Aristotelis Panos

Impending Paradoxical Embolism: Systematic Review of Prognostic Factors and Treatment

BACKGROUND Little is known about the optimal management of impending paradoxical embolism (IPDE), a biatrial thromboembolus caught in transit across a patent foramen ovale. Our aim was to review observational studies on this subject to identify prognostic factors and to compare mortality and systemic embolism between treatments. METHODS Systematic literature searches in Medline, Embase, and Cochrane Library identified 154 studies (174 patients). The primary end point was 30-day mortality. The secondary end point was systemic embolism during treatment. RESULTS Thirty-day mortality was 18.4%. On univariate analysis, age (64+/-13.9 vs 56.7+/-16.5; P = .01), coma (12.9% vs 2.2%; P = .02), and systemic embolism (71.9% vs 51.4%; P = .048) at presentation were significantly increased among nonsurvivors. Surgical thromboembolectomy had lower mortality than other treatment groups (10.6%; P = .04). In multivariable models, no prognostic factor was a significant independent predictor of mortality. Surgically treated patients had nonsignificantly reduced mortality (odds ratio [OR], 0.65 [0.24-1.72]; P = .65) and thrombolysis-treated patients had increased mortality (OR, 1.62 [0.43-5.97]; P = .47). However, systemic embolism during treatment and combined mortality and systemic embolism was decreased in the surgery group (OR, 0.13 [0.03-0.67]; P = .02 and OR, 0.26 [0.11-0.60]; P = .001). CONCLUSIONS This review attempts to help guide what to do in IPDE, despite severe limitations of the methods. Surgical thromboembolectomy showed a nonsignificant trend toward improved survival, significantly reduced systemic embolism, and composite of mortality and systemic embolism, compared with anticoagulation alone. Thrombolysis, on the other hand, had the opposite effect, although not significantly.

Original ResearchVenous ThromboembolismImpending Paradoxical Embolism: Systematic Review of Prognostic Factors and Treatment

BACKGROUND Little is known about the optimal management of impending paradoxical embolism (IPDE), a biatrial thromboembolus caught in transit across a patent foramen ovale. Our aim was to review observational studies on this subject to identify prognostic factors and to compare mortality and systemic embolism between treatments. METHODS Systematic literature searches in Medline, Embase, and Cochrane Library identified 154 studies (174 patients). The primary end point was 30-day mortality. The secondary end point was systemic embolism during treatment. RESULTS Thirty-day mortality was 18.4%. On univariate analysis, age (64+/-13.9 vs 56.7+/-16.5; P = .01), coma (12.9% vs 2.2%; P = .02), and systemic embolism (71.9% vs 51.4%; P = .048) at presentation were significantly increased among nonsurvivors. Surgical thromboembolectomy had lower mortality than other treatment groups (10.6%; P = .04). In multivariable models, no prognostic factor was a significant independent predictor of mortality. Surgically treated patients had nonsignificantly reduced mortality (odds ratio [OR], 0.65 [0.24-1.72]; P = .65) and thrombolysis-treated patients had increased mortality (OR, 1.62 [0.43-5.97]; P = .47). However, systemic embolism during treatment and combined mortality and systemic embolism was decreased in the surgery group (OR, 0.13 [0.03-0.67]; P = .02 and OR, 0.26 [0.11-0.60]; P = .001). CONCLUSIONS This review attempts to help guide what to do in IPDE, despite severe limitations of the methods. Surgical thromboembolectomy showed a nonsignificant trend toward improved survival, significantly reduced systemic embolism, and composite of mortality and systemic embolism, compared with anticoagulation alone. Thrombolysis, on the other hand, had the opposite effect, although not significantly.

Left atrial myxoma presenting with myocardial infarction: Case report and review of the literature

Coronary artery embolization is an extremely rare and potentially lethal complication of atrial myxomas. We present a case report and a literature review of this clinical association. A 53-year-old woman presented with an acute infero-lateral myocardial infarction. Coronary angiography performed 1 h after the onset of pain disclosed an abrupt stop and multiple embolization of the peripheral right coronary artery (RCA). A transthoracic echocardiographic study revealed the presence in the left atrium of an echogenic, mobile mass, compatible with myxoma. The tumour was successfully removed surgically 2 weeks later and the patient is doing well one year post operatively.

