Peter Pohlner

The long‐term outcomes of transcoronary ablation of septal hypertrophy compared to surgical myectomy in patients with symptomatic hypertrophic obstructive cardiomyopathy

The aim of this study was to compare the long‐term outcomes of transcoronary ablation of septal hypertrophy (TASH) with open surgical myomectomy (SM) in patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM).Objectives The aim of this study was to compare the long-term outcomes of transcoronary ablation of septal hypertrophy (TASH) with open surgical myomectomy (SM) in patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM). Methods We reviewed patients who underwent either procedure at our institution. The demographics, clinical outcomes, echocardiographic parameters, and complications were compared. Results Seventy patients with HOCM were treated with either TASH (n = 47, 26 male) or SM (n = 23, 10 male). Compared to those treated with SM, patients undergoing TASH were older (57+/− 14.7 years versus 47 +/− 20.6 years, P = 0.021) and more symptomatic. A higher proportion of patients had syncope as a presenting feature in the TASH group compared to the SM group (57.5% vs. 17.4%, P = 0.002) respectively. They were also more likely to be in New York Heart Association (NYHA) class III/IV compared to the patients who underwent SM (85.1% vs. 39.1%; P < 0.001). Patients were followed for a mean period of 43 months (TASH) and 46 months (SM). Repeat procedures were more common in the TASH group (17% vs. 0%, P = 0.04) but mitral valve replacement was more common in the SM group (0% vs. 8.7%, P = 0.105). Symptom improvement, the rate of complications and all cause mortality rates were similar in both groups. Conclusions TASH compares favorably with surgical myectomy with regard to symptom resolution, rate of complications and mortality in a tertiary referral centre and should be seen as an attractive alternative to surgical myectomy in the appropriate patient population.

The management of the older adult patient with anomalous left coronary artery from the pulmonary artery syndrome: a presentation of two cases and review of the literature.

ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital abnormality that involves an anomalous insertion of the left coronary artery into the pulmonary artery. Ninety percent of patients present in the first year of life with signs and symptoms of heart failure or sudden cardiac death secondary to chronic myocardial ischemia. There have been an increasing number of reports of ALCAPA patients surviving to adulthood. There seems, however, to be a tendency to die suddenly in the third decade of life. Adult survivors are either asymptomatic or present with mitral regurgitation, cardiomyopathy, myocardial ischemia, or malignant arrhythmias. The management of the older patient presenting with symptoms resulting from ischemia and progressive left ventricular dysfunction remains a challenge. Treatment is largely based on guidelines for adult congenital heart disease management and an extrapolation of evidence from heart failure practice. Currently, surgical reimplantation of the anomalous coronary onto the aorta is the mainstay of treatment. The management of heart failure, sudden cardiac death, and ventricular arrhythmia present problems that are not addressed by reimplantation of the anomalous vessel alone. In this report, we present two cases with different modes of presentation and discuss treatment options.ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital abnormality that involves an anomalous insertion of the left coronary artery into the pulmonary artery. Ninety percent of patients present in the first year of life with signs and symptoms of heart failure or sudden cardiac death secondary to chronic myocardial ischemia. There have been an increasing number of reports of ALCAPA patients surviving to adulthood. There seems, however, to be a tendency to die suddenly in the third decade of life. Adult survivors are either asymptomatic or present with mitral regurgitation, cardiomyopathy, myocardial ischemia, or malignant arrhythmias. The management of the older patient presenting with symptoms resulting from ischemia and progressive left ventricular dysfunction remains a challenge. Treatment is largely based on guidelines for adult congenital heart disease management and an extrapolation of evidence from heart failure practice. Currently, surgical reimplantation of the anomalous coronary onto the aorta is the mainstay of treatment. The management of heart failure, sudden cardiac death, and ventricular arrhythmia present problems that are not addressed by reimplantation of the anomalous vessel alone. In this report, we present two cases with different modes of presentation and discuss treatment options.

Percutaneous treatment of an occlusive left main pseudoaneurysm: a role for multimodality imaging

A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia was successfully treated with a covered stent. We report this rare complication of cardiac surgery for infective endocarditis with a large root abscess. The patient developed a pseudoaneurysm arising from the body of the left main and causing compression of this vessel following his fourth redo aortic valve replacement for staphylococcal endocarditis. The endocarditis had been successfully managed and ongoing infection was excluded. The patient was then treated percutaneously with a covered stent that excluded the aneurysm and relieved the stenosis in the vessel.

Partial replacement of tricuspid valve using cryopreserved homograft.

