Alastair Graham

Incidence and outcome of re-entry injury in redo cardiac surgery: benefits of preoperative planning

OBJECTIVES Repeat sternotomy for redo cardiac surgery may be associated with catastrophic injuries to mediastinal structures. The purpose of this study was to determine the frequency of these injuries, associated outcome and if a preoperative computerized tomography (CT) scan reduces the risk of re-entry injury. METHODS Five hundred and forty-four patients who underwent redo cardiac surgery between 2001 and 2011 were identified by review of our units prospectively maintained cardiac surgery database. Demographic details, surgical strategy, re-entry injuries, hospital stay, in-hospital mortality and long-term survival were analysed. RESULTS The mean age was 61 years; 326 were male, 218 were female. Four hundred and eighty six patients underwent first time redo surgery, while 58 patients had multiple previous operations. The median logistic EuroSCORE was 11, in-hospital mortality rate was 9.5% and observed to expected mortality rate was 0.8. Re-entry complications occurred in 15 cases (2.7%). These included injuries to the aorta (n = 2), right atrium (n = 1), innominate vein (n = 2), internal mammary artery (n = 2), pulmonary artery (n = 2), lung parenchyma (n = 1), saphenous vein graft (n = 2), right ventricle (n = 2) and ventricular fibrillation (n = 1). The mortality rate in patients with re-entry injury was 26% (n = 4) compared with 9% (n = 48) in those without re-entry complications. Preoperative planning by CT scan was performed in 162 cases and adherence of vital structures to the sternum was found in 60 cases; the right ventricle, innominate vein and bypass grafts in 41, 11 and 8, respectively. The incidence rate of re-entry injury was 0.6% in these patients vs 3.6% in those who did not have a preoperative CT scan (P = 0.046). Peripheral arterial cannulation was carried out in 35 patients (6.4%) to establish cardiopulmonary bypass (CPB) prior to sternotomy, and there were no mediastinal injuries observed in these cases. Multivariate logistic regression analysis revealed re-entry injury as one of the independent predictors of in-hospital mortality (P = 0.039). CONCLUSIONS The incidence of re-entry injury during repeat sternotomy is low; however, it is associated with a significant increase in the risk of in-hospital mortality. Preoperative planning using CT scan reduces the risk by identifying adherent structures, and, in selected patients, establishing CPB prior to sternotomy is a safe strategy in redo cardiac surgery.

Kommerell's Diverticulum, Risk Factor for Aortic Dissection

Abstract  A 54‐year‐old man presented with sharp chest pain and hypertension. He was treated with intravenous antihypertensive with good control of the blood pressure. Chest X‐ray showed widened mediastinum, and subsequent computed tomography scan of the chest demonstrated dissection of the descending thoracic aorta. It also showed an aberrant right subclavian artery with retrograde extension of dissection and Kommerells diverticulum, which is dilatation at the origin of the aberrant subclavian artery.

Massive pulmonary embolism due to late-onset heparin-induced thrombocytopenia following coronary artery bypass graft surgery: successful treatment with lepirudin.

Abstract  Most cardiac surgical patients have had previous exposure to heparin for diagnostic or therapeutic interventions and hence have an increased susceptibility to developing heparin‐induced thrombocytopenia (HIT) postoperatively. HIT is an immune‐mediated adverse drug reaction that may be associated with limb or life‐threatening thrombosis. Heparin cessation is a vital first step in treatment; however, alternative anticoagulant therapy is essential. Recombinant hirudin (lepirudin), a thrombin‐specific inhibitor, provides safe and effective anticoagulation in such patients. We describe a case of delayed onset HIT with resulting massive pulmonary embolism postcardiac surgery that was successfully managed with lepirudin. (J Card Surg 2003; 18:316‐318)Most cardiac surgical patients have had previous exposure to heparin for diagnostic or therapeutic interventions and hence have an increased susceptibility to developing heparin-induced thrombocytopenia (HIT) postoperatively. HIT is an immune-mediated adverse drug reaction that may be associated with limb or life-threatening thrombosis. Heparin cessation is a vital first step in treatment; however, alternative anticoagulant therapy is essential. Recombinant hirudin (lepirudin), a thrombin-specific inhibitor, provides safe and effective anticoagulation in such patients. We describe a case of delayed onset HIT with resulting massive pulmonary embolism postcardiac surgery that was successfully managed with lepirudin. (J Card Surg 2003; 18:316-318)

