Lemierre-like syndrome, an atypical variant of Lemierre's syndrome, is characterised by septic thrombophlebitis without classical features and may be complicated by descending necrotising mediastinitis (DNM). Contrast-enhanced computed tomography revealed extensive thrombosis of the right internal jugular, external jugular, and subclavian veins, along with multiple cervical and mediastinal abscesses, consistent with DNM. A cystic lesion in the right upper lobe suggested a lung abscess. Emergency cervical drainage was performed, followed by thoracoscopic mediastinal drainage. Communication between the mediastinal and pulmonary abscess cavities was identified intraoperatively. As no air leak was detected during a 20 cmH₂O leak test, pulmonary resection was avoided. Methicillin-susceptible Staphylococcus aureus was isolated, and the patient recovered with antibiotics and anticoagulants. The patient remained recurrence-free for 7 months. Careful intraoperative assessment may allow successful management without resection in selected cases of mediastinal-pulmonary communication.
OBJECTIVES:In high-risk patients, transcatheter mitral valve replacement (TMVR) is an alternative to surgery and transcatheter edge-to-edge repair (TEER). This study aims to evaluate the mid-term results of TMVR with the Tendyne System in a real-world population at a single center. METHODS:Between November 2018 and December 2023, all consecutive patients undergoing TMVR with the Tendyne System were included. The primary outcomes were overall and cardiovascular death. Secondary outcomes included the absence of mitral regurgitation (MR) >mild, improved functional status and device success, as defined by the Mitral Valve Academic Research Consortium criteria. RESULTS:Thirty patients were included. Mean age was 74.6±7.1 years, with a mean EuroScore 2 of 7.7±3.8%. MR was severe in 90% of cases and moderate with concomitant stenosis in 10%; 57% of patients were in NYHA class III-IV, and left ventricular ejection fraction was 42±13%. Technical success was 100%; 30-day mortality was 3.3%; there was no MR > mild; 4 (13%) patients had mild MR; and the mean transvalvular gradient was 3.7±1.1 mmHg. At a median follow-up of 2.8 (IQR 2) years, overall mortality was 50% and cardiovascular mortality was 27%, and we had no device-related complications, apart from one case of bacterial endocarditis that was medically treated. None of the patients presented MR >mild; the mean transvalvular gradient was 2.9±1.7 mmHg. At the latest follow-up, the device success rate was 100%, and NYHA class II was observed in 94% of patients, compared with 43% at baseline (p < 0.001); however, 30% have had a rehospitalization for acute heart failure during FU. CONCLUSIONS:In high-risk patients, TMVR with the Tendyne device is associated with acceptable procedure-related morbidity and mortality and leads to mid-term improvement in functional class; however, mid-term survival remains poor.
OBJECTIVES:To compare long-term outcomes across different models of mechanical and biological aortic valve prostheses after surgical aortic valve replacement (SAVR) in the Netherlands. METHODS:Data from the Netherlands Heart Registration on isolated, primary SAVR procedures performed from 2007 to 2018 in adult patients were used, excluding active endocarditis. Ten-year survival and freedom from valve-related reintervention were estimated for models that were implanted >200 times, using Cox proportional hazards models for survival and Fine and Gray's models with death as the competing-event for freedom of reintervention. RESULTS:For 11,139 patients treated with a biological prosthetic aortic valve, ten-year survival was highest for the Perimount Magna Ease (72.6%) and Epic (70.0%), and significantly lower for the Perimount Magna (65.1%), Trifecta (63.1%), Perimount (61.4%), Freedom Solo (51.5%), and Mitroflow (50.7%). Ten-year freedom from reintervention was highest for the Perimount Magna (99.3%), and significantly lower for the Perimount Magna Ease (98.2%), Perimount (98.2%), Epic (97.3%), Trifecta (96.8%), Freedom Solo (93.2%) and Mitroflow (90.5%). For 2,123 patients treated with a mechanical prosthetic aortic valve, ten-year survival was highest for the Regent (91.2%) and not significantly different for the Open Pivot (89.2%), Slimline (87.5%), HP (87.3%) and significantly lower for the Carbomedics Reduced (87.0%). Ten-year freedom from reintervention was highest for the Carbomedics Reduced (97.1%), not significantly different for the Open Pivot (96.1%), Slimline (96.5%), Regent (95.9%), and significantly lower for the HP (94.9%). CONCLUSIONS:Differences in ten-year outcomes after SAVR were observed for the different prosthetic aortic valve models that were used in the Netherlands Heart Registration, especially for biological prosthetic aortic valve models, with survival varying from 50.7% to 72.6% and freedom from reintervention from 90.5% to 99.3%.
