Klodian Krakulli

Pseudoaneurysm of the Descending Aorta Complicating an Untreated Aortic Coarctation

A 22-year-old man was referred for severe aortic coarctation. Contrast-enhanced computed tomography confirmed the aortic coarctation diagnosis and showed an aortic pseudoaneurysm arising from the anterior and left surface of the descending aorta, communicating with the aortic lumen with a small neck. Under cardiopulmonary bypass through the femoral vessels, the patient underwent closure of the pseudoaneurysm neck using a synthetic patch and interposition of a prosthetic graft between the left subclavian artery and the descending aorta below the pseudoaneurysm. The patients postoperative course was uneventful.

Surgical excision of a giant calcified amorphous tumour of the right ventricle and right pulmonary artery

A cardiac calcified amorphous tumour (CCAT) is a rare non-neoplastic intracavitary mass with unknown causes. We describe a 32-year old male presenting with progressive dyspnoea, cough and oedemas. The transthoracic echocardiography and contrast-enhanced angio-computed tomography demonstrated a 4 × 10 cm calcified mass into the right ventricle and total occlusion of the right pulmonary artery. The patient underwent successful total removal of the mass through a transverse right ventriculotomy, and right pulmonary embolectomy. Histopathological examination of mass confirmed the diagnosis of a CCAT. The postoperative course was uneventful. To our knowledge, this is the first reported case with a confirmed diagnosis of CCAT at two different locations and the third undergoing a combined approach aiming at total mass excision.

Hemodynamics of 17-mm vs. 19-mm St. Jude Medical Regent and annulus enlargement

Objective We aimed to compare early and midterm clinical and hemodynamic outcomes of 17-mm vs. 19-mm St. Jude Medical Regent valves with concomitant aortic annulus enlargement. Methods Between 1999 and 2012, 20 patients (group 1) underwent first-time aortic valve replacement with a 17-mm St. Jude Medical Regent valve, and 35 patients (group 2) had a 19-mm valve and concomitant aortic annulus enlargement. The mean follow-up was 81 ± 37 months (range 20–110 months). Results There was one death in group 1 vs. 4 in group 2 (p > 0.05). The mean postoperative transprosthetic gradient was 17.5 ± 4.5 in group 1 and 17 ± 6.4 mm Hg in group 2 (p = 0.83), and 37 ± 10.7 and 32 ± 13 mm Hg, respectively, under stress (p = 0.17). Left ventricular mass and left ventricular mass index were reduced and similar in both groups. Postoperative effective orifice area index was higher in group 2 (0.85 ± 0.17 cm2 m−2) than group 1 (0.76 ± 0.2 cm2 m−2; p > 0.05). A multivariate Cox model identified a 19-mm valve with aortic annulus enlargement (p = 0.032), functional class (p = 0.025), reoperation (p = 0.04), ejection fraction < 35% (p = 0.042), and combined surgery (p = 0.04) as strong predictors of poorer overall event-free survival. Conclusions The 17-mm St. Jude Medical Regent valve may be employed with satisfactory postoperative clinical and hemodynamic outcomes in patients with a small aortic annulus, as an alternative to a larger prothesis with aortic annulus enlargement.

Early and mid-term postoperative outcome of inflammatory abdominal aortic aneurysms.

INTRODUCTION AND OBJECTIVES The aim of this study is to report our experience on the postoperative outcome of surgical treatment of inflammatory abdominal aortic aneurysm (IAAA). MATERIALS AND METHODS Between January 1997 and March 2014, 35 patients with IAAA underwent surgery. The mean age was 63 ± 18 years. Chronic renal failure was identified in 11 (31.4%) patients, and ischemic heart disease was confirmed in 15 (43%) patients. The mean aortic aneurysm diameter was 68 ± 25 mm. The abdominal aorta was clamped above the renal arteries in 6 (17%) patients. RESULTS The hospital mortality was 5.7% (2 patients). Three patients developed an aortic pseudoaneurysm and underwent reoperation. Another patient developed a femoral anastomotic pseudoaneurysm 7 years after operation, which was treated surgically. The overall reoperation-free actuarial survival at 1, 5, and 7 years was 94, 62, and 50%, respectively. The Cox model revealed the delta erythrocyte sedimentation rate (p = 0.002), ischemic heart disease (p = 0.006), and renal failure (p = 0.036) as strong predictors for poor overall outcome. CONCLUSION Early postoperative outcome in terms of mortality and morbidity seems acceptable; however, patients with IAAA have an increased risk for reoperation due to pseudoaneurysm formation. Strong predictors for poor overall outcome seem to be elevated erythrocyte sedimentation rate, ischemic heart disease, and chronic renal failure.

