Asian Cardiovascular and Thoracic Annals current issue

[ELECTRONIC CASE STUDIES] Correction of Anomalous Drainage of Right Superior Vena Cava to Left Atrium

Sajja, Koneti, Mannam, Sundaram — 2008-07-31

A 2-year-old boy with cyanosis was found to have normal situs and looping with anomalous drainage of a right-sided superior vena cava to the left atrium, and intact interatrial septum in association with anomalous drainage of the left pulmonary veins to the right superior vena cava. He underwent successful surgical repair of this rare congenital malformation.

[ELECTRONIC CASE STUDIES] Right Atrial Thrombus Masquerading as Intracardiac Cyst: a Case Report

Singh, Walsh, Birdi — 2008-07-31

Intracardiac cystic lesions are rare. Hydatid disease, blood cysts and bronchogenic cysts in various chambers of the heart have been reported. Right atrial thrombus presenting as a cystic lesion on echocardiogram has not been reported. We describe a patient with mitral regurgitation in atrial fibrillation with a right atrial cyst, which was found to be a cavitating thrombus.

[ELECTRONIC CASE STUDIES] Right Cervical Aortic Arch with Aberrant Left Subclavian Artery

Tjang, Aramendi, Crespo, Hamzeh, Voces, Rodriguez — 2008-07-31

The combination of right cervical aortic arch, aberrant retroesophageal left subclavian artery originating from a Kommerell’s diverticulum, and a ligamentum arteriosum, constitutes a rare form of vascular ring. Two patients aged 21 days and 54 years, who were diagnosed by multislice 3-dimensional computed tomography and magnetic resonance imaging, underwent surgical division of a vascular ring. The adult required resection of a Kommerell’s aneurysm and subclavian artery reimplantation.

[EDITORIAL] Surgical Ventricular Restoration and the STICH Trial

Di Donato, Menicanti, Suma — 2008-07-31

[EDITORIAL] Endovascular Management of Complicated Acute Type B Aortic Dissection

Chan, Cheng — 2008-07-31

[ORIGINAL CONTRIBUTIONS] Arterial Switch Operation: Troponin T Does Not Predict Ventilation Requirements

Maddali, Valliattu, al Delamie, Zacharias, Ahmed, Ganguly — 2008-07-31

The aim of this study was to assess whether postoperative cardiac troponin T levels could predict ventilation requirements in infants undergoing the arterial switch operation. Cardiac troponin T was measured 6 hours after aortic cross clamping and prior to tracheal extubation in 20 consecutive patients; 10 had simple and 10 had complex (with ventricular septal defect) transposition of the great arteries. The mean plasma troponin T level prior to extubation did not differ significantly in patients who were re-intubated and those who were successfully extubated. The initial cardiac troponin T levels in the complex defect group was significantly higher than in the simple transposition group. There was no correlation between initial cardiac troponin T levels and the duration of mechanical ventilation. There was no difference in mean duration of ventilation between the 2 groups. It was concluded that the postoperative cardiac troponin T level is not a predictor of successful extubation or prolonged artificial ventilation in this subset.

[ORIGINAL CONTRIBUTIONS] Hemodynamic Evaluation of Aortic Regurgitation by Magnetic Resonance Imaging

Wittlinger, Dzemali, Bakhtiary, Moritz, Kleine — 2008-07-31

Magnetic resonance imaging was compared with echocardiography and angiography in determining the regurgitant volume in patients with aortic regurgitation. Forty patients were examined at 1.5 T. The regurgitant jet was located using a gradient-echo sequence. Cine measurements were performed to calculate left ventricular function. For flow evaluation, a velocity-encoded breath-hold phase-difference magnetic resonance sequence was used. The degree of aortic regurgitation assessed by magnetic resonance imaging agreed with that of angiography in 28 of 40 (70%) patients, and with the echocardiography result in 80%. Correlation between calculated stroke volume by magnetic resonance cine and flow measurements was very good (r > 0.9). Magnetic resonance imaging enables quick and reliable quantitative assessment of aortic regurgitant volume, and it might be the optimal technique for multiple follow-up studies and assessment of left ventricular function, leading to better evaluation of disease severity and optimization of the timing of valve surgery.

