Aristotle D. Protopapas

Meta-Analysis of Organ Damage After Conversion From Off-Pump Coronary Artery Bypass Procedures

The relative efficacy of off-pump and on-pump coronary revascularization is uncertain. A complication of off-pump surgery which is rarely considered is intraoperative conversion to cardiopulmonary bypass. Consequently, meta-analysis was performed of studies comparing morbidity after converted and nonconverted off-pump coronary revascularization. There were significant increases in the likelihood of stroke, myocardial injury, bleeding, renal failure, wound infection, intraaortic balloon pump requirement, transfusion, and respiratory and gastrointestinal complications after conversion. The underlying mechanisms need to be urgently elucidated. Prevention and treatment protocols for conversion warrant serious consideration and the risk of conversion may need to be discussed when obtaining informed patient consent.

Pulmonary Embolism Following Coronary Artery Bypass Grafting

Abstract  Background: Pulmonary embolism (PE) is a life‐threatening complication, with a deceptive clinical presentation following coronary artery bypass grafting (CABG). Methods: We identified 13 studies on PE in post‐CABG patients, spanning a period of 34 years. Results: The overall cumulative incidence of PE following CABG was 1.3% (111 PEs in 8553 CABGs). Conclusion: We suggest further prospective randomized studies to examine the effect of saphenous system vein grafting, and choice of low molecular weight heparin prophylaxis on the incidence of post‐CABG PE. (J Card Surg 2011;26:181‐188)

Evolving dimensions in medical case reporting

Medical case reports (MCRs) have been undervalued in the literature to date. It seems that while case series emphasize what is probable, case reports describe what is possible and what can go wrong. MCRs transfer medical knowledge and act as educational tools. We outline evolving aspects of the MCR in current practice.

Tropical diseases of the myocardium: a review

Cardiovascular diseases are widely distributed throughout the world. Human parasitic infections are ubiquitous. Tropical parasites are increasingly recognized as causes of cardiovascular diseases. In this review, we address the most frequently reported parasites that directly infect the myocardium, including Trypanosoma cruzi, the protozoal causative agent of American trypanosomiasis (Chagas disease), and Taenia solium, the cestode causative agent of taeniasis and cysticercosis. We also discuss tropical endomyocardial fibrosis, trichinellosis and schistosomiasis. Health systems, attitudes, the perceptions of both patients and physicians as well as socioeconomic factors should all be explored and recognized as crucial factors for improving the control of cardiovascular diseases in the tropics. Clinicians throughout the world must remain aware of imported parasites as potential causes of cardiac diseases.

Bilateral harvesting of internal thoracic artery for coronary bypass: augmenting the risk for postoperative airway obstruction?

perimembranous VSD coming from the vague definition given by many authors using the term subarterial or subaortic VSD to describe perimembranous VSD. When the aorta is far away, it seems that there is difficulty in distinguishing perimembranous VSD from inlet VSD. The definition of the membranous septum is independent from the aortic annulus. It is defined by Anderson [1] as being in contact with the central fibrous body, next to the tricuspid valve. The two specimens shown in our article are true DORV noncommitted VSD as stated by authors Bob Anderson and Bob Freedom [2]; the VSD are perimembranous VSD with inlet extension. The difference with a Taussig-Bing is not due to the nature of the VSD that is also a perimembranous VSD (but with outlet extension) but to a greater distance to the pulmonary valve. As shown by Bob Freedom [2], in Taussig-Bing the VSD is immediately located beneath the pulmonary valve and located above the posterior limb of the trabecula septomarginalis. In DORV non-committed VSD, the VSD is distant from the pulmonary valve and located beneath the posterior limb of the trabecula septomarginalis. True muscular inlet or trabecular VSDs are possible, although we have not found any in our series. As stated by Belli [3], in DORV non-committed VSD, the distance from both arterial annuli should be greater than an aortic annulus diameter. In Taussig-Bing, the distance of the VSD from the pulmonary artery is less than an aortic valve diameter and in DORV non-committed VSD this distance is greater. One consequence is that the VSDs in DOR noncommitted VSD are frequently restrictive which we have never seen in Taussig-Bing. The VSD has to be enlarged anteriorly, as was done in all the cases published. There was no heart block in our series, confirming the perimembranous location of the VSD. I consider that the VSD depicted by Barbero-Marcial [4] as muscular VSD are in fact mostly true perimembranous VSD. Notice also that an AVSD defect is in contact with the tricuspid annulus and is a perimembranous VSD with inlet extension. Another difference in Taussig-Bing is the usual overriding of the pulmonary artery that is partly located on the left ventricle (now named DORV-TGA type). In DORV noncommitted VSD, the vessels are very clearly 200% on the RV. In DORV non-committed VSD hearts, there is an association with subpulmonary stenosis which is never the case in Taussig-Bing. Finally, Taussig-Bing belongs more to the group of TGA VSD and is almost exclusively treated by arterial switch (the Kawashima operation being rarely indicated) and on the contrary, the DORV non-committed VSD can be treated differently by VSD tunnellization to the aorta in favourable forms and by tunnellization to the PA and ASO in the most severe forms. References

