Gou-Jieng Hong

Ruptured congenital sinus of valsalva aneurysms.

Abstract  Background and aim of the study: Rupture of the sinus of Valsalva is rare, and there is a higher incidence of such rupture in Oriental countries than elsewhere. The objective of this study is to present the pathologic features and the clinical outcome after surgery in such patients. Methods: Between 1980 and 2001, a total of 17 patients (15 males and 2 females) with ruptured aneurysm of sinus of Valsalva underwent surgical intervention at the Tri‐Service General Hospital, Taiwan. Their age ranged from 22 to 59 years with a mean of 33.5 years. These surgical operations made up 0.51% of the total cardiac operations (3305) performed during this period. The medical records were retrospectively reviewed. Results: The origin of the ruptured aneurysm of the sinus of Valsalva was the right coronary sinus in 12 patients, the noncoronary sinus in 4, and the left coronary sinus in one patient. The aneurysms ruptured into the right ventricle in 12 patients, into the right atrium in 3 patients, and into the left ventricle in 2 patients. Associated cardiac anomalies were aortic regurgitation in eight patients, ventricular septal defect in seven, and coronary artery fistula in one patient. There was no early postoperative death and one patient underwent a second operation after aneurysm of the sinus of Valsalva (ASV) relapse. Conclusions: The operation for a ruptured aneurysm of sinus of Valsalva carries a low operative risk and results in excellent long‐term survival after surgical treatment. (J Card Surg 2004;19:99‐102)

Congenital coronary artery fistulas: clinical considerations and surgical treatment.

Background:  Coronary artery fistulas are uncommon abnormalities that can cause significant cardiac morbidity. Indications for operation vary, particularly, for asymptomatic patients. Early surgical correction is indicated because of the high incidence of late symptoms and complications.

Off-pump technique in coronary artery bypass grafting in elderly patients.

Background:  The use of cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG) is associated with substantial morbidity and mortality, especially in the elderly. The purpose of this study was to evaluate the feasibility of beating heart coronary artery revascularization in patients aged at least 80 years.

Infective Endocarditis from Streptococcus viridans Associated with Colonic Carcinoma: A Case Report

Abstract  Streptococcal bacteremia is an uncommon presentation for colorectal malignancy, yet most physicians would probably be aware of the association between Streptococcus bovis infection and such malignancy; however, many physicians may be unaware that other streptococcal species are also associated with colon and rectal cancers. We describe a 62‐year‐old male with adenocarcinoma of the sigmoid colon with the presentation of infective endocarditis due to infection by Streptococcus viridans, and we also report on the conditions successful treatment.

Successful treatment of Salmonella mycotic aneurysm of the descending thoracic aorta

Salmonella mycotic aneurysms of the descending thoracic aorta are exceedingly rare. There are few case reports and even fewer reports of long term survival. The case of a 68-year-old female presenting with a mycotic aneurysm of the descending thoracic aorta caused by Salmonella species is described, which involved successful surgical intervention.

Left Atrial Appendage Aneurysm with Paroxysmal Atrial Fibrillation

Aneurysm of the left atrial appendage is extremely rare, and afflicted patients most commonly present with atrial tachyarrhythmia or thromboembolism. For these patients, resection of the aneurysm is the recommended and preferred therapy. We present the case of a 57-year-old woman who was found incidentally to have a large aneurysm of the left atrial appendage presenting as atrial fibrillation. After surgical intervention with resection of the aneurysm and a Cox maze III procedure, the patient recovered and was discharged in sinus rhythm.

Long-Term Experience of Anticoagulant Therapy in Chinese Patients with Mechanical Valves

Background: Many targets of the currently therapeutic range of the international normalized ratio anticoagulant therapy for patients with mechanical heart valves were recommended on the base of Caucasian patient groups. To the best of our knowledge it is not clear whether this therapeutic range is optimal for corresponding Chinese individuals. Methods: Between January 1996 and January 2005 inclusively, 229 patients undergoing heart-valve replacement with a mechanical device at the Tri-Service General Hospital, Taipei, were enrolled into this study. Mean patient age was 58.8±14.5 years. Various collected data pertaining to these 229 patients following aortic-valve replacement (n=87), mitral valve replacement (n=109) and double-valve replacement (n=33) with the CarboMedics prosthetic heart valve were analysed herein, and all associated complications were investigated retrospectively. Results: During the course of treatment for these 229 enrolled patients, the mean warfarin sodium dose administered was 2.81±0.75mg per day and the mean international normalized ratio value was 2.04±0.73. Perioperative mortality occurred for seven patients (3.06%), whilst major bleeding events occurred for 16 patients (1.17% per patient-year), and thromboembolism events for 14 patients (1.02% per patient-year). Conclusion: From our study, to keep international normalized ratio anticoagulant therapy above 1.5 is enough to prevent mechanical-valve associated thrombosis on Chinese patient groups.