OBJECTIVES:To analyse the relationship between effective height and other morphological parameters of the aortic valve complex when the aortic valve is closed. METHODS:We retrospectively analysed 105 patients (mean age 70.7±10.1 years) with morphologically normal aortic valves, roots, or ascending aortas who had undergone electrocardiography-gated cardiac computed tomography as a screening test of the coronary artery, from August 2014 to December 2018. Parameters of the aortic valve complex configuration (effective height, geometric height, aortic annular diameter, sinus of Valsalva diameter, sinotubular junction diameter, commissure height, and Valsalva height) in diastole were measured using Ziostation2 software. Pearson's correlation was used to evaluate the associations between the effective height and other parameters. Multiple regression analysis was performed to evaluate the variables independently associated with effective height. RESULTS:Significant associations were observed between the effective height and geometric height, sinus of Valsalva diameter, sinotubular junction diameter, commissure height, and Valsalva height (all p < 0.001) but not between effective height and aortic annular diameter (p = 0.227). Multivariable analysis showed that geometric height, aortic annular diameter, and sinotubular junction diameter were independently associated with effective height (all p < 0.001; overall model fit: R2=0.739). CONCLUSIONS:Our findings demonstrate that effective height is strongly associated with geometric height, which remained independently associated after adjustment, along with aortic annular and sinotubular junction diameters. These results provide quantitative in vivo evidence regarding the anatomical determinants of effective height in morphologically normal tricuspid aortic valves and may serve as anatomical reference data for future research on individualised approaches to aortic valve repair.
OBJECTIVE:Surgical repair of supravalvar aortic stenosis (SVAS) provides excellent early outcomes; however, late reintervention remains common. The determinants of left ventricular outflow tract (LVOT) failure, particularly the role of residual haemodynamics, remain incompletely defined. We sought to identify predictors of LVOT reintervention in a contemporary cohort. METHODS:A retrospective study of consecutive patients aged <18 years undergoing SVAS repair between 2005 and 2024 was performed. Primary endpoints were overall survival and freedom from LVOT reintervention. Survival and freedom from reintervention were assessed using Kaplan-Meier analysis. Multivariable Cox regression was used to identify independent predictors of LVOT reintervention. RESULTS:Seventy-seven patients underwent repair at a median age of 3 (1-8) years, with median follow-up of 9.3 (6-14) years. There was no early or late mortality, nineteen patients (25%) required reintervention, including 16 (21%) LVOT-related procedures. Freedom from LVOT reintervention was 74% at 10 years and 71% at 15-20 years. Discharge LVOT velocity >3 m/s was independently associated with LVOT reintervention (HR 11.66, 95% CI 3.56-38.18; p < 0.001). Younger age was also independently associated with increased risk (HR per year 0.74, 95% CI 0.59-0.94; p = 0.013) for LVOT re-intervention. Coronary abnormalities were documented in 17% of patients, with one early coronary reintervention. CONCLUSION:SVAS repair is associated with excellent long-term survival. Residual discharge velocity emerged as an independent predictor of late LVOT reintervention supporting the importance of achieving optimal haemodynamic relief at the index operation and structured lifelong surveillance.
