Nicholas S. Clarke

Coxiella burnetti‐associated thoracic endovascular stent graft infection

A 69-year-old female underwent a thoracic endovascular aneurysm repair (TEVAR) for a 7 × 5.4-cm Crawford type 1 thoracoabdominal aneurysm. She was subsequently readmitted with fatigue, weight loss, night sweats, and abdominal pain. A computed tomogram angiogram (CTA) demonstrated an enlarging aneurysmal mass with thickened walls concerning for an infected TEVAR graft (Fig. 1). An extensive workup revealed an increased IgG titer; phase I 1:16384, phase II 1:8182 consistent with a Coxiella burnetti infection. Doxycyline (200mg/day) and hydroxychloroquine (200mg tid) were instituted to decrease titers to <1:800, to minimize the risk of aerosolization and potential exposure to healthcare personnel. During this period of medical therapy, she continued to have fatigue and weight loss and developed hematemesis. A follow-up CTA now demonstrated perianeurysmal air and fat stranding concerning for an aorto-graftesophageal fistula (Fig. 2). She underwent emergent surgical repair through a left posterolateral thoracoabdominal incision using left heart bypass instituted with cannulation of the transverse arch and an 8-mm Hemashield graft (MAQUET Holding B.V. & Co. KG, Rastatt, Germany)

Hypertrophic obstructive cardiomyopathy: review of surgical treatment

Hypertrophic cardiomyopathy ranks among the most common congenital cardiac diseases, affecting up to 1 in 200 of the general population. When it causes left ventricular outflow tract obstruction, treatment is guided to reduce symptoms and the risk of sudden cardiac death. Pharmacologic therapy is the first-line treatment, but when it fails, surgical myectomy or percutaneous ablation of the hypertrophic myocardium are the standard therapies to eliminate subaortic obstruction. Both surgical myectomy and percutaneous ablation are proven safe and effective treatments; however, myectomy is the gold standard with a significantly lower complication rate and more complete and lasting reduction of left ventricular outflow tract obstruction.

Aortoesophageal Fistula in a Child With Undiagnosed Vascular Ring: Life-Threatening or Lethal?

Exsanguinating hematemesis secondary to an aortoesophageal fistula from an impacted foreign body occurred in a patient with a vascular ring. This report describes successful resuscitation and repair in a 6-year-old boy who was transferred from an outside hospital in extremis with an aortoesophageal fistula from a foreign body in the presence of a vascular ring.

Transplantation in a patient on extracorporeal membrane oxygenation with infective endocarditis, pericarditis and heparin-induced thrombocytopenia.

Heart failure patients with pacemaker or defibrillator-associated endocarditis in cardiogenic shock have few treatment options. We present a case of an INTERMACS I patient who developed device infection, sepsis, bacterial pericarditis and heparin-induced thrombocytopenia. The patient was stabilized with extracorporeal membrane oxygenation and successfully transplanted.

Retrosternal lead placement: an attractive alternative to subcutaneous tunneling

Complex lead placement is on the rise. When ipsilateral lead placement is unavailable, a retrosternal approach offers minimal cosmetic defects while minimizing lead injury. A retrosternal technique has yet to be described in the literature. Here, we describe our technique, tricks, and pitfalls to performing such an operation in three patients.

Persistent Left Superior Vena Cava: Incidence and Management in Patients Undergoing Repair of Partial Anomalous Pulmonary Venous Connection

