Magdalena Zagrodzka

Challenges in cardiac surgery: how to operate mitral valve in patient with pectus excavatum

Pectus excavatum is the most common structural anomaly of the chest. Its presence is associated with many clinical challenges, especially when it comes to interventions within. Disorders of the cardiopulmonary system are not rare in patients with advanced stage of deformation. A 37-year-old male patient with pectus excavatum and history of mitral valve insufficiency due to posterior leaflet prolapse was admitted to hospital because of infective endocarditis. The symptoms of the infection began six months before the admission; the patient had fever 40°C, muscle pain, night sweats, lack of appetite, and a 15-kg fall in body mass. The patient was hospitalised twice due to pneumonia; each time he was successfully treated with antibiotics. Echocardiographic study revealed thickening and fibrosis of mitral leaflets (thickness of posterior leaflet: 8 mm) with bacterial vegetation on both of them, severe mitral insufficiency (previously the regurgitation was solely a consequence of posterior leaflet prolapse due to mitral annular deformation, which is very common in patients with pectus excavatum), and enlargement of the left atrium. Transoesophageal echocardiography confirmed the presence of vegetation on both leaflets. Laboratory tests revealed high levels of inflammatory markers, and colonies of Streptococcus parasanguinis were isolated from the blood culture. The patient was treated, according to antibiogram, with amoxicillin with clavulanic acid and gentamicin. The treatment was stopped after 24 days due to liver damage. After withdrawal of antibiotics, biochemical hepatic markers returned to normal level. Subsequent blood culture did not reveal any bacterial growth. Despite this fact, the patient had recurrent subfebrile rises in body temperature. Transoesophageal echocardiographic evaluation did not visualise any new vegetations. However, old organised 2 × 5 mm vegetation on the posterior mitral leaflet was observed. Computed tomography with angiography was essential to study organ relations in the deformed chest. It revealed advanced structural anomaly with minimal distance between sternum and vertebrae estimated at 19 mm; dislocation of heart to the left; 28 mm aorta; 20 mm right pulmonary artery, and 21 mm left pulmonary artery. Ground-glass opacification was seen at the base of the right lung and scarification was observed in the left pleura (Fig. 1A–C). The surgery was performed through ministernotomy. The vegetation was removed. Due to the social status of the patient and the likelihood of poor compliance, bioprosthesis was implanted with the intention of avoiding persistent use of vitamin K antagonists. Patent foramen ovale was sutured. Extracorporeal circulation time was 69 min and aortic cross-clamp time came to 60 min. Total chest tube drainage was 540 mL. Further hospitalisation was uneventful. The patient was discharged to the rehabilitation department five days after the surgery with continuation of the antibiotics (Fig. 2). Scheduled clinical and echocardiographic evaluation 60 days after the surgery confirmed proper function of the bioprosthesis. Laboratory tests were normal and no signs of infection were observed. The patient was referred to the surgery department to consider a planned pectus excavatum correction.

Dyspnoea related to pre-excitation during sinus rhythm as a new indication for catheter ablation

BACKGROUND Patients with pre-excitation without arrhythmic symptoms are diagnosed as Wolff-Parkinson-White (WPW) pattern. AIM To evaluate the efficacy of radiofrequency ablation (RFA) in patients with a WPW pattern and reported dyspnoea. METHODS Five patients (four adults and one adolescent, all female, age 33 ± 15 years) with a WPW pattern were referred due to dyspnoea and exercise intolerance. None had a history of paroxysmal syncope, pre-syncope, dizziness or palpitation. Before and after RFA, additional tests were used to exclude organic diseases of the pulmonary vessels, heart and lung, as well as bronchial hyperreactivity and metabolic diseases. Cardiopulmonary exercise test (CPET), echocardiography, time of forced expiration, baseline dyspnoea index (BDI), and transition dyspnoea index (TDI) were included into an objective evaluation of breath pattern. RESULTS In all investigated patients, no arrhythmia was inducible during the electrophysiology study. The time of forced expiration increased immediately after RFA from 15.8 ± 2.9 to 29.2 ± 4.4 s (p < 0.001). The BDI score before RFA was 6.7 ± 1.9 and the TDI score after RFA showed a significant improvement: 8.0 ± 1.2 (p < 0.05). CPET revealed significant improvement in cardiopulmonary capacity after RFA in all cases: peak oxygen consumption [mL/kg/min]: 31.1 ± 7 vs. 42.6 ± 9.6 (p = 0.014); peak exercise minute ventilation [L/min]: 60.0 ± 19.9 vs. 82.0 ± 27 (p = 0.006); peak exercise tidal volume [L]: 1.56 ± 0.25 vs. 2.04 ± 0.24 (p = 0.002); ratio dead space/tidal volume at the end of exercise: 28 ± 2.6 vs. 25 ± 2.3 (p = 0.005). CONCLUSIONS Dyspnoea during sinus rhythm in women with pre-excitation may be considered to be an evaluation criterion before RFA.