OBJECTIVES:Transcatheter aortic valve implantation (TAVI) via the transfemoral (TF) approach is widely used. However, patients with unsuitable peripheral arterial anatomy require alternative transthoracic access. In such patients, the transaortic TAVR via right mini-thoracotomy (Rt-TAo) approach offers a less invasive option than conventional sternotomy. Therefore, this study aimed to evaluate the procedural and 2-year clinical outcomes of TF TAVI versus Rt-TAo TAVI. METHODS:Patients who underwent TAVI via the TF approach or the Rt-TAo approach between January 2012 and November 2023 were retrospectively reviewed. Baseline characteristics and clinical outcomes were compared, and propensity score matching was performed to adjust for baseline differences. The primary end-points were in-hospital mortality, stroke, other periprocedural morbidities, and postprocedural length of hospitalization. Secondary end-points included overall survival, freedom from cardiac-related death, and major adverse cardiac and cerebrovascular events (MACCE) at 2 years. RESULTS:A total of 767 consecutive patients were included in the analysis, of whom 694 underwent TF TAVI and 73 underwent Rt-TAo TAVI. Before matching, the Rt-TAo group had higher baseline prevalences of comorbidities and Society of Thoracic Surgeon risk scores. After matching, the Rt-TAo group had a longer procedural time, higher transfusion requirements, and longer lengths of intensive care unit and total hospital stays. However, the 2 groups had similar rates of periprocedural stroke, coronary obstruction, annular rupture, access-related complications, and in-hospital mortality. The 2 groups had similar 2-year rates of survival and freedom from MACCE. CONCLUSIONS:The Rt-TAo TAVI is a safe and feasible alternative for patients with unsuitable peripheral arterial access, demonstrating comparable 2-year outcomes to TF TAVI.
OBJECTIVE:Acute type A aortic dissection during pregnancy with situs inversus totalis is exceptionally rare. METHODS:We report a 27-year-old woman at 24 weeks of gestation who underwent emergency ascending aortic and total arch replacement with frozen elephant trunk implantation. RESULTS:Fetal demise occurred on postoperative day 1, but the mother recovered without neurological deficit and remained well at 10-year follow-up. CONCLUSIONS:This case demonstrates the feasibility of complex arch repair in mirror-image anatomy and highlights the importance of individualized operative planning and multidisciplinary maternal-fetal management in experienced aortic centres.
OBJECTIVES:Acute kidney injury (AKI) following transcatheter aortic valve replacement (TAVR) is a prevalent complication that impacts patient prognosis. While blood pressure variability (BPV) has been implicated in AKI among patients undergoing other surgical procedures, its association with AKI following TAVR remains uncharted. This study aimed to investigate the association between BPV and post-TAVR AKI. METHODS:Based on the Medical Information Mart for Intensive Care database, logistic regression models were employed to investigate the associations of average real variability of systolic blood pressure (ARV-SBP) and average real variability of diastolic blood pressure (ARV-DBP) with AKI following TAVR. Multiple sensitivity analyses evaluated the robustness of the results. The marginal standardization analysis estimated the odds of AKI after ARV-SBP adjustment. RESULTS:A total of 340 patients undergoing TAVR were enrolled, among whom 107 (31.5%) developed AKI. Logistic regression analysis demonstrated a positive correlation between ARV-SBP and the odds of post-TAVR AKI (OR = 1.34, 95%CI: 1.03-1.74, P=0.029) in the fully adjusted model. In contrast, no significant correlation was observed between ARV-DBP and AKI (P=0.559). In covariate and blood pressure measurement sensitivity analyses, the direction of the ARV-SBP effect was generally consistent with that in the primary analysis. Marginal standardization analysis demonstrated that higher ARV-SBP levels were associated with elevated odds of AKI. CONCLUSIONS:Elevated ARV-SBP was associated with increased odds of post-TAVR AKI. ARV-SBP may serve as an auxiliary indicator for early risk identification of post-TAVR AKI, yet its clinical value remains to be validated in prospective studies.
