Jamil Hajj-Chahine

Surgical management of a circumflex aneurysm with fistula to the coronary sinus

We report the successful management of a circumflex coronary artery aneurysm with fistula to the coronary sinus. Our strategy aimed at closing the fistula and grafting the obtuse marginal artery. The calcified aneurysm was left intact, and showed secondary thrombus formation on the postoperative angiogram.

Flail Chest in Polytraumatized Patients: Surgical Fixation Using Stracos Reduces Ventilator Time and Hospital Stay

Objectives. Conservative management of patients with flail chest is the treatment of choice. Rib fracture repair is technically challenging; however, with the advent of specially designed molding titanium clips, surgical management has been simplified. Surgical stabilization has been used with good outcomes. We are reporting on our institutional matched-case-control study. Methods. Between April 2010 and April 2011, ten polytraumatized patients undergoing rib stabilization for flail chest were matched 1 : 1 to 10 control patients by age ±10 years, sex, neurological or vertebral trauma, abdominal injury, and arm and leg fractures. Surgery was realized in the first 48 hours. Results. There were no significant differences between groups for matched data and prognostic scores: injury severity score, revised trauma score, and trauma injury severity score. Ventilator time (142 ± 224 versus 74 ± 125 hours, P = 0.026) and overall hospital stay (142 ± 224 versus 74 ± 125 hours, P = 0.026) were significantly lower for the surgical group after adjustment on prognostic scores. There was a trend towards shorter ICU stay for operative patients (12.3 ± 8.5 versus 9.0 ± 4.3 days, P = 0.076). Conclusions. Rib fixation with Stracos is feasible and decreases the length of ventilation and hospital stay. A multicenter randomized study is warranted so as to confirm these results and to evaluate impact on pulmonary function status, pain, and quality of life.

Pleural lipoma: a non-surgical lesion?

Pleural lipomas are benign tumours that develop at the expense of adipose tissues, and they never evolve towards liposarcoma. Located usually at the mediastinal, bronchial and pulmonary levels, a pleural situation is extremely rare. Chest X-rays usually detect them and computed tomography scans confirm the diagnosis. As complications occur, a wait-and-see policy is common. We report our pleural lipoma surgical exeresis experience since 1999. We have operated on five cases of pleural lipomas among nearly 1800 cases of thoracic exeresis: three male and two female patients, without obesity (in all cases, body mass index (BMI) < 28). The mean age was 54.6 years (range 35-72 years). Four patients were electively operated and one in emergency, three with video-assisted thoracic surgery (VATS) procedure and two with open chest surgery, without recurrent cases. Advancements in VATS have greatly reduced the morbidity rate of these benign tumours especially if exeresis is performed early on a small, uncomplicated adhesion-free tumour. On the other hand, the operation may be deleterious, complicated by the presence of a large lipoma or in a complicating situation. In our opinion, we should revise the wait-and-see policy when facing these lesions considering their evolutionary potential. We should advise VATS in pleural lipomas.

Acute aortic valve thrombosis secondary to recombinant factor VIIa.

A60-year-old male patient was admitted on an elective basis for coronary artery bypass grafting. His past medical history included hypertension and multiple sclerosis. He had experienced an acute inferior myocardial infarction 1 month earlier. Coronary angiography revealed severe triple-vessel disease. Transthoracic echocardiography disclosed a normal aortic valve and an ejection fraction of 45%. The patient had normal hepatic and renal function and a normal coagulation profile before the operation. Cardiopulmonary bypass was established through a median sternotomy. A saphenous vein was grafted onto the right coronary artery, and the left internal thoracic artery was anastomosed to the left anterior descending artery. The obtuse marginal artery was not identified during the operation and was therefore left ungrafted. Attempts to wean the patient from cardiopulmonary bypass were unsuccessful, and femorofemoral extracorporeal membrane oxygenation (ECMO) was instituted. Electrocardiography revealed ST segment elevation in lateral chest derivations. The patient was

A true and a false acute aortic syndrome in the same patient

A 59-year-old woman experienced unexplained sudden cardiac arrest. A femorofemoral extracorporeal membrane oxygenation device was implanted. An electrocardiogram revealed no signs of myocardial infarction; therefore, cardiac catheterization was not performed. Computed tomography showed the classic finding of false aortic dissection, usually depicted in the setting of extracorporeal membrane oxygenation use, however, an intramural hematoma of the ascending and descending aorta was also found (Figure 1).

