Abnormalities, multiple; aorta, thoracic/abnormalities/surgery; aortic arch syndromes/congenital/surgery; aortic coarctation/complications; cardiovascular surgical procedures/methods; infant; palliative care/methods; pulmonary artery/surgery; transposition of great vessels/surgery
Localized aneurysms of the sinus of Valsalva are uncommon. Repair is tailored to the defective anatomy of the sinus, the aortic valve, and the coronary artery.
Herein, we report the successful surgical treatment of 2 patients who had unruptured pseudoaneurysms of the sinus of Valsalva. An evident fissure in the intima of the sinus of Valsalva was seen in both patients. Patient 1 was a 57-year-old man with annuloaortic ectasia who was diagnosed with pseudoaneurysm of the right sinus of Valsalva. A thrombus that had formed in the pseudoaneurysm subsequently migrated into the right coronary artery. Aortic root remodeling was performed. Patient 2 was a 23-year-old man with a history of blunt chest trauma. He developed a pseudoaneurysm in the right sinus of Valsalva and tears on the aortic cusps. He underwent aortic valve replacement and repair of the Valsalva wall.
Aorta/injuries; aortic aneurysm/complications/diagnosis/epidemiology/pathology/surgery; heart valve prosthesis implantation; sinus of Valsalva/abnormalities/pathology/radiography/surgery; thrombosis/complications/surgery; vascular fistula
Pseudoaneurysm formation is a rarely reported phenomenon after percutaneous coronary intervention. The natural course and clinical complications of coronary pseudoaneurysms are not well described, and the possible contribution of drug-eluting stents to the formation of coronary artery pseudoaneurysms is ill defined. Herein, we describe the case of a patient who experienced pseudoaneurysm formation 1 month after deployment of a paclitaxel-eluting stent. Healing was delayed, and there was resolution after 2 years of follow-up.
Aneurysm, false/complications/diagnosis/etiology/ultrasonography; angioplasty, transluminal, percutaneous coronary; blood vessel prosthesis implantation/adverse effects; coronary aneurysm/diagnosis/etiology/pathology/therapy; coronary vessels/pathology; incidence; paclitaxel/adverse effects; remission, spontaneous; stents/adverse effects; treatment outcome
Coma or stroke with secondary brain malperfusion is usually considered a strong contraindication for emergent surgical treatment of acute aortic dissection.
Herein, we present the case of a 30-year-old woman who presented with sudden left hemiplegia and level-7 coma on the Glasgow Coma Scale. Transthoracic echocardiography showed type A aortic dissection. Although the patient was unable to communicate, her family approved an emergency Bentall operation. She regained consciousness but developed anisocoria and Glasgow Coma Scale level-4 coma 30 hours after the operation. Computed tomography showed massive cerebral infarction with hernia of the uncus gyri hippocampi. Emergency surgical cerebral decompression was performed. The patient survived; after 1 year, she had full mental acuity and minor left motor sequelae.
Age factors; aneurysm, dissecting/complications/surgery; aortic aneurysm, thoracic/complications/mortality/surgery; brain ischemia/surgery; cardiovascular surgical procedures; cerebrovascular disorders/etiology/mortality/surgery; coma/complications; emergency treatment/contraindications; postoperative complications/prevention & control; risk management; stroke/complications; treatment outcome
Airway obstruction/etiology; aorta, thoracic/abnormalities; aortic arch syndromes/congenital; aortic diseases/congenital/diagnosis/surgery; constriction, pathologic; esophageal stenosis/etiology; tracheal stenosis/etiology
Congestive heart failure has long been one of the most serious medical conditions in the United States; in fact, in the United States alone, heart failure accounts for 6.5 million days of hospitalization each year. One important goal of heart-failure therapy is to inhibit the progression of congestive heart failure through pharmacologic and device-based therapies. Therefore, there have been efforts to develop device-based therapies aimed at improving cardiac reserve and optimizing pump function to meet metabolic requirements. The course of congestive heart failure is often worsened by other conditions, including new-onset arrhythmias, ischemia and infarction, valvulopathy, decompensation, end-organ damage, and therapeutic refractoriness, that have an impact on outcomes. The onset of such conditions is sometimes heralded by subtle pathophysiologic changes, and the timely identification of these changes may promote the use of preventive measures. Consequently, device-based methods could in the future have an important role in the timely identification of the subtle pathophysiologic changes associated with congestive heart failure.