OBJECTIVES:To report our strategy and outcomes in open surgically treating adult Kommerell's diverticulum (KD) over the past decade. METHODS:44 patiens who underwent open surgical repair for KD at our institution between 2015 and 2024 were enrolled. Patients were classified as aneurysm group (n = 25, 56.8%) or dissection (n = 19, 43.2%) group. Depending on the position and pathology, 1 of 4 procedures was performed: (1) descending aorta replacement and aberrant subclavian artery reconstruction; (2) total arch and partial descending aorta replacement; (3) thoracoabdominal aortic replacement; or (4) total arch replacement with frozen elephant trunk. Long-term prognosis and perioperative safety were analyzed. RESULTS:Early mortality and composite adverse events for the overall cohort were 13.6% and 20.5%, respectively, without significant differences between the aneurysm and dissection groups (8.0% vs 21.1%, P = 0.42; 16.0% vs 26.3%, P = 0.32). However, the dissection group had a higher rate of acute kidney injury (52.6% vs 20.0%, P = 0.02), longer mechanical ventilation (33.4 [13.2∼122.1] vs 14.2 [6.8∼22.7] h, P = 0.005), longer intensive care unit stay (5 [3∼10] vs 2 [1∼5] d, P = 0.001), and longer postoperative hospitalization (15 [14∼21] vs 10 [7∼18] d, P = 0.007). For the entire cohort, 5-year overall survival and freedom from aortic-related reintervention were 77.8% and 88.9%. Patients in the dissection group had significantly lower 5-year overall survival (61.2% vs 92.0%, P=0.022) and freedom from aortic-related reintervention rates (77.3% vs 100%, P=0.036). CONCLUSIONS:Open surgical strategy was selected arrording to the position and pathology of KD. Open surgery achieved acceptable early and long-term outcomes. Once KD progressed to dissection, the difficulty and risk of open surgery increased and the long-term prognosis was impaired.
Intraoperative iatrogenic aortic dissection is a rare but potentially catastrophic complication of cardiovascular surgery. Although transoesophageal echocardiography (TEE) is considered a key diagnostic tool, its practical value and limitations are not fully appreciated. From the perspective of a TEE observer with more than 30 years of experience, only 7 cases of intraoperative iatrogenic aortic dissection were encountered. Review of these cases yielded 3 practical observations: conventional monitoring modalities may fail to detect developing dissection; the mere presence of a TEE probe does not guarantee recognition; and some forms of aortic wall injury may challenge conventional interpretations. Representative cases demonstrated that dissection can progress without immediate changes in haemodynamic variables or surgical findings, and that clinically important pathology may extend beyond the visible operative field. Additional observations suggested that intraoperative aortic wall injury may present with diverse morphologic appearances depending on the involved layer of the aortic wall. These experiences support considering proactive TEE surveillance during initiation of arterial perfusion and suggest that recognition of otherwise occult pathology may facilitate timely intervention and improve situational awareness during cardiovascular surgery.
BACKGROUND:Pulmonary vascular variations may complicate thoracic surgery, particularly video-assisted procedures, where such anomalies increase the risk of bleeding. CASE PRESENTATION:We report a 77-year-old female undergoing right upper lobectomy for invasive mucinous adenocarcinoma. Imaging revealed a 2 cm posterior right upper lobe nodule with low FDG uptake. Histology showed mixed adenocarcinoma and large-cell neuroendocrine carcinoma (stage IA). Intraoperatively, a vascular connection consistent with an arteriovenous fistula between the superior pulmonary vein and the interlobar pulmonary artery was identified and ligated. CONCLUSIONS:Recognition of rare pulmonary vascular anomalies through careful preoperative imaging and intraoperative assessment is essential to minimize surgical complications and ensure safe thoracic resection..
OBJECTIVES:Low haematocrit during cardiopulmonary bypass is a known risk factor for acute kidney injury, but it is unclear whether high haematocrit also increases acute kidney injury risk. We examined if a haematocrit range associated with a reduced risk for acute kidney injury could be identified. METHODS:This observational study included cardiac surgery patients operated on between 2016 and 2020, using prospectively collected data from the SWEDEHEART registry and a local cardiopulmonary bypass database. Acute kidney injury was defined by registry-available data as a postoperative serum‑creatinine increase >1.5 times baseline or postoperative initiation of renal replacement therapy. For each predefined haematocrit threshold, weighted exposure was calculated as the accumulated time‑and‑magnitude by which haematocrit rose above or fell below the thresholds. Associations between weighted exposure and acute kidney injury were analysed using multivariable logistic regression adjusted for established acute kidney injury risk factors. RESULTS:A total of 3798 patients were included. Postoperative acute kidney injury occurred in 598 of 3798 patients (15.7%). After adjustment, a non‑linear association between haematocrit weighted exposure during aortic cross‑clamp and acute kidney injury was observed. AKI risk increased with haematocrit below 25% (adjusted odds ratio [aOR] 1.006 per 1 [%×min]; 95% CI 1.002-1.009; P < .001) and above 38% (aOR 1.006 per 1 [%×min]; 95% CI 1.001-1.011; P = .019). CONCLUSIONS:In this cohort, haematocrit exposure below 25% and above 38% during aortic cross-clamp was associated with higher postoperative acute kidney injury risk. Further studies are needed to confirm these findings.