Williams Syndrome in an Adult

Abstract  We report a case of a diagnosis of Williams syndrome in a 57‐year‐old male referred for cardiac surgery with a presumptive diagnosis of aortic valvular stenosis and ascending aortic aneurysm, supravalvular stenosis being first suspected during surgery. Williams syndrome was subsequently confirmed via genetics testing. In patients presenting with an ascending aortic aneurysm, developmental delay, and with poorly visualized coronary arteries during angiography, the diagnosis of supravalvular aortic stenosis or Williams syndrome should be considered. (J Card Surg 2010;25:339‐342)

Off-pump coronary artery bypass grafting and left lower lobectomy simultaneously performed via a left postero-lateral thoracotomy.

Abstract A 75‐year‐old male with angina and a squamous carcinoma of the left lower lobe underwent a single‐stage procedure for the treatment of these lesions. Through a left postero‐lateral thoracotomy, a left lower lobectomy was performed with systematic nodal dissection including the subcarinal and paraaortic lymph nodes. A reversed saphenous vein segment was used to bypass the left anterior descending artery from the ascending aorta without cardiopulmonary bypass. (J Card Surg 2003; 18:22‐24)

Diffuse Coronary Artery Disease and Dystrophic Calcification of the Radial Artery—Is There an Association?

Abstract  Arterial revascularization is an attractive surgical option in the management of coronary artery disease (CAD). In the recent years, the radial artery (RA) has enjoyed resurgence in popularity as the preferred arterial conduit of choice after the internal mammary artery. Despite renewed interest in RA conduits, little is known of the prevalence of preexisting disease in this vessel, and in particular which patient subgroups are most affected, hence implications for long‐term graft patency remain uncertain. We present our experience of three patients with diffuse CAD, found to have dystrophic calcification of their radial arteries intraoperatively. In all cases, the radial arteries were used, and the patients remain well and symptom‐free. Soft tissue X‐rays of the contra lateral forearm taken postoperatively demonstrated obvious calcification in the radial arteries in all patients. Diffuse CAD may reflect calcific disease in the RA. Suitability of a calcified RA as a conduit for CABG depends on long‐term patency, which requires further evaluation.

Traumatic Aortic Rupture During Pregnancy

Abstract  A 29‐year‐old woman, in her third trimester of pregnancy, underwent emergency Caesarian section for placental abruption following a road traffic accident. Following transfer, an abrupt change in the diameter of the aorta was noted on CT scan. Aortography confirmed aortic rupture distal to the left subclavian artery and Dacron graft replacement of this segment was carried out, utilizing a left atrial to descending aorta partial bypass through a centrifugal pump. The mother is alive and well at 4 months follow‐up. (J Card Surg 2003;18:557‐561)

Hazards of interpreting the late results on durability of bioprosthetic valves. Cautions & suggestions.

Article history: Received 1 June 2016 Accepted 7 July 2016 Available online 9 July 2016 they be used in patients younger than 65? For example, there have been recent claims of excellent long term results in patients with bioprosthetic implants in the age range 50–65. This editorial is an attempt to outline the various hazards in interpretation of the long term results presented in the literature for the different bioprosthetic valves.

Systolic anterior motion of mitral valve with calcified annulus in octogenarians.

Systolic anterior motion of the mitral leaflet causing left ventricular outflow tract obstruction is commonly seen in hypertrophic cardiomyopathy and also in patients with advanced mitral valve disease with excessive anterior leaflet tissue or a reduced aortic-mitral angle. We describe 2 octogenarians who presented with systolic mitral leaflet anterior motion in advanced mitral valve disease with severe mitral annular calcification and associated asymmetrical septal hypertrophy.

Seronegative rheumatoid arthritis: a rare cause of effusive–constrictive pericarditis requiring pericardiectomy

Effusive-constrictive pericarditis is a rare condition. In this report, we describe a case of effusive-constrictive pericarditis caused by seronegative rheumatoid arthritis which was successfully treated with surgical pericardiectomy.