[ORIGINAL CONTRIBUTIONS] Cardiac Troponin T in Acute Coronary Syndrome with Renal Insufficiency

Chew — 2008-07-31

Cardiac troponin levels are frequently elevated in patients with chronic renal failure, hence diagnosis of myocardial necrosis is difficult. The prevalence of elevated serum troponin T was determined and its diagnostic value in acute coronary syndrome was assessed in patients with chronic renal insufficiency. A retrospective cross-sectional analysis was performed in 227 patients with chronic renal insufficiency and a diagnosis of unstable angina, non-ST or ST-segment elevation myocardial infarction. All patients had baseline serum troponin T levels measured at previous visits; the baseline troponin T level was raised in 53.3%. Cardiac troponin T levels did not correlate with creatinine levels, and were not affected by dialysis. Mortality after an acute coronary event was high (46.3%). Because of the elevated baseline cardiac troponin T levels, detection of acute coronary syndrome in patients with chronic renal failure requires evaluation of serial cardiac enzyme measurements and serial 12-lead electrocardiograms. Early and definitive cardiac interventions may contribute towards decreasing the mortality rate in this group of patients.

[ORIGINAL CONTRIBUTIONS] Esophageal Stethoscope in Thoracoscopic Interruption of Patent Ductus Arteriosus

Kahrom, Kahrom — 2008-07-31

There is a significant rate of residual or recurrent ductal patency after video-assisted thoracoscopic closure of patent ductus arteriosus. Between February 2000 and October 2004, this procedure was carried out on 145 consecutive patients in whom heart sounds were monitored intraoperatively with an esophageal stethoscope. Changes in continuous cardiac murmurs were recorded after placing the 1^st and 2^nd vascular clips. There was no ductal flow after clipping twice in 138 (95%) patients; in the other 7, residual flow was abolished at the 3^rd attempt. All patients left the operating room with no residual ductal patency on echocardiography. After 6 months, there was no incidence of residual patency. Intraoperative esophageal stethoscopy provides remarkably loud and clear heart sounds for direct monitoring and reliable evaluation of the entire course of thoracoscopic patent ductus arteriosus closure, without interrupting the surgical procedure, thus avoiding re-intervention and complications associated with residual ductal flow.

[ORIGINAL CONTRIBUTIONS] Predictors of Sinus Rhythm after Radiofrequency Maze and Mitral Valve Surgery

Chaiyaroj, Ngarmukos, Lertsithichai — 2008-07-31

The prevalence and predictors of postoperative sinus rhythm in patients undergoing a radiofrequency ablation maze operation and mitral valve surgery were assessed in 63 patients of whom 54 (86%) were in permanent atrial fibrillation. Operative mortality was 3.17%. At a median follow-up of 18 months, 54 (88.5%) patients were in sinus rhythm and 7 (11.5%) were in atrial fibrillation. The probability of sinus rhythm at 30 months was 92%. Left atrial diameter was the most significant prognostic factor for sinus rhythm on multivariate proportional-hazard regression analysis. The cutoff value of preoperative left atrial diameter for predicting persistent atrial fibrillation at 6 months was 6 cm (100% sensitivity and 73.6% specificity). The radiofrequency ablation maze operation can be performed in addition to mitral surgery with a high rate of successful conversion to sinus rhythm. Preoperative left atrial diameter < 6 cm is an important prognostic factor for sinus rhythm conversion.

[ORIGINAL CONTRIBUTIONS] Esophageal Injuries Due to Aluminum Phosphide Tablet Poisoning in India

Darbari, Tandon, Chaudhary, Bharadwaj, Kumar, Singh — 2008-07-31

Aluminum phosphide is a lethal systemic poison with 80%–90% mortality. Survivors have taken either a very small amount or the tablet had been exposed to air, rendering it less toxic, but often causing severe esophageal injuries. The presentation and treatment of 11 cases of esophageal injury due to aluminum phosphide are described. Ten patients had esophageal stricture, and 1 had tracheoesophageal fistula with stricture. Endoscopic bougie dilatation was sufficient in 7 patients, and surgical intervention was required in 4 who underwent definitive repair via gastric tube or feeding jejunostomy with a 2^nd stage repair planned in 2. There was no mortality but significant morbidity. Mortality and morbidity might be prevented by withdrawing this pesticide from the market, making its sale difficult, or modifying the packaging.

