Augustine Tang

Sinus of valsalva aneurysm in Blau's syndrome

Blau syndrome is a rare granulomatous disorder inherited in an autosomal dominant manner characterized by the early appearance of granulomatous arthritis, skin rash and anterior uveitis. There are very few data on the cardiovascular manifestations of Blau syndrome. Here we report the first case of sinus of valsava aneurysm in Blau syndrome. In isolated unruptured aneurysms of a sinus of Valsalva without compromise of the aortic valve and/or the coronary ostia, repair may be accomplished by simple placation of the aneurysm or excision of the aneurysm(s) and patch closure of the defect(s) between the aortic annulus and the sinu-vascular ridge. Because of the particular conditions in our case, the repair was performed with replacement of the aortic valve and root using a composite graft employing a modified Bentalls technique.

Does getting smokers to stop smoking before lung resections reduce their risk

A best-evidence topic in thoracic surgery was written according to a structured protocol. The question of whether the incidence of major pulmonary morbidity after lung resection was associated with the timing of smoking cessation was addressed. Overall 49 papers were found using the reported search outlined below, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In most studies, smoking abstinence was shown to reduce the incidence of post-operative pulmonary complications (PPCs) such as pneumonia, respiratory distress, atelectasis, air leakage, bronchopleural fistula and re-intubation. The timing of cessation is not clearly identified, although there is some evidence showing reduction in risk of PPCs with increasing interval since cessation. Two studies suggested that smoking abstinence for at least 4 weeks prior to surgery was necessary in order to reduce the incidence of major pulmonary events. Furthermore, it was also shown that a pre-operative smoke-free period of >10 weeks produced complication rates similar to those of patients who had never smoked. We conclude that smoking cessation reduces the risk of PPCs. All patients should be advised and counseled to stop smoking before any form of lung resection.

The impact of major perioperative renal insult on long-term renal function and survival after cardiac surgery

Temporary renal replacement therapy (RRT) facilitates recovery from a major perioperative renal injury and, although RRT can improve the hospital outcome, it is not known as to whether it mitigates long-term renal sequelae. Therefore, we investigated the risk of long-term dialysis after RRT post-cardiac surgery. We analysed prospectively the data collected for all hospital survivors who received RRT following cardiac surgery between March 1996 and July 2010, excluding those on dialysis preoperatively or with a functioning renal transplant. The follow-up data were obtained for all surviving patients. The mean age of the 82 patients was 68.6 ± 9.9 years, and 60 (73%) were male. Severe pre-existing renal dysfunction with a serum creatinine level of >200 μmol/l was present in 15 (18%) patients and diabetes in 31 (38%) patients. Operative procedures included redo surgery (n = 11, 13%) and thoracic aortic surgery (n = 9, 11%). During a 13.4-year follow-up, there were 38 late deaths. Only three patients with severe preoperative renal dysfunction received dialysis. The Kaplan-Meier 5- and 7-year survival rates for this patient cohort were 54% and 38%, respectively. In conclusion, a major renal insult requiring temporary RRT after cardiac surgery does not increase the risk for renal dialysis in the long term for patients with normal renal function preoperatively.

Early and late prognostic implications of coronary artery bypass timing after myocardial infarction.