Atrial fibrillation/complications; disease progression; disease management; heart atria/pathology; heart failure, congestive/outcomes/prevention/therapy; prognosis; tachycardia, supraventricular
End-stage heart-failure patients in acute refractory cardiogenic shock with multi-organ dysfunction require aggressive medical therapy that includes inotropic support. Historically, the intra-aortic balloon pump was the last option for patients who were dying of acute cardiogenic shock. Short-term extracorporeal pulsatile or nonpulsatile cardiac assist devices or extracorporeal membrane oxygenation offered further treatment options; however, these therapies required invasive surgical procedures. Patients in this high-risk group had increased mortality rates from major procedures that required cardiopulmonary bypass. We used the TandemHeart®, a percutaneously implanted device for short-term cardiac assistance, to lower the risk of death and improve hemodynamic performance and end-organ perfusion before implanting long-term assist devices in selected patients with signs of profound cardiogenic shock.
Nine end-stage heart-failure patients (mean age, 37.7 yr) in acute refractory hemodynamic decompensation received a percutaneously implanted TandemHeart pump as a bridge to an implantable axial-flow pump. To determine the relative risk for these patients, prognostic scores were calculated before and after insertion of the TandemHeart.
Percutaneous support times ranged from 1 to 22 days (mean, 5.9 d). The mean cardiac index before support, 1.02 L/(min·m2) (range, 0.0–1.8 L/[min·m2]) (0.0 L/[min·m2] implies active cardiopulmonary resuscitation), improved to 2.97 L/(min·m2) (range, 2.2–4.0 L/[min·m2]) during support. Three patients underwent successful cardiac transplantation; 5 are currently supported by axial-flow pumps; and 1 died of complications unrelated to the axial-flow pump, after 587 days.
End-organ function and overall condition improved uniformly in our patients, thus decreasing the preoperative risk factors for implantation of the long-term device.
Cardiac output, low/mortality/therapy; cardio-myopathies; heart-assist devices/design/standards/statistics & numerical data; heart failure/mortality/therapy; prostheses and implants; risk management; severity of illness index; shock, cardiogenic/complications/mortality/therapy; survival analysis; treatment outcome
We sought to determine U.S. physicians' knowledge and perspectives regarding the 2004 American College of Cardiology/American Heart Association guidelines for management of patients who have ST-segment–elevation myocardial infarction (STEMI). We invited 45,998 physicians from the American Medical Association's roster to take an Internet survey of U.S. cardiologists and emergency physicians who were hospital-based or who had hospital-admitting privileges. To represent individual and combined populations, data were weighted on the basis of years in practice, sex, and geographic region. Of 505 cardiologists and 509 emergency physicians who completed the survey, 90% worked in an urban or suburban setting and 82% at hospitals with a cardiac catheterization laboratory. Sampling error was ±3.4%. Most respondents (61%) believed that overall myocardial infarction treatment needed a “great deal” or “fair amount” of improvement; 24% were “somewhat” or “not at all” familiar with the guidelines. Although 84% knew the recommended STEMI treatments for a patient who presents within 3 hours of symptom onset without contraindications to reperfusion or delay to invasive treatment, only 11% knew that there is no preferred approach. If percutaneous coronary intervention proved impossible within 90 minutes of presentation, 21% reported that eligible patients—assuming early presentation, confirmed STEMI diagnosis, and no high-risk STEMI or contraindications to fibrinolysis—would “rarely” or “never” receive guideline-recommended fibrinolysis.
Many cardiologists and emergency physicians are unfamiliar with the guidelines and with the uncertainty that surrounds therapeutic approaches, which suggests the need for increased education on effective treatments to expedite myocardial reperfusion in STEMI.
Angioplasty, transluminal, percutaneous coronary/standards/utilization; cardiovascular diseases/epidemiology/mortality; chronology as topic; delivery of health care/standards; fibrinolysis; guideline adherence; hospitals/standards; practice guidelines as topic; quality assurance/health care; randomized controlled studies as topic; statistics & numerical data; statistics as topic; time factors; treatment outcome
Congenital atresia of the left main coronary artery, a condition in which the left main trunk is developed but has been occluded since birth, is a rare coronary anomaly. Herein, we describe this anomaly's association with a subannular location of an obliterated left main ostium in a patient with a bicuspid aortic valve and severe aortic stenosis. The patient underwent successful surgery. We discuss the embryologic implications of congenital atresia of the left main coronary artery, in view of the exceptional anatomic features of this condition. To our knowledge, this is the 1st report of a left coronary artery that was found to arise from the left ventricle.
Aortic stenosis, supravalvular/complications/diagnosis/surgery; coronary disease/classification/congenital/diagnosis; coronary vessel anomalies/classification/complications/diagnosis/pathology/surgery; echocardiography; heart defects, congenital/diagnosis/pathology/surgery
We investigated the relationship between acute coronary ischemia and the presence of Helicobacter pylori DNA in aortic regions that were absent macroscopic atheromatous plaques.
The study group (Group 1) consisted of 42 patients who underwent coronary artery bypass grafting. Biopsy samples were obtained from 2 different locations: from regions of the aorta that were free (macroscopically) of atheromatous plaque (Group 1A), and from the internal mammary artery (Group 1B). The control group (Group 2) of 10 patients who had no atherosclerotic vascular disease provided aortic tissue samples for comparison. The real-time polymerase chain reaction method was used to detect H. pylori DNA in all biopsy samples.