[ORIGINAL CONTRIBUTIONS] Mortality in Open Heart Surgery with Intraaortic Balloon Pump Support

Karimi, Movahedi, Salehiomran, Marzban, Hesameddin Abbasi, Yazdanifard — 2008-07-31

Mechanical circulatory assistance is frequently needed to support the failing heart. The aim of this study was to determine perioperative prognostic factors for hospital mortality in patients undergoing open heart surgery who required intraaortic balloon pump support. Between January 2002 and September 2006, 475 patients received an intraaortic balloon pump perioperatively. Hospital mortality was 21.89%. Risk factors for hospital death identified by multivariate logistic regression analysis were peripheral vascular disease, left main coronary artery disease, postoperative renal failure, postoperative cardiac arrest, and prolonged hospital stay. Minor and major intraaortic balloon pump-related complications were not significant in univariate and multivariate analysis; the incidence was 5.05%. It is suggested that the threshold for using balloon pump support is decreased in high-risk patients undergoing cardiac surgery.

[ORIGINAL CONTRIBUTIONS] Anomalous Origin of Right Coronary Artery From Left Coronary Sinus

Hamzeh, Crespo, Estaran, Rodriguez, Voces, Aramendi — 2008-07-31

Anomalous aortic origin of the coronary arteries is uncommon but clinically significant. Manifestations vary from asymptomatic patients to those who present with angina pectoris, myocardial infarction, heart failure, syncope, arrhythmias, and sudden death. We describe 4 patients, aged 34 to 59 years, who were diagnosed with right coronary artery arising from the left sinus of Valsalva, confirmed by coronary angiography, which was surgically repaired. Three patients presented dyspnea and angina, and one with acute myocardial infarction. At operation, the right coronary artery was dissected at the take-off from the intramural course, and reimplanted into the right sinus of Valsalva. There was no mortality. One patient had associated coronary artery disease that required stent placement postoperatively. This reimplantation technique provides a good physiological and anatomical repair, eliminates a slit-like ostium, avoids compression of the coronary artery between the aorta and the pulmonary artery, and gives superior results to coronary artery bypass grafting or the unroofing technique.

[ORIGINAL CONTRIBUTIONS] Novel Anti-Adhesive Pericardial Substitute for Multistage Cardiac Surgery

Matsumura, Shin'oka, Ikada, Sakamoto, Kurosawa — 2008-07-31

Dense adhesions in the retrosternal space make reoperations difficult in the field of cardiovascular surgery. Several substitutes for pericardium have been employed to prevent dense adhesions forming, but they have been unsatisfactory because of peel formation, calcification, and infection. To overcome these drawbacks, a novel biodegradable pericardial substitute was developed from gelatin obtained from specific-pathogen-free porcine skin and a bioabsorbable polyester mesh, which persists while the adhesion reaction occurs in the retrosternal space. A clinical pilot study of this gelatin sheet was carried out in patients scheduled to receive multistage cardiac surgery. From February 2003 to July 2004, the material was used in 5 patients aged 0.4 to 3.0 years. There were no complications related to the gelatin sheet. The effectiveness of the material was evaluated when the sternum was reopened 1.4 ± 0.5 years later. It took 24.5 ± 6.0 min for the resternotomy, and all surgeons who participated in the surgery rated the effectiveness of the gelatin sheet as "good". This anti-adhesive sheet prevented dense adhesions, suggesting that this material may be useful as a pericardial substitute for multistage pediatric cardiac surgery.

[ORIGINAL CONTRIBUTIONS] Mammary Artery Patch Reconstruction of Left Anterior Descending Coronary Artery

Prabhu, Thazhkuni, Rajendran, Thamaran, Vellachamy, Vettath — 2008-07-31

Most patients with diffuse coronary disease require endarterectomy for revascularization. In view of the high morbidity and mortality associated with coronary endarterectomy, patch angioplasty and reconstruction of the coronary artery was developed. We retrospectively evaluated 104 patients who underwent mammary artery patch angioplasty of the left anterior descending coronary artery. The procedure consisted of laying open the entire diseased segment of the coronary artery and patching it with an in-situ left internal mammary artery onlay patch, without endarterectomy, in an off-pump procedure. One (0.9%) patient died, 2 (1.8%) suffered perioperative myocardial infarction, and an intraaortic balloon pump was used in 2. The mean blood loss was 224 mL. Intensive care unit stay was 2.5 days, and hospital stay was 7.8 days. At 1-year follow-up, most patients were in New York Heart Association functional class I. Follow-up angiography was carried out in 16 patients and showed good patency of all anastomoses. Arterial patch reconstruction of the left anterior descending coronary artery can be performed safely and effectively in an off-pump procedure, with excellent early and intermediate results.

[CASE STUDIES] Early Repair of Acquired Tracheoesophageal Fistula

Yeh, Chou — 2008-07-31

We report early direct repair of a cuff-related tracheoesophageal fistula in a 30-year-old alcoholic man with diabetic ketoacidosis who fell unconscious and was ventilated via an endotracheal tube. He was successfully weaned from the ventilator 1 week after the operation.