Aortic Root Replacement in a Patient With Left Ventricular Noncompaction

We describe the case of a 57-year-old woman with noncompaction of the left ventricle and regurgitant bicuspid aortic valve who presented with progressive congestive heart failure and was successfully treated with aortic root replacement. The long-term outcome for these patients is poor because of progressive left ventricular impairment, increased rates of life-threatening arrhythmias, and intraventricular thrombi. To our knowledge, only 3 patient with noncompaction of the left ventricle has been reported to have undergone aortic valve replacement for severely regurgitant bicuspid aortic valve. Herein, we describe a patient with noncompaction of the left ventricle who underwent successful mechanical aortic root replacement.

Post-cardiotomy type A aortic dissection

I read with great interest the article by Rylski et al. [1] investigating the management and outcomes of iatrogenic acute type A aortic dissection (AAAD) in the current era by extracting data from an international registry. AAAD after non-aortic cardiac surgery is considered an extremely dreadful complication, converting a low-risk procedure into a high-risk rescue situation. In the present report, the authors found that 30-day mortality after surgical correction of postsurgical-induced AAAD (n = 43 patients) is 12%. This relatively low mortality rate contradicts the findings of previous reports. A report from the International Registry of Aortic Dissection published in 2002 [2] establishes that the mortality of iatrogenic AAAD is higher than that of spontaneous aortic dissection. They identified in this observational registry 18 patients with postsurgical-induced AAAD with a mortality rate of 32%. Recently, Leontyev et al. [3] reported the outcomes of 36 patients with postsurgical-induced AAAD in a single high-volume cardiac surgery centre over a 14-year period. Once again, the mortality rate was high in this subset of patients at 35.5% for those diagnosed perioperatively and exceedingly high at 60% for those detected in the early postoperative period. More recently, the largest post-cardiotomy AAAD report [4] has been published with similarly high in-hospital mortality rate. Of note, the overall operative mortality observed was 27% in a cohort of 103 patients. This paper was the collaborative result between nine heart centres in four European countries. Although this study excluded patients with previous aortic surgery for aneurysm or dissection, the mortality rate was somewhat higher than that in the current published series. The discrepancy between data can be attributed to ambiguous definitions and varying inclusion and exclusion criteria. Therefore, for accurate comparison of data for future reporting, Stanger et al. [4] advocated using the following definitions. AAAD should be categorized into four different entities depending on the time interval between the primary cardiac surgery and the diagnosis of the dissection. AAAD is considered intraoperative when the dissection is recognized and treated during the initial cardiac surgery. Dissection within 2–4 weeks of index cardiac surgery is classified as early postoperative AAAD and this occurrence is associated with a woefully high risk of mortality. Late dissection is defined as occurring >30 days after primary heart surgery. Symptomatic patients are considered having late acute dissection, however late chronic dissection is a radiological incidental finding without acute symptoms. In the latest report [4], the mortality rates for intraoperative, early postoperative, late acute and chronic AAAD were 17, 42, 32 and 22%, respectively. Another important finding is the valuable effect of preoperative coronary angiography implementation to assess coronary artery and grafts status especially in patients with previous coronary artery bypass grafting surgery. With the increasing number of patients undergoing heart surgery and because previous cardiac surgery is increasingly recognized as an additional risk factor for aortic dissection [5], the incidence of post-cardiotomy aortic dissection will continue to increase. With careful planning by using preoperative coronary angiography and prompt execution, the outcomes in redo sternotomy operations for aortic dissection will parallel the results of spontaneous aortic dissection.

Resuscitation by extracorporeal membrane oxygenation with or without subsequent embolectomy