Eleven of 42 aortic tissue samples (26%) in Group 1A were positive for H. pylori DNA. Neither biopsies from the left internal mammary arteries of those patients nor biopsies from the aortas of the control group (Group 2) were positive for H. pylori DNA. There was a statistically significant difference between 1A and 1B in terms of H. pylori positivity (P=0.001). In Group 1 as a whole, acute coronary ischemia was more prevalent in the H. pylori-positive patients than in the H. pylori-negative patients (P=0.001).
To our knowledge, this is the 1st study to investigate the detection of H. pylori DNA in aortic biopsy samples that are macroscopically free of atheromatous plaque. Such detection in patients who have atherosclerotic coronary artery disease could be an important indication of the role of microorganisms in the pathogenesis of atherosclerosis.
Aorta; arteriosclerosis/etiology; Helicobacter infections/complications; Helicobacter pylori/pathogenicity; polymerase chain reaction; prospective studies; real-time PCR; mammary arteries; muscle, smooth, vascular
We analyzed the postoperative short- and mid-term outcomes of a series of patients with annuloaortic ectasia who underwent a modified Bentall operation in our clinic from September 2000 through March 2006.
The study included 44 patients. Their average age was 53.4 ± 14.1 years. The underlying disease was degenerative aortic aneurysm in 42 patients (95.5%) and acute aortic dissection in 2 patients (4.5%). Six patients (13.6%) had Marfan phenotype. Aortic insufficiency was moderate in 30 patients (68.2%) and severe in 14 patients (31.8%).
In our modification of the Bentall technique, we completed the resection of the aortic root while leaving 5 to 10 mm of native aortic wall tissue to support the anastomosis. A long piece of Teflon felt (width, 0.5–1 cm) was laid on the annulus, and nonpledgeted 2–0 polyester sutures were passed in turn through the Teflon felt, the preserved aortic tissue, and the aortic annulus. A thin piece of Teflon felt was also used in the coronary artery reimplantation sites. Fibrin glue was routinely applied to all anastomoses.
There were no intraoperative deaths. One patient died in the hospital after surgery for acute type I aortic dissection. Another patient died 1 year after the operation from prosthetic-valve endocarditis. No patient required surgical correction of excessive postoperative bleeding. Kaplan-Meier curves showed overall survival of 0.94 (95% confidence intervals, 0.9–0.99).
We consider our approach an easy, effective way to minimize bleeding from the anastomoses and at the aortic root—a common challenge in aortic surgery.
Anastomosis, surgical; aneurysm, dissecting/complications/surgery; aorta, thoracic/surgery; aortic valve insufficiency/surgery; cardiac surgical procedures/methods; coronary vessels/surgery; heart valve prosthesis implantation/methods; retrospective studies; survival analysis; suture techniques; treatment outcome
We report what we believe is the 1st case in the medical literature in which an intravenous thrombolytic agent was used successfully—without massive intracranial bleeding—to treat acute stroke induced by atrial myxoma. Our patient, who had biatrial myxomas with a dual blood supply from the right coronary artery, presented with cerebral ischemia. Transesophageal echocardiography was essential in clarifying the diagnosis and in helping to direct surgical treatment.
Cerebrovascular accident; echocardiography, transesophageal; embolism; heart atria/surgery; heart neoplasms/complications/diagnosis/surgery; intracranial embolism and thrombosis/etiology/drug therapy; myxoma; thrombolytic therapy; tissue plasminogen activator
We compared the diagnostic accuracy of N-terminal prohormone brain natriuretic peptide (NT-proBNP) with that of echocardiography in the evaluation of left ventricular diastolic dysfunction after coronary artery bypass grafting.
Thirty patients were studied prospectively. Patients who had recent myocardial infarction, unstable angina pectoris, or low ejection fraction with systolic dysfunction were excluded. Two blood samples were obtained: before anesthetic induction and on the 7th postoperative day. Levels of NT-proBNP were measured by electrochemiluminescence immunoassay. Comprehensive echocardiographic Doppler examinations were performed on admission and on the 7th postoperative day. Relationships between NT-proBNP levels and echocardiographic indices were evaluated by correlation, multiple linear regression, and receiver-operating characteristic curve analysis.
There were significant and correlated worsenings in diastolic stage as determined both by echocardiographic indices and NT-proBNP levels. Early transmitral-to-early diastolic annular velocity ratio (E/Ea) was found to correlate with both NT-proBNP and postoperative diastolic functional stage (r=0.78, P <0.001). Mitral E/Ea was significantly more sensitive than were NT-proBNP levels in predicting diastolic functional stage. The area under the receiver-operating characteristic curve for NT-proBNP was significantly lower than that of mitral E/Ea (mean difference, 0.12; P=0.024). The NT-proBNP had 87.5% sensitivity and 55% specificity, whereas E/Ea had 87.5% sensitivity and 86.4% specificity.