OBJECTIVES The optimal timing of coronary artery bypass grafting (CABG) after myocardial infarction (MI) is still controversial. With advances in perioperative care and myocardial protection, CABG is not infrequently undertaken sooner. Although CABG soon after MI is associated with high morbidity and mortality, the impact of CABG timing on late survival is not clear. METHODS We analysed prospectively collected data for 8320 patients who underwent primary CABG from 1996 through 2010. Operative outcomes and late survival were compared between patient categories based on MI-to-CABG days: groups A (0-30, n = 658), B (31-60, n = 734), C (>90, n = 2698) and D (no MI, n = 4230). The effect of the timing of surgery on survival was determined using multivariate and Kaplan-Meier analyses. RESULTS As the MI-to-CABG interval increased, the frequency of urgent/emergency operations decreased and hospital mortality (A, 3.5% vs B, 2.6% vs C, 1.2%, vs D, 1.1%, P < 0.0001) steadily declined. In general, patients who had CABG within 90 days of MI had more cardiac morbidity and co-morbidities. Expectedly, therefore, postoperative organ system dysfunction (cardiac, renal, respiratory and neurological) was more frequent in these groups. Reoperation for bleeding was similar for all groups, but blood product transfusion decreased as the MI-to-CABG days increased. The 10-year survival improved with the MI-to-CABG interval (A, 72.2% vs B, 73.4% vs C, 75.8% vs D, 81.4%, P < 0.0001). By multivariate analysis, the MI-to-CABG interval was not a risk factor for operative or late mortality. However, less frequent were left internal mammary artery use, non-elective surgery and high blood transfusion rates; all more often associated with shorter MI-to-CABG intervals. CONCLUSIONS Early and late mortality risk for CABG declines with increasing interval from MI for reasons indirectly linked to the timing of surgery. Our findings emphasize the importance of preoperative organ system optimization and consistent left internal mammary artery use, regardless of the proximity of surgery to MI or the exigency of surgery.

Balloon assisted retraction of a migrated CoreValve Evolut R bioprosthesis during cardiac arrest

We describe a case of balloon assisted retraction of a migrated CoreValve Evolut R bioprosthesis during trans-femoral TAVI.

Use of contrast-enhanced computed tomography for management of a late-onset spontaneous massive chest wall hematoma

This is a rare case of a 68-year-old woman who was rehospitalized after uneventful redo double-valve surgery. An 8.3 × 12.9 × 16.4 cm tense right chest wall hematoma was diagnosed. This was precipitated by a single cough. Contrast-enhanced computed tomography revealed a bleeding source. Hematoma evacuation and hemostasis following emergency warfarin reversal produced an excellent outcome.

Off-pump coronary artery bypass in poland syndrome with dextrocardia: case report.

Poland Syndrome is a congenital disorder characterised by hypoplasia of the pectoral muscles along with upper extremity deformities. We encountered a patient with Poland syndrome associated with dextrocardia and also failed pectus excavatum repairs who presented to us with symptomatic ischaemic heart disease requiring intervention. He underwent successful off-pump coronary artery bypass surgery (OPCABG). As far as we are aware, this is the first case report of OPCABG in a case of Poland syndrome with dextrocardia. We describe here the management of this complex patient and wish to emphasise that the off-pump option is feasible in dextrocardia with some technical modifications.

Duplicated common femoral artery can be safely cannulated for femorofemoral cardiopulmonary bypass.

The duplicated common femoral artery can be safely cannulated for femorofemoral bypass, but we recommend postoperative imaging to identify potential complications. We found no previous reports of duplicated common femoral artery.

A surgical strategy for cor triatriatum atrial septal defect--A1 lam subclass.

Atrial fibrillation and a heart murmur were diagnosed in a 68-year-old woman during a routine medical examination. She presented 2 years later with pulmonary edema. A transthoracic echocardiography examination revealed a tunneled atrial septal defect (ASD) and severe tricuspid regurgitation. Transesophageal echocardiography and 3-dimensional computed tomography evaluations revealed multiple intracardiac defects, including abnormal atrial septation suggestive of a typical cor triatriatum sinistrum (A1 Lam subclass), a rare congenital defect in adults. The patient underwent tricuspid valve repair with concomitant closure of the ASD by using the cor triatriatum curtain to form an autologous transposition flap. The intraoperative transesophageal and predischarge imaging evaluations confirmed an excellent repair. The patient made a swift recovery and demonstrated improvement in her symptoms at follow-up. This previously undescribed technique eliminates the need for a prosthetic implant and is applicable in >80% of cor triatriatum cases in which an ASD exists.