Stridor in adult patients presenting from the community: An alarming clinical sign

Following our recent management of an adult patient with stridor, we performed a systematic review of published case reports and case series of adult patients presenting to the emergency department with stridor. The aim of our search was to outline the underlying causes of stridor in adults and we present our findings below. Our experience also emphasises the need for immediate management using a multi-disciplinary approach. We performed a PubMed literature search from January 1951 to September 2014 using the following medical subject heading terms: ‘stridor’ OR ‘stridorous’ OR ‘stridors’ [Title], in English. Stridor was reported in 249 patients from 99 publications (87 were single-patient case reports). We excluded reports on children and hospital acquired stridors (as a complication of tracheal intubation/general anaesthesia, thyroidectomy, pneumonectomy, nerve injury or other) as their management follows different pathways. Malignant obstruction was reported in 15 patients. Fifty six percent of the reported patients were female. Approximately 50% of patients required definitive airway management, invasive ventilation and admission to the intensive care unit (ICU). The overall mortality rate was 6.4%. The identified aetiologies of the cases are summarised in Table 1. The commonest systemic cause of stridor was neurological (65 patients from 13 papers). The commonest neurological cause was multiple system atrophy (53 patients) followed by myasthenia gravis (five patients). The commonest local causes were vocal cord conditions (27 patients from 10 papers). Fifty-three patients from three reports had psychogenic stridor, a diagnosis of exclusion. The number of reported local causes for stridor was 59 versus 40 systemic causes. Subgroup analysis of obscure laryngeal causes of stridor revealed: redundant aryepiglottic fold (seven patients), focal dystonia (six patients), functional dyskinesia (six patients), paradoxical motion (five patients), laryngocele (one patient), subglottic stenosis (one patient) and tracheomalacia (one patient). Regardless of cause, stridor implies critical airway obstruction of at least 50% of the airway lumen. Patients with stridor are at high risk of respiratory failure and death and require initial stabilisation to maintain ventilation and oxygenation, if this is consistent with the goals of care. The degree of respiratory distress depends on whether partial airway obstruction has developed gradually (e.g. laryngeal tumour) or rapidly (e.g. acute epiglottitis). Unless resolved promptly in the emergency department, Table 1. Causes of stridor in adults presenting from the community as identified from a review of published case reports and case series.

Tumour Thrombi in the Suprahepatic Inferior Vena Cava: The Cardiothoracic Surgeons' View

Background. Retroperitoneal tumours propagate intrathoracic caval tumour thrombi (ICTT) of which we consider two subgroups: ICTT-III (extracardiac) and ICTT-IV (intracardiac). Methods. Case series review. Results. 29 series with 784 patients, 453 with extracardiac and 331 with intracardiac ICTT. Average age was 59 years. 98% of the tumours were RCC, 1% adrenal and Wilms’ tumours, and 1% transitional cell carcinomas. The prevalent incision was rooftop with or without sternotomy. Mortality was 10% (5% for ICTT-III, 15% for ICTT-IV). Morbidity was 56% (36% for ICTT-III, 64% for ICTT-IV) and reoperation for bleeding was the commonest complication (14%). Mean Blood loss was 2.6 litres for ICTT-III and 3.7 litres for ICTT-IV. Mean blood product use was 2.4 litres for ICTT-III and 3.5 litres for ICTT-IV. Operative and anaesthetic times exceeded 5 hours. Hospital stay averaged 13 days. Variations in perioperative care included preoperative embolisation, perioperative transoesophageal echo, surgical incisions, and extracorporeal circulation. Brief Summary. Surgery for ICTT has high transfusion, operating/anaesthetic time, and in-hospital stay requirements, and intracardiac ICTT also attract higher risk. Preoperative tumour embolisation is controversial. The cardiothoracic team offers proactive optimisation of blood loss and preemptive management of intracardiac thrombus impaction: we should always be involved in the management the ICTT.

The natural bifurcating internal thoracic artery graft: another technique for bypassing two vessels with one conduit

We present our reproducible technique of achieving two bypasses from selected pedicled internal thoracic arteries. We feel that awareness of this technical modification is to the benefit of patients.

Elastin deficiency in Williams syndrome may explain postoperative major adverse cardiac events.

1380 The Jour surgery are common in patients who have Williams syndrome. They suggest a multifactorial explanation. Williams syndrome is now recognized as a clinical manifestation of elastin deficiency, with a mutation sequenced in chromosome 7q11.23. Elastin, an extracellular matrix protein, is the major component of elastic fibers responsible for the elastic and rheologic properties of arteries. Normal deposition of elastin is a critical event in vessel development. Defective elastin has been implicated in aortic dissection for some time. Therefore, consideration of pathologic elastin as one factor that may explain the findings of Dr Hornik and colleagues is prudent.

eComment. Further tips on partial sternotomy

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