microscopy to examine the effect of LVAD type (pulsatile vs non-pulsatile) on upregulation and redistribution of adrenoreceptors in core biopsy samples of the myocardium before and after the removal LVAD.We noted no major differences between the pulsatile and non-pulsatile groups; however, an individual patient's 'recovery' in adrenoreceptor numbers depended on the pre-LVAD number of receptors.These findings suggest that ventricular unloading is beneficial regardless of LVAD type; however, the degree of repair and recovery may correlate with the patient's level of ventricular dysfunction at implant and the pre-LVAD number of adrenoreceptors (130).
Purpose: To assess whether preoperative screening using venous duplex scanning (VDS) of the bilateral lower extremities is useful for identifying patients at risk of developing postoperative venous thromboembolism (VTE). Materials and Methods: Three hundred fifty-two consecutive referral patients at high or highest risk for postoperative VTE according to the guidelines of the American College of Chest Physicians were studied. After VDS, all patients re- ceived low-dose unfractionated heparin for postoperative thromboprophylaxis. Patients were then followed for 3 months after surgery for investigation of clinically significant VTE. Results: Three hundred thirty patients were finally enrolled. Of these, orthopedic surgery patients were most common (140 patients, 42.4%), followed by general surgery (104 patients, 31.5%) and gynecologic (42 patients, 12.7%) surgery patients. Preoperative VDS identified 66 (20.0%) patients with deep vein thrombosis (DVT). Twenty-three (7.0%) pa- tients had proximal DVT and the remaining 43 (13.0%) had distal DVT. Postoperative symptomatic VTE was found in 26 (7.9%) patients who had no evidence of preoperative DVT. Twenty-two patients developed calf DVT, two developed proximal DVT and two developed pulmonary embolism. In contrast, no propagation of DVT or new thrombus formation was found after surgery in patients who had preoperative DVT. Multivariate analysis showed that an age of >75 years (OR 2.57, 95% CI 1.14-5.82, p = 0.023) was the only significant predictor of postoperative VTE.