OBJECTIVES:The surgical treatment of multiple synchronous bilateral primary lung cancer (mSBPLC) showed promising results and the aims of this retrospective study were to assess the oncologic outcomes and the presence of risk factors of worse survival. METHODS:Patients underwent radical (all lesions removed) lung resection for mSBPLC from 2017 to 2024 were included. Exclusion criteria: patients unfit for bilateral surgery, pneumonectomy, multifocal ground-glass opacities, clinical stage IIIA or more, and preoperative treatment. Overall and disease-free survival (DFS) analyses were conducted with the Kaplan-Meier method and log-rank test, Cox-regression analysis was used to identify the predictors of worse survival. RESULTS:During the study period, 64 patients were screened for the presence of bilateral lung nodules, 45 patients (median age 69 years) were operated for mSBPLC and during the follow-up (median 34 months) we observed 11 deaths and 15 cancer recurrence. In the 80% of patients the main cancer was solid, contralateral was a part-solid in 20%, or pure ground-glass opacity in 20%. Adenocarcinoma was present in 77.8% at first surgery and in 80% at the second. Spread Through the Air Spaces (STAS) was present in 17.8%. The 5-year overall and DFS rate were 77% (median 86 months, 95% CI 72.4-99.5-) and 57% (median 69 months, 95% 32-105.9), respectively. Comparing survivals among patients with and without STAS, we had an overall survival of 0% vs 85% (86 vs 29 months, P < .01) and a DFS of 0% vs 63% (69 vs 9 months, P < .01). The multivariable analysis demonstrated STAS as significant predictor of worse overall (HR 7.08, P = .02) and DFS (HR 5.63, P = .017). CONCLUSIONS:Taking into account the small and highly selected study population, staged bilateral surgery could be considered safe and oncologically adequate, showing the association between the presence of STAS and unfavourable long-term outcomes.
OBJECTIVES:Mediastinal lymph-node dissection (MLND) is recommended for resectable non-small-cell lung cancer (NSCLC); however, its prognostic impact remains controversial. We evaluated whether MLND improves prognosis in patients with radiologically solid-dominant clinical stage I NSCLC. METHODS:We retrospectively reviewed 2212 patients who underwent lobectomy for solid-dominant clinical stage I NSCLC between 2010 and 2022. Prognosis and local control were compared between the MLND and non-MLND groups. RESULTS:The MLND and non-MLND groups included 1912 and 300 patients, respectively. After propensity score matching, 5-year overall survival did not show a statistically significant difference between the groups (85.3% vs 79.3%, P = .089). MLND identified occult pN2 metastasis in 7.3% (138/1912) of patients. Notably, 3.6% (68/1912) of the entire MLND cohort had pN2 disease yet remained recurrence-free. Furthermore, the MLND group demonstrated significantly lower mediastinal lymph-node recurrence than the non-MLND group (P = .017). Among patients with pN2 disease in the MLND group, those with recurrence (n = 70) had a higher incidence of intrapulmonary metastases (P = .042), a higher number of mediastinal lymph-node metastases (P = .002), and a lower rate of skip-N2 involvement (P = .031). CONCLUSIONS:Mediastinal lymph-node dissection provides superior local control by reducing mediastinal recurrences and enables accurate pathological staging. While this advantage guides appropriate adjuvant therapy selection, the direct impact of MLND on overall survival remains uncertain. Its true survival benefit should be evaluated in future prospective randomized trials.