Extracorporeal Membrane Oxygenation for Management of Carbon Monoxide Intoxication

Emergency use of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary failure is well documented. However, the use of ECMO for carbon monoxide (CO) poisoning is rare. We report a case of a patient with severe CO poisoning that initially manifested as stunned myocardium-induced acute pulmonary edema. The patient was severely hypoxemic and refractory to mechanical ventilation at 7 hours after hospitalization. We applied veno-arterial ECMO for rescue life support for 3 days. The patient had a dramatic full recovery without immediate neurologic sequelae for the 3-day period. Under ECMO support, PaO2 increased from 34.8 to 299.9 mmHg, and ventilator FiO2 decreased to 0.4 within 3 days. The patients consciousness also improved, with the Glasgow Coma Scale (GCS) score increasing from 8 to 15. Although the standard treatment for CO poisoning remains controversial, an aggressive rescue strategy is warranted for concurrent cardiovascular collapse and acute respiratory failure after severe CO poisoning in order to reduce the mortality of a reversible etiology.

Coronary artery fistula detected by 64-slice multidetector computed tomography: case report.

Coronary artery fistula (CAF), a rare anomaly of a coronary artery, is defined as an anomalous communication between a coronary artery and a cardiac chamber or vessels. Coronary angiography remains the main modality for diagnosing CAF. We present a case of fistulous communication between the left anterior descending coronary artery and the main pulmonary artery. The exact anatomy of the fistula was demonstrated by 64-slice multidetector computed tomography (MDCT). Surgical ligation on a beating heart was carried out. Intraoperative Doppler flow detection was used to evaluate the shunt of the CAF. We prefer MDCT as a new diagnostic modality to provide the detailed anatomy of a CAF.

Haemangioma arising from external jugular vein.

Haemangioma arising from blood vessels is very rare and should be differentiated from other vascular tumour. Once haemangioma presents as a lateral neck mass, it should be distinguished from other malignancies. A 67-year-old female was seen at our vascular surgery section with a painless, nodular, 4 cm in diameter, right-sided neck mass of one-year duration. The patient was otherwise asymptomatic, but the lesion gradually increased in size. The neck mass was not obvious at rest but became prominent on straining or Valsalva manoeuvre. The patient felt embarrassed during work because it enlarged on exertion. On physical examination, the mass showed firm in consistency, not pulsatile, and free from superficial and muscular layer. Palpation revealed the mass was along the course of the external jugular vein (EJV) and positive empty sign. Doppler scan confirmed a solid nodule, hypoechoic, well-defined and with involvement of EJV. Pressure exerted by the probe showed that the mass was collapsible. Under general anaesthesia, a mass of 4.7 ¥ 4.2 ¥ 0.6 cm (Fig. 1) arising from the EJV was isolated by careful dissection. Proximal and distal feeding vessels were ligated. Macroscopically, the tumour was reddish, not encapsulated and not infiltrated beyond the surrounding tissue. Histolopathologic examination showed pictures of thin-wall capillaries with haematoma and focal necrosis and was consistent with haemangioma. The post-operative course was uneventful, and no recurrence was detected after one-year follow-up period. The first description of benign intravascular tumour was given by Masson in 1923. Clinical presentation included subcutaneous nodule with growing in size, with signs of venous thrombosis or varicose venous dilatation. Intrinsic vascular haemangiomas arising from the EJV are very rare. To our knowledge, only three reports have been described previously. Most of these cases were confirmed by surgical excision. Preoperative biopsy is not preferable because of the possible extensive bleeding. Definite diagnosis of primary vascular tumour requires histopathologic examination. Total excision allows a better histopathological definition and is curative unless malignancies are suspected. Although these tumours are very rare, several imaging studies provide important features to differentiate. The first description of a haemangioma of EJV goes back to 1967, and the venogram of EJV outlined a polypoid filling defect with reticulated pattern. In 1999, Sarteschi et al. first reported a case of right EJV haemangioma in which colour-coded duplex sonography contributed significantly to the diagnosis. The venous wall haemangioma appeared as a welldefined, solid, hypoechoic nodule with endoluminal involvement. The greyscale imaging features were similar to those of intravascular thrombus, but the venous lumen was collapsible on probe compression. In our case, the diagnosis was made by physical examination and the sonographic features, which is similar to previous described case. The venogram was not considered because the procedure was more invasive. Ahuja et al. first demonstrated the magnetic resonance (MR) imaging appearances in haemangiomas of EJV. These masses showed intermediate signal intensity (slightly higher than that of muscles) on T1-weighed images, usually heterogeneous high signal intensity on T2-weighed images, and variable enhancement after intravenous gadolinium administration. Preoperative MR imaging not only provides distinguishing features for diagnosis but also anatomic details to plan surgical treatment and prevent excess vascular trauma and bleeding during operation. Primary tumours originating in EJV are uncommon. Preoperative differential diagnosis included other malignant vascular tumours (i.e. malignant hemangioendothelioma, hemangiosasarcoma and leiomyosarcoma). If the lesion shows rapid enlargement or local infiltration, malignancy should enter the differential list. Total excision is curative for EJV haemangiomas. No recurrence was reported in previous cases. It is important to keep in mind that intravascular benign tumour can present as neck mass and be diagnosed on physical examination and imaging studies.