Ruptured mediastinal bronchial artery aneurysm: A dilemma of diagnosis and therapeutic approach

R E F E R E N C E S 1. Keane JF, Plauth WH, Nadas AS. Ventricular septal defect with aortic insufficiency. Circulation 1979;56(Suppl):I72-7. 2. Cosgrove DM, Rosenkranz ER, Hendren WG, Bartlett JC, Stewart WJ. Valvuloplasty for aortic insufficiency. J Thorac Cardiovasc Surg 1991;102:571-6. 3. Chauvaud S, Serraf A, Mihaileanu S, Soyer R, Blondeau P, Dubost C, et al. Ventricular septal defect associated with aortic valve incompetence: results of two surgical managements. Ann Thorac Surg 1990;49:875-80. 4. Cosgrove DM, Fraser CD. Aortic valve repair. In: Cox JL, Sundt TM, editors. Operative techniques in cardiac & thoracic surgery: a comparative atlas. Philadelphia: WB Saunders; 1996. p. 30-7. 5. Schoof PH, Cromme-Dijkhuis AH, Bogers JJ, Thijssen EJ, Witsnburg M, Hess J, et al. Aortic root replacement with pulmonary autograft in children. J Thorac Cardiovasc Surg 1994;107:367-73. 6. Elkins RC, Knott-Craig CJ, Ward KE, McCue C, Lane MM. Pulmonary autograft in children: realized growth potential. Ann Thorac Surg 1994;57:1387-93. 7. van Son JAM, Reddy VM, Black MD, Rajasinghe H, Haas GS, Hanley FL. Morphologic determinants favoring surgical aortic valvuloplasty versus pulmonary autograft aortic valve replacement in children. J Thorac Cardiovasc Surg 1996;111: 1149-57.

Bispectral index and detection of acute brain injury during cardiac surgery.