INTRODUCTION:Primary cardiac angiosarcoma is an exceptionally rare malignancy. Familial occurrences are even less common and associated with hereditary cancer syndromes; notably, all previously reported familial cases occurred in young individuals. CASE:We encountered 2 elderly sisters who both developed morphologically similar primary cardiac angiosarcomas arising from the right atrium. The elder sister presented with nocturnal wheezing, and a large right atrial tumour was found at age 70. She underwent surgical resection followed by radiotherapy. The younger sister presented with a similar cough, and screening transthoracic echocardiography revealed a right atrial mass at age 74. She received similar treatment. DISCUSSION:These cases suggest a potential hereditary predisposition and further highlight that familial occurrence of primary cardiac angiosarcoma can manifest even at advanced age, challenging the conventional understanding of this disease.
Severe myocardial failure after acute type A aortic dissection is usually attributed to structural coronary malperfusion. We report catastrophic global left ventricular failure despite preserved epicardial coronary anatomy, successfully bridged with durable mechanical circulatory support. A 57-year-old man presented with acute type A dissection and cardiogenic shock with extensive precordial ST-segment elevation. Emergency total arch replacement with a frozen elephant trunk was performed. Intraoperative inspection and postoperative coronary angiography confirmed patent coronary ostia and arteries. Postoperatively, venoarterial extracorporeal membrane oxygenation and a percutaneous microaxial flow pump was instituted; extracorporeal membrane oxygenation was weaned on day 4, but the patient remained pump-dependent. Perfusion imaging showed extensive fixed defects in the left coronary distribution, and durable left ventricular assist device implantation was required 6 weeks later. Severe myocardial injury can occur in acute type A aortic dissection without demonstrable fixed coronary obstruction. When dysfunction persists after successful repair, early viability assessment is essential to guide timely transition to durable mechanical circulatory support.
OBJECTIVES:The increasing prevalence of acute Stanford type A aortic dissection (ATAAD) among octogenarians necessitates robust, large-scale data to inform surgical decision-making and risk stratification. Thus, we investigated the multicentre Tokyo Acute Aortic Super-Network database to demonstrate in-hospital mortality trends in this vulnerable patient population. METHODS:We analysed patients with ATAAD transported to the network's participating hospitals between January 2015 and December 2022. The study population was stratified into 2 age-based groups: octogenarians (≥80 years) and non-octogenarians (<80 years). Multivariate logistic regression analysis identified independent predictors of in-hospital mortality specifically within the octogenarian group. RESULTS:Among 5361 patients, 1467 (27.4%) were octogenarians. Overall mortality was significantly higher in the octogenarians compared to non-octogenarians (34.5% vs 15.9%; P < .001), whereas operative mortality for those undergoing surgery remained acceptable (10.5% vs 8.1%; P = .035). Multivariable analysis revealed that open false lumen (odds ratio [OR], 3.77; 95% confidence interval [CI], 2.51-5.67; P < .001), shock at arrival (OR, 2.62; 95% CI, 1.68-4.08; P < .001), out-of-hospital cardiopulmonary arrest (OR, 18.99; 95% CI, 7.72-46.72; P < .001), in-hospital cardiopulmonary arrest (OR, 17.39; 95% CI, 6.21-48.67; P < .001), and cerebral malperfusion (OR, 2.17; 95% CI, 1.16-4.06; P = .016) were related to higher mortality in octogenarian patients. Conversely, surgical intervention (OR, 0.15; 95% CI, 0.10-0.22; P < .001) and higher serum albumin levels (OR, 0.65; 95% CI, 0.42-1.00; P = .049) were associated with lower risk of mortality. CONCLUSIONS:Although octogenarians with ATAAD had higher overall mortality, operative mortality among selected patients undergoing surgery remained acceptable, suggesting that advanced age alone should not preclude surgical intervention.
Racemose haemangioma of the bronchial artery is a rare vascular malformation characterized by abnormal communication between the bronchial and pulmonary vasculature. Coronary arterial inflow may further complicate minimally invasive cardiac surgery because excessive collateral flow can impair myocardial protection and increase intracardiac return during cardiac arrest. We report a case of atrial functional mitral regurgitation and tricuspid regurgitation associated with racemose bronchial artery malformation with coronary arterial inflow from the left circumflex artery. Preoperative embolization of systemic feeders from the bronchial and left subclavian arteries was followed by minimally invasive valve repair and surgical ligation of the coronary inflow vessel. The postoperative course was uneventful. A staged hybrid strategy may be effective for managing racemose bronchial artery malformation with coronary arterial inflow.