Plasma NT-proBNP levels are significantly related to mitral E/Ea ratio, which is a predictor of diastolic stage. Therefore, elevated NT-proBNP levels may indicate the time for a Doppler echocardiographic evaluation and identify a subgroup of patients at high risk who need closer monitoring during the early postoperative period.
Diastole/physiology; echocardiography; heart ventricles; left ventricular dysfunction; myocardial ischemia/diagnosis; natriuretic peptide, brain/blood/diagnostic use; predictive value of tests; pro-brain natriuretic peptide; sensitivity and specificity; ventricular dysfunction, left/blood/diagnosis/physiology
Statin treatment markedly reduces the incidence of acute coronary events in patients with coronary atherosclerosis. Although imaging studies have indirectly shown the beneficial effects of statins on plaque morphology, there has to our knowledge been no reported histologic comparison of the morphology of coronary plaque in statin-treated versus untreated patients who had substantial coronary artery atherosclerosis.
We retrospectively studied arterial sections from the native hearts of patients who had experienced end-stage ischemic heart disease and subsequent cardiac transplantation. Of 44 qualified patients, 33 study patients had received pre-transplantation statin therapy, and 11 control patients had not.
Pathologic examination of each explanted heart confirmed coronary artery disease and previous myocardial infarction in all patients. Diabetes mellitus was more prevalent in the study group. The groups were similar in levels of total and low-density lipoprotein cholesterol, and in the available number of arterial cross-sections per patient.
All patients had plaques. High-grade lesions were found in 66.3% of cross-sections in the control group, and in 34.6% in the study group (P=0.011). Conversely, the degree of inflammation was markedly lower in the study group: low-grade fibrous plaques occurred in 45.7% of cross-sections in the study group, versus 11.3% in the control group (P=0.006).
The study group had significantly fewer high-grade plaques and more fibrous plaques than did the control group at the time of transplantation. Our findings show that statin therapy substantially enhances plaque stabilization. We further suggest that reduction of plaque inflammation is an important aspect of this stabilization.
Antilipemic agents/therapeutic use; arteriosclerosis/drug therapy; coronary artery disease/classification/complications/drug therapy/pathology/prevention & control; coronary vessels/pathology; hydroxymethylglutaryl-CoA reductase inhibitors/therapeutic use; hyperlipidemias/blood/complications/drug therapy; immunohistochemistry; inflammation/drug therapy/physiopathology; macrophages/drug effects/pathology; muscle, smooth, vascular/drug effects/pathology; vascular patency/drug effects
During coronary artery bypass grafting, the length of the graft to the circumflex coronary artery or its end branches can be underestimated because of the posterior location of the circumflex. Herein, we describe a new bypass route—which we consider the shortest—to the ascending aorta.
In 2 patients, during proximal anastomosis of the saphenous vein bypass graft (via a route either anterior to the pulmonary artery or the transverse sinus) from the circumflex to the ascending aorta, the vein graft (approximately 5–6 cm in length) proved too short. We performed bypass in a new direction—from the circumflex coronary artery to the right side of the ascending aorta, under the inferior and superior venae cavae and along the interatrial groove—without the need for graft lengthening.
To our knowledge, the bypass route to the circumflex system described herein is new. This new route can be successfully used when the bypass conduit is too short to follow the conventional route. Our 2 patients benefited from this approach and were in Canadian Cardiovascular Society Class l two years after the surgical procedure.
Anastomosis, surgical/methods; cardiac surgical procedures/methods; cardiopulmonary bypass/methods; coronary artery bypass/methods; coronary artery disease/surgery; coronary vessels/surgery; treatment outcome
The CentriMag left ventricular assist system can be used for perioperative or postcardiotomy circulatory support of the failing heart. The device resides at the patient's bedside, and the cannulae are usually inserted through a midline sternotomy, with the inflow cannula in the left ventricle or right superior pulmonary vein and the outflow cannula in the aorta. In a patient whose chest has been closed and who has a delayed need for temporary mechanical support, a less invasive method of left ventricular assist device cannula insertion is preferred. In these cases, the CentriMag cannulae can be inserted through a right minithoracotomy with the inflow cannula in the right superior pulmonary vein and the outflow cannula in the aorta, with no heparinization. Herein, we describe this approach in a patient who experienced postcardiotomy cardiogenic shock after aortocoronary bypass surgery. This technique may facilitate ambulation and recovery in selected patients.
Centrifugation/instrumentation; equipment design; extracorporeal circulation/instrumentation; heart-assist devices; heart failure/therapy; heart valve prosthesis implantation; patient selection; treatment outcome