EDITOR: Stroke, encephalopathy and cognitive disorders following cardiac surgery remain devastating problems as a result of macroor micro-embolic phenomena or global cerebral hypoperfusion [1]. Besides, more sophisticated neuromonitoring systems (i.e. raw electroencephalogram (EEG), evoked potential, near infra-red spectroscopy), the bispectral index (BIS) derived from a single channel frontal EEG may serve as a simple and less-expensive tool, which affords the unique opportunity to gauge the hypnotic level while detecting cortical dysfunction [2]. Herein, we report a case of severe depression of the BIS index and discuss a multimodal approach for early diagnosis of neurological dysfunction. A 62-yr-old female with an aneurysm of the ascending aorta and stable aortic insufficiency was scheduled for elective valve replacement and aortic prosthetic graft insertion. The patient was chronically treated for diabetes, hyperlipidaemia and hypertension. Four weeks previously, she had suffered a stroke associated with atrial fibrillation. Preoperative cardiac investigations demonstrated normal ventricular function, patent coronary arteries and a 50% stenosis on the left carotid artery with a hypoplastic right vertebral artery. At arrival in the operating room – in addition to standard equipment – a 4-electrodes BIS sensor was placed on the forehead and connected to the AXP-2000 monitoring system (software version 4.0; Aspect Medical, Newton, MA, USA). After intrathecal injection of 0.7 mg morphine, general anaesthesia was induced and maintained with a propofol infusion targeted to BIS values between 40 and 60. After endotracheal intubation and mechanical lung ventilation, transoesophageal echocardiography (TOE) demonstrated the absence of patent foramen ovale and intracardiac thrombi, whereas the ascending aorta appeared free from calcification, atheromatous plaque, intimal flap or false lumen suggestive of dissection. After heparinization, normothermic cardiopulmonary bypass (CPB) was instituted with cannula inserted in the right subclavian artery and the right atrium. After aortic cross-clamping, myocardial protection was accomplished by antegrade infusion of hyperkalaemic blood solution; 2 min later, haemodynamic and blood parameters were unchanged, but the BIS value abruptly decreased from 40 to 0 along with a steep increase in the burst suppression index to 100% (Fig. 1). While any cause of technical artefacts was excluded, the infusion of propofol was slightly decreased and the surgeons were asked to verify the position of the cannulas. Using a transthoracic 4–8 MHz echographic probe at the right temporal acoustic window, colour and pulsed Doppler failed to demonstrate blood flow in the middle and anterior cerebral arteries. While the subclavian arterial cannula was slightly withdrawn, direct puncture of the innominate artery revealed a non-pulsatile pressure value equal to the monitored radial pressure (55–60 mmHg). Although the BIS index persisted at ‘near-zero’ values with the raw EEG resembling a flat line (burst suppression ratio of 100), the surgeons completed the intervention (aortic cross-clamp time of 60 min) by inserting a 24-mm St Jude stentless valve and a 24-mm collagen impregnated Dacron graft. After ventricular de-airing, the patient was weaned from CPB without pharmacological support. Postoperatively, no clinical sign of awakening was noticed and magnetic resonance imaging documented severe and diffuse cortical lesions consistent with anoxic encephalopathy. The patient remained in a persistent coma and active life support was withdrawn on the eleventh postoperative day. Autopsy examination confirmed global brain ischaemic injuries and documented a common origin of right and left carotid arteries. Although BIS index is not designed as a tool for neurological monitoring during cardiac surgery, the sudden and sustained decrease in BIS concurrent with a flat EEG line in our case was highly suspicious for global ischaemic-induced cortical dysfunction at the time of aortic cross-clamping. Among likely causes leading to severe brain damage, one should consider malposition of the subclavian cannula (advanced too proximally) and/ or disruption of atheromatous plaque due to a ‘sandblasting’ effect generated by a high-velocity flow pattern at the orifice of the CPB cannula. Intraoperative TOE and autopsy ruled out arterial Correspondence to: Marc Licker, Service d’Anesthésiologie, Hôpital Universitaire, Rue Micheli-du-Crest, CH-1211 Geneva. E-mail: marc-joseph.licker@ hcuge.ch; Tel: 141 22 3827439; Fax: 141 22 38 27 403

Video-Assisted Cardiac Myxoma Resection: Basket Technique for Complete and Safe Removal From the Heart

Video assistance can replace sternotomy in cardiac operations with excellent results. Because myxomas are very friable tumors, their removal from the heart and chest cavity through a working port in video-assisted or robotic procedures may be challenging. We used a laparoscopic basket to safely catch and remove these friable tumors in 10 patients undergoing video-assisted myxoma resection between December 2008 and June 2011. Complete excision and removal was achieved in all patients. No neurologic, vascular, or wound complications were observed. This minimally invasive myxoma technique gives excellent and reproducible results without a higher risk for the patient.

Is minimally invasive mitral valve repair with artificial chords reproducible and applicable in routine surgery

OBJECTIVES Traditional resectional techniques and chordal transfer are difficult to apply in video-assisted mitral valve repair. Using artificial chords appears easier in this setting. The purpose of this study was to review the effectiveness and reproducibility of neochordal repair as a routine approach to minimally invasive mitral repair, and to assess the stability of neochord implantation using the figure-of-eight suture without pledgets in this setting. METHODS This is a retrospective review of all patients who underwent minimally invasive video-assisted mitral valve repair from 2008 to 2013. The primary endpoints were recurrent mitral regurgitation and reoperation. RESULTS A total of 426 consecutive patients were included during the study period, with a mean age of 55 ± 18 years. Neochords were used in all patients, and in association with leaflet resection in 47 patients. One patient was not repairable and underwent valve replacement (repair rate, 99.8%). Fifteen patients had Grade I (3.5%) regurgitation, whereas the remainder had none. Patients were fast-tracked, with 25% extubated in the operation theatre and the remainder within 6 h. There were 5 deaths within 30 days (1.2%). Follow-up ranged 3-60 months, during which all of the patients remained with no or trace mitral regurgitation. No de-insertion or rupture of any neochords was found, and no patients required a reoperation. CONCLUSIONS Minimally invasive mitral valve repair using neochords provided a high rate of repair, reproducible results in a routine cardiac surgery setting and stable repair during follow-up. This has become our preferred technique for mitral valve surgery.