I read with great interest the article by He et al. [1]. In this valuable review, I think that there is yet another topic to be discussed. The authors stated that there are four therapeutic options in the setting of acute pulmonary embolism (PE), including heparin therapy, thrombolysis, catheter-based embolectomy and surgical embolectomy under cardiopulmonary bypass. However, they failed to include a valuable alternative in the management of moribund acute PE, that is extracorporeal membrane oxygenation (ECMO) support. There have been occasional reports describing the use of ECMO in the management of acute PE. Kolvekar et al. [2] implanted a veno-arterial ECMO in 2 patients with massive PE. They were successfully weaned after 3–4 days and did not undergo surgical embolectomy; of note, these 2 patients remained non-intubated during the ECMO support. Others have advocated the use of ECMO to provide emergency support for unstable patients with massive PE until surgical embolectomy could be performed [3, 4]. This is particularly correct in places where experienced and welltrained ECMO teams can expeditiously perform the mechanical support in critically ill patient or en route towards a centre that can offer surgical or catheter-based embolectomy. Recently, the use of peripheral ECMO for massive PE as a definitive therapy with concomitant heparin infusion for high-risk surgical candidates has been reiterated in a study by Malekan et al. [5]. Three patients were weaned after 5.3 days of ECMO support with a near-complete lysis of the embolus on the computed tomography scan. They showed that ECMO can be an effective alternative to surgical embolectomy in this subset of inoperable patients. In contrast, the use of ECMO not as a bridge to surgery but as an ultimate therapeutic option has been criticized sharply for introducing additional risks of chronic pulmonary hypertension in patients experiencing massive PE. To date, only a handful of reports, most of which are isolated case reports and small clinical series, have described the use of ECMO in this patient population and long-term results regarding chronic pulmonary hypertension are lacking. Despite advances in surgical techniques and excellent results following surgical embolectomy [6], open surgical intervention may not be the best option in patients with limited life expectancy, advanced debilitating disease or a combination of high surgical risk and a hostile reoperative mediastinal field. Early veno-arterial ECMO support has been shown to be effective in severely compromised patients with PE, even for patients undergoing prolonged cardiac resuscitation. It plays a major role as a rescue therapy in patients with severe compromise after severe PE, with or without subsequent surgical embolectomy.

Post‐Myocardial Infarction Ventricular Septal Defect

A 74-year-old patient presented with shortness of breath one week after untreated anterior myocardial infarction (MI). Coronary angiography showed an occluded left anterior descending artery and a severe stenosis of the circumflex artery and the diagonal branch. An echocardiogram revealed an antero-apical large aneurysm with a left-to-right shunt flow (Fig. 1A) and a depressed left ventricle ejection fraction (EF 1⁄4 40%). A cardiac-enhanced CT scan depicted clearly aneurysm location and small septal perforation site (Fig. 1 B). Prompt surgical treatment was undertaken (Fig. 2). The small septal channel was identified after

eComment. Percutaneous closure of post-myocardial infarction septal defect

We read with great interest the paper by Papalexopoulou et al. regarding the best timing of surgery in patients with post-infarct ventricular septal rupture [1]. After carefully reviewing the literature, the authors conclude that the best strategy is to delay the surgery by 3-4 weeks if the haemodynamic status of the patient allows. However, current guidelines advocate immediate surgical closure of the ventricular septal defect (VSD) irrespective of the patients haemodynamic status to circumvent further haemodynamic decline [2]. First described by Lock et al. in 1988, the transcatheter closure of VSD has gained a widespread use, and devices originally intended to close the patent foramen ovale or atrial septal defects, have been modified for closure of muscular VSD. This less-invasive interventional approach allows, in the majority of cases, rapid haemodynamic stabilization by reducing the left-to-right shunt [3]. Anatomical considerations, best depicted by echocardiography, represent a major limitation of this procedure. Large VSDs exceeding 35 mm, apical VSDs without suitable rim or basal VSDs in the vicinity of mitral apparatus or the aortic valve represent a contraindication to the percutaneous closure with Amplatzer devices [4]. Another important drawback is the limited number of centres with sufficient expertise in performing these challenging procedures, because percutaneous closure of an acute postinfarct VSD remains one of the most demanding procedures in interventional cardiology. Costache et al. used an Amplatzer occluder as a bridge-to-surgical procedure in a 79-year old woman in cardiogenic shock secondary to a post-infarct VSD [5]. The combined approach enabled them to perform surgery on a more stable patient. Recently, Thiele et al. [4] evaluated, in a prospective study, the outcomes of primary interventional closure of postinfarction VSD in an acute setting as an alternative to surgical closure. The overall 30-day mortality of this less-invasive approach was 35%. Not surprisingly, the mortality rate was higher in patients with cardiogenic shock. Major complications occurred in 41% and these included free ventricular wall rupture, device embolization or dislocation and residual left-to-right shunting. Despite advances in medical and surgical care intervention, mortality of postinfarction VSD remains high, especially in patients with haemodynamic compromise. Future multicentre studies are warranted to identify patients best suited for surgical or interventional closure, in the era of evolving alternative technologies. Conflict of interest: none declared