Early and Mid-term Outcome of the St. Jude Medical Regent 19-mm Aortic Valve Mechanical Prosthesis. Functional and Haemodynamic Evaluation

BACKGROUND AND OBJECTIVES The aim of the present study is to report the early and mid-term clinical and haemodynamic results of the St Jude Medical Regent 19-mm aortic mechanical prothesis (SJMR-19). MATERIALS AND METHODS Between January 2002 and January 2012, 265 patients with aortic valve disease underwent AVR (Aortic Valve Replacement) with a SJMR-19 (St Jude Medical Regent Nr.19). There were 51 males. Mean age was 67.5±12.72years and mean body surface area (BSA) was 1.67±0.14m2. Thirty-six patients required annulus enlargement. The mean follow-up was 34.5±18.8months (range 6-60 months). All patients underwent echocardiographic examination at discharge and within 1 year after surgery. RESULTS There were 14 (5.3%) hospital deaths. Six of the hospital deaths were identified in patients undergoing reoperation, significantly higher than patients undergoing first time operation (p=0.0001). Also the postoperative mortality was significantly higher in patients undergoing annulus enlargement versus patients not requiring annulus enlargement (p=0.02). The mean transprosthesis gradient at discharge was 19±9mmHg. At 6 months follow-up the mean NYHA FC class was 1.6±0.5 significantly lower than preoperatively 2.4±0.75 (p <0.0001). The M-TPG was 15.2±6.5mmHg within 1 year after surgery. Left ventricular mass (LVM) and indexed left ventricular mass (LVMi) were significantly lower than preoperatively The actuarial survival and cumulative freedom from reoperation at 1, 2 and 3 years follow-up were 99.5%, 97.5%, 96.7% and 99.2%, 96.5%, 94.5% respectively. The cumulative actuarial free-events survival at 4 years was 92%. The Cox model identified age (p=0.015), LVEF≤35% (p=0.043), reoperation (p=0.031), combined surgery (p=0.00002), and annulus enlargement (p=0.015) as strong predictors for poor actuarial free-major events survival. CONCLUSIONS The SJMR-19 offers excellent postoperative clinical, haemodynamic outcome and LVMi reduction in patients with small aortic annulus. These data demonstrate that the modern St Jude small mechanical protheses do not influence the intermediate free-reoperation survival.

Successful surgical employment of Impella recovery system for right ventricular failure after previous aortic valve replacement

ABSTRACT A 58-year-old woman underwent aortic valve replacement. On the second postoperative day the patient referred a sharply chest pain, and an emergent coronary angiography revealed total occlusion of the right coronary artery. An intra-aortic ballon pump was placed and the patient underwent emergent off-pump coronary revascularization of the right coronary artery. Five hours later, due to unstable hemodynamic the extracorporeal membrane oxygenation was implanted without improvement of the right ventricular (RV) function. Then we decided to implant the Impella Right Direct (RD). After 9 days of Impella’s insertion the RV was recovered and the device was successfully explanted. After 16 days of Impella explanted the patient was discharged. This case suggest that implantation of Impella RD is clinically feasible, associated with hemodynamic improvement, and facilitate successful bridge-to-recovery in patients with post-cardiotomy RV failure due to myocardial infarction unresponsive to coronary artery bypass grafting, maximal medical therapy, contrapulsation and extracorporeal membrane oxygenation.

A rare coronary anomaly consisting of a single right coronary ostium in an adult undergoing surgical coronary revascularization: a case report and review of the literature

BackgroundCoronary arteries originating from the right coronary ostium in the ascending aorta represent a very rare anatomic presentation. Also, the presence of a single coronary ostium is an extremely rare finding.Case presentationWe present the case of a 74-year-old Albanian man from Kosovo. He had unstable angina due to critical triple vessel disease and a single coronary artery originating from a single ostium in the right sinus of Valsalva with an anomalous course of his left anterior descending artery anteriorly to the right ventricular outflow tract as a “T-vessel” from which originated the proximal and distal left anterior descending artery, the circumflex artery originating from the mid portion of the right coronary artery which had a normal course. He underwent successful coronary revascularization consisting of three vein grafts to the right coronary artery, first diagonal and obtuse marginal artery, and left internal mammary artery anastomosed to left anterior descending artery.ConclusionsWe describe a proposed IID1 pattern. After a careful revision of the literature, only six cases have been reported with a similar anomalous coronary origin. Only two out of six patients underwent surgical coronary revascularization. In our case the aberrant vessel arising from his right coronary artery coursed anteriorly to the right ventricle and continued as a left anterior descending artery at its mid portion which then continued distally as the distal left anterior descending artery and proximally as a proximal left anterior descending artery, having the shape of a “T vessel”. The “T-vessel” configuration has never been reported in the literature.The reported case with its specific presentation adds further information on this rare form of anomalous origin of the coronary arteries, representing a first report of a configuration that we name the “T-vessel” of the left anterior descending artery. Diagnosis of the coronary anatomy is very important for the invasive cardiologist and cardiac surgeon in cases with a single coronary ostium, such as our case, so that they can proceed with the invasive or surgical treatment when critical coronary artery disease is present.