[CASE STUDIES] Retrieval of Broken Paravertebral Catheter by Video-Assisted Thoracic Surgery

Sihoe, Das, Ling, Cheng — 2008-07-31

A paravertebral catheter was placed in a 34-year-old man to provide analgesia after a right upper lobectomy. On removal, the catheter broke within the chest wall. Although bedside exploration and computed tomography scanning failed to locate it, the 13-cm long retained fragment was easily retrieved by video-assisted thoracic surgery, using a single-port technique.

[CASE STUDIES] Anomalous Left Coronary Artery from Non-facing Pulmonary Sinus

Hirota, Kawada, Ishino, Sano — 2008-07-31

A case of anomalous left coronary artery originating from the non-facing pulmonary sinus, located at the most distal position from the aorta, is described. An intrapulmonary tunnel was created without causing undue stenosis or kinking. The Takeuchi procedure is considered to be a useful surgical technique when the origin of the anomalous left coronary artery is far from the aorta.

[CASE STUDIES] Simultaneous Bilateral Carotid Endarterectomy Under Local Anesthesia

Portinos, Kefaloyannis, Philippakis, Dountsis, Zisis, Bellenis — 2008-07-31

A 75-year-old man with bilateral carotid stenosis and severe coronary artery disease underwent successful simultaneous bilateral carotid endarterectomy under local anesthesia. A few days later, coronary artery bypass grafting was performed with no complications.

[HOW TO DO IT] A Simple Method of Inspection of Proximal Bleeding in Bentall Procedure

Song, Tokuda, Nakayama, Hattori — 2008-07-31

A simple method of checking for bleeding from the proximal anastomosis site in Bentall operations is described. After suturing a Carbo-Seal prosthesis to the aortic annulus, using a folding-over technique, the left ventricle is filled with cardioplegic solution through the prosthetic valve, and the heart is massaged to visualize possible leaks at the level of the suture.

[REVIEW PAPER] Pathophysiology of Aortocoronary Saphenous Vein Bypass Graft Disease

Hassantash, Bikdeli, Kalantarian, Sadeghian, Afshar — 2008-07-31

Aortocoronary saphenous vein bypass grafting relieves anginal pain in patients with coronary artery disease. However, its effectiveness is limited due to graft failure; the 10-year patency rate is 50%–60%. Early, 1-year and late graft failure may be due to thrombosis, fibrointimal hyperplasia and atherosclerosis, respectively. There is general agreement that vein graft atherosclerosis differs from arterial lesions in terms of temporal and histological changes. Vein graft atherosclerosis is more rapid, with diffuse concentric changes and a less noticeable fibrous cap, making venous plaques more vulnerable to rupture and subsequent thrombus formation. Despite progress in understanding the pathophysiology, some aspects of vein graft atherosclerosis need to be clarified. This review focuses on the pathophysiologic aspects of this widespread, costly and disabling disease, with emphasis on late graft occlusion and distinctions between arterial and venous atherosclerosis in terms of histology, pathophysiology and risk factors.

[REVIEW PAPER] Endovascular Repair of Traumatic Thoracic Aortic Injuries: a Critical Appraisal

Lin, Huynh, Kougias, Wall, Coselli, Mattox — 2008-07-31

Blunt trauma to the thoracic aorta is life-threatening, with instant fatality in at least 75% of victims. If left untreated, nearly half of those who survive the initial injury will die within the first 24 hours. Surgical repair has been the standard treatment of blunt aortic injury, but immediate operative intervention is frequently difficult due to concomitant injuries. Although endovascular treatment of traumatic aortic disruption is less invasive than conventional repair via thoracotomy, this strategy remains controversial in young patients due to anatomical considerations and device limitations. This article reviews the likely advantages of endovascular interventions for blunt thoracic aortic injuries. Potential limitations and clinical outcomes of this minimally invasive technique are also discussed.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Left Upper Limb Shortening Following Reverse Flap Subclavian Artery Angioplasty

Maddali, Menon, Valliattu, Maimouna — 2008-07-31

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] A Rare Cause of Pericardial Tamponade

Nanjappan, RajagopalaReddy, Velayutham, Rajagopal, DoraiRajan — 2008-07-31

[LETTER TO EDITOR] NEONATAL SHUNT OPERATIONS

Erer, Banach, Ugurlucan — 2008-07-31