BACKGROUND The optimal choice of prosthesis for tricuspid valve (TV) replacement is yet to be determined. Partial replacement of the TV using a homograft atrioventricular valve might offer resistance to infection, good durability, and excellent functionality, in addition to avoiding prosthesis-related morbidity. METHODS We present 14 patients who underwent replacement of the TV using a homograft between 1997 and 2008. The mean age at operation was 32 years, including 5 patients younger than the age of 10. All patients preoperatively showed severe TV regurgitation as a result of active infective endocarditis in 5 patients, Ebstein anomaly in 4 patients, other cardiac anomalies in 4 patients, and rheumatic valvular disease in 1 patient. The TV homograft was used in 13 patients, and mitral homograft was used in 1 patient. Eleven patients had replacement of one leaflet only, whereas 3 patients required replacement of two leaflets. Concomitant cardiac procedures were performed in 7 patients. RESULTS No mortalities occurred during the average postoperative follow-up of 61 months (range, 12 to 126 months). Reoperation for TV regurgitation after TV repair with homograft was performed in 3 patients. The remaining 11 patients had minimal symptoms without reintervention for TV regurgitation. CONCLUSIONS Partial replacement of the TV using a homograft provided good hospital and mid-term outcomes. This strategy might be useful in active infective endocarditis and congenital TV disease.

Successful hybrid coronary artery revascularisation in a patient with severe cerebrovascular disease: a new treatment option to minimise the risk of stroke

Here we present a case involving a patient with severe distal left main coronary artery stenosis with extensive coexisting extracranial cerebrovascular disease where hybrid coronary artery revascularisation was successfully performed. This illustrates the potential for hybrid revascularisation in those patients with an inherit risk of stroke.

The Management of the Older Adult Patient with Anomalous Left Coronary Artery from the Pulmonary Artery Syndrome: A Presentation of Two Cases and Review of the Literature: Management of Adult Patient with ALCAPA

ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital abnormality that involves an anomalous insertion of the left coronary artery into the pulmonary artery. Ninety percent of patients present in the first year of life with signs and symptoms of heart failure or sudden cardiac death secondary to chronic myocardial ischemia. There have been an increasing number of reports of ALCAPA patients surviving to adulthood. There seems, however, to be a tendency to die suddenly in the third decade of life. Adult survivors are either asymptomatic or present with mitral regurgitation, cardiomyopathy, myocardial ischemia, or malignant arrhythmias. The management of the older patient presenting with symptoms resulting from ischemia and progressive left ventricular dysfunction remains a challenge. Treatment is largely based on guidelines for adult congenital heart disease management and an extrapolation of evidence from heart failure practice. Currently, surgical reimplantation of the anomalous coronary onto the aorta is the mainstay of treatment. The management of heart failure, sudden cardiac death, and ventricular arrhythmia present problems that are not addressed by reimplantation of the anomalous vessel alone. In this report, we present two cases with different modes of presentation and discuss treatment options.ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital abnormality that involves an anomalous insertion of the left coronary artery into the pulmonary artery. Ninety percent of patients present in the first year of life with signs and symptoms of heart failure or sudden cardiac death secondary to chronic myocardial ischemia. There have been an increasing number of reports of ALCAPA patients surviving to adulthood. There seems, however, to be a tendency to die suddenly in the third decade of life. Adult survivors are either asymptomatic or present with mitral regurgitation, cardiomyopathy, myocardial ischemia, or malignant arrhythmias. The management of the older patient presenting with symptoms resulting from ischemia and progressive left ventricular dysfunction remains a challenge. Treatment is largely based on guidelines for adult congenital heart disease management and an extrapolation of evidence from heart failure practice. Currently, surgical reimplantation of the anomalous coronary onto the aorta is the mainstay of treatment. The management of heart failure, sudden cardiac death, and ventricular arrhythmia present problems that are not addressed by reimplantation of the anomalous vessel alone. In this report, we present two cases with different modes of presentation and discuss treatment options.

Fistula Between Subclavian Arterial Graft and Oesophagus

This is the first reported case of an oesophageal fistula arising from a subclavian arterial graft. A 28 year-old woman presented with massive haematemesis in severe haemorrhagic shock, three months after surgery to detach and relocate an aberrant right subclavian artery. Acutely, she was haemodynamically unstable and required transfusion of 45 units of blood. The fistula was identified with angiography (via the right brachial artery) after endoscopic and open visualisation were unsuccessful because of the torrential haemorrhage. The patient was stabilised and the fistula was managed with an endovascular covered stent. She had further surgery subsequently to remove the infected graft and to salvage the right arm.