Introduction: A association between partial anomalous pulmonary venous connection (PAPVC) and systemic venous anomalies has been described in the literature, but the true incidence is yet to be elucidated. At our institution, we sought to find the incidence of a persistent left superior vena cava (PLSVC) in patients undergoing an operation for PAPVC. Methods: A retrospective review of all pediatric and adult patients with PAPVC who underwent surgical repair from February 2006 to February 2016. All clinical, radiographic, and operative data were reviewed. Results: Eighty-five patients underwent surgical repair. A PLSVC was identified in 15 (17.6%) patients. Every PLSVC drained/connected to the coronary sinus. A bridging vein was present in only 26.7% (4 of 15). Intraoperative management of the PLSVC consisted of direct cannulation in nine (60%) patients, temporary occlusion in one (6.7%) patient, and ligation in one (6.7%) patient. In the 15 PLSVC patients, 6 (40%) had a secundum atrial septal defect (ASD), 2 (13.3%) had a patent foramen ovale (PFO), 10 (66.6%) had a sinus venosus type defect, and 3 (20%) had both an ASD and sinus venosus–type defect. Of the 15 patients with PAPVC and PLSVC, 14 (93%) had anomalous drainage of pulmonary vein(s) on the right side, whereas 1 (7%) had veins on both sides with anomalous drainage. Conclusion: Persistent left superior vena cava is present in 17.6% of patients undergoing an operation for PAPVC. Awareness of this association as well as the intraoperative management of PLSVC is advised for those that perform operations for PAPVC. As improper myocardial protection and cardiopulmonary bypass strategies in the presence of a PLSVC can result in deleterious outcomes.

Mixed Total Anomalous Pulmonary Venous Return With Ascending and Descending Vertical Veins

An 8-day-old girl born at 41 weeks’ gestation weighing 4.1 kg was diagnosed with total anomalous pulmonary venous return (TAPVR) and transferred to our facility for further evaluation. Examination showed trigonocephaly, hypertelorism, and a webbed neck. Genetic analysis revealed a 9p deletion. Computed tomography scan (Figure 1) demonstrated mixed TAPVR with a single confluence of all pulmonary veins, in continuity with both a superior and inferior vertical vein (VV). The superior VV connected to the posterior aspect of the juncture of the superior vena cava and brachiocephalic vein. The inferior VV connected to the hepatic veins through the ductus venosus. No pulmonary vein obstruction was identified. Magnetic resonance imaging of the brain demonstrated a severely dysgenetic forebrain. After consultation with family, a decision not to proceed with surgical intervention was reached. In our patient, mixed TAPVR is characterized by the failed union of the pulmonary venous plexus with the developing left atrium, resulting in a persistent embryologic connection between the pulmonary veins and right common cardinal and umbilicovitelline systems. Total anomalous pulmonary venous return is generally classified into four major types as originally described by Darling based on anatomic location of the pulmonary venous drainage in relation to the heart: supracardiac, cardiac, infracardiac, and mixed. Pulmonary venous obstruction in this population is a surgical emergency. Obstruction at the level of the superior vertical vein may occur between the left pulmonary Figure 1. Computed tomography that demonstrates (A) superior vertical vein on sagittal view and (B) inferior vertical vein on coronal view with (C) representing a three-dimensional reconstruction. White arrowheads point to vertical veins.

Influence of metformin and insulin on myocardial substrate oxidation under conditions encountered during cardiac surgery

Background The influence of diabetic therapies on myocardial substrate selection during cardiac surgery is unknown but may be important to ensure optimal surgical outcomes. We hypothesized that metformin and insulin alter myocardial substrate selection during cardiac surgery and may affect reperfusion cardiac function. Methods Rat hearts (n = 8 per group) were evaluated under 3 metabolic conditions: normokalemia, cardioplegia, or bypass. Groups were perfused with Krebs‐Henseleit buffer in the presence of no additives, metformin, insulin, or both insulin and metformin. Perfusion buffer containing physiologic concentrations of energetic substrates with different carbon‐13 (13C) labeling patterns were used to determine substrate oxidation preferences using 13C magnetic resonance spectroscopy and glutamate isotopomer analysis. Rate pressure product and oxygen consumption were measured. Results Myocardial function was not different between groups. For normokalemia, ketone oxidation was reduced in the presence of insulin and the combination of metformin and insulin reduced fatty acid oxidation. Metformin reduced fatty acid and ketone oxidation during cardioplegia. Fatty acid oxidation was increased in the bypass group compared with all other conditions. Conclusion Metformin and insulin affect substrate utilization and reduce fatty acid oxidation before reperfusion. These alterations in substrate oxidation did not affect myocardial function in otherwise normal hearts.