Extended mild hypothermic aortic surgery

We read with great interest the report by Urbanski et al. [1] on their approach to mild hypothermic aortic arch surgery and the associated editorial [2]. We congratulate the authors for their impressive series, thoughtful approach and excellent results. We would like to discuss the previously published alternative strategies for mild and normothermic total arch replacement. They demonstrate that an approach to bypass tailoring the degree of cooling to the anticipated extent of repair and duration of corporeal circulatory arrest can be rewarded with excellent outcomes [2]. Nonetheless, the authors had a mean circulatory arrest time of the lower body of 34 ± 12 min, extending to 70 min, at 30°C. These numbers are pushing the limits on warm ischaemia, as ‘safe’ ischaemic times are in the range of 35 min for the liver, 90 min for the kidneys and 20 min for the spinal cord [3] at mild hypoor normothermia. Furthermore, their approach required an elaborate succession of cannulations (up to four) and retrograde descending aorta perfusion (as well as a portion of the arch vessels at intermediate steps of completing the arch replacement) through the femoral artery. In a patient population burdened with atheromatous large vessel disease such as this one, this is not an innocuous choice devoid of risk compared with antegrade perfusion. Axillary artery cannulation has been shown to provide adequate antegrade cerebral perfusion, which we have been using routinely since 2001, including in patients with acute aortic dissection [4]. We have continued to apply this approach routinely since then, with comparable results. Total arch replacement is also possible under whole body antegrade perfusion [5], by placing a Medtronic DLP© venous cannula (Y-ed from the arterial line) through the tube graft into the distal aorta for antegrade lower body perfusion (see figure available at: http://ats.ctsnetjournals.org/content/vol85/issue1/ images/large/347.S0003497507013525.gr1.jpeg). The brain and lower body are continuously perfused with the exception of a very limited circulatory arrest time (6–8 min) of the lower body, which only represents the time necessary for resection of the aortic tissues, positioning of the cuffed DLP cannula in the descending aorta and the inflation of the occlusion balloon. In this way, an arch repair is transformed into a standard cardiopulmonary bypass heart operation, with vascular exclusion of the aortic arch and total body antegrade perfusion. The 8 min limited duration of the circulatory arrest in the lower body is safe for the spinal cord and splanchnic organs at this temperature and even in normothermia, as can be necessary in patients who cannot be cooled, such as with cold reactive agglutinins [6]. Furthermore, cannulation of the newly implanted graft is not necessary to achieve antegrade systemic perfusion after the completion of the distal aortic anastomosis. We would also like to note that we have applied this approach in emergent situations, such as acute aortic dissection, with good results, and not restricted this technique to elective cases as reported by Urbanski et al. [1].

Multimodality imaging in the evaluation of aorta-right atrial tunnel

Aorta—right atrial tunnel is a rare congenital anomaly characterized by an extracardiac tunnel-like vascular communication arising from an aortic sinus and emptying into the right atrium (RA) (Fig. 1). We report the case of a 33-year-old man diagnosed following Streptococcus viridans endocarditis. The patient underwent successful surgical repair (Fig. 2). The proximal ostiumwas closed using a pericardial patch sutured inside the tunnel, distal to the takeoff of the left main coronary artery approximately 2 cm within the tunnel. The distal tunnel ostium was oversewn primarily in the RA. www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 40 (2011) e153

Aorta-cutaneous fistula as a rare complication of localized chronic mediastinitis

A 35-year-old man was admitted 5 years after congenital heart surgery complicated by Staphylococcus aureus and a cutaneous fistula located at the left fourth intercostal space. He was febrile (40 degrees C), suffering from sternal pain and suppuration from the old fistula. During examination arterial blood suddenly discharged from the fistula, so that surgery was immediately instituted. An infected Dacron tube implanting on the ascending aorta for a central aorto-pulmonary shunt was at the origin of a false aneurysm: this had led to the repeat formation of an aorta-cutaneous fistula and outbreak of external bleeding.