Rachit Saxena

Role of systemic to pulmonary artery shunt after cavopulmonary anastomosis.

Superior cavopulmonary anastomosis and total cavopulmonary anastomosis are the procedures of choice for the management of patients with a functionally univentricular heart. We review the various indications, sites, advantages, and complications of a systemic to pulmonary artery shunt after the creation of superior cavopulmonary anastomosis. Systemic pulmonary artery shunt may be useful as a palliative strategy in patients who have hypoxemia and completion of total cavopulmonary anastomosis is not feasible. doi: 10.1111/jocs.12154 (J Card Surg 2013;28:599–603)

Migrated Kirschner wire in the posterior mediastinum.

At the age of 11 years, a female patient had sustained a fracture of the right humerus. She underwent open reduction and internal fixation with two straight Kirschner wires (K-wires). Twenty years later, at the age of 31 years, she underwent a chest roentgenogram for suspected respiratory symptoms when it was discovered that one of the K-wires (arrow in Fig. 1) had migrated to the mediastinum. Contrast enhanced computed tomography scans (Figs. 2 and 3) revealed that the K-wire (green arrow) had migrated to the posterior mediastinum across the midline in the pre vertebral space posterior to the oesophagus and arch of aorta (red arrow). Because the sharp edge had already crossed the

Extraanatomic Bypass to Supraceliac Abdominal Aorta for Complex Thoracic Aortic Obstruction.

BACKGROUND The standard surgical treatment of coarctation of the aorta is through a left posterolateral thoracotomy. However, when a concomitant cardiac procedure is required or the conventional approach is not possible or is hazardous, extraanatomic bypass to the supraceliac abdominal aorta may be advantageous. We discuss our technique and report the long-term results. METHODS Between January 1986 and January 2015, 25 patients (16 males, 9 females) underwent extraanatomic bypass to the supraceliac abdominal aorta for various lesions of the arch and the descending thoracic aorta. Extraanatomic bypass to the supraceliac abdominal aorta was performed for patients in whom balloon dilatation was not feasible due to associated arch hypoplasia (n = 9), long-segment thoracic aorta narrowing due to nonspecific aortoarteritis (n = 3), or isolated long-segment coarctation of the aorta (n = 3). Patients who needed concomitant cardiac procedures, such as aortic valve replacement (n = 4), ascending aortic aneurysm repair (n = 2), or coronary artery bypass grafting (n = 1), and in whom balloon dilatation had failed, also underwent extraanatomic bypass to the supraceliac abdominal aorta. Extraanatomic bypass was also performed in 3 patients with recurrent coarctation after surgical repair and in whom balloon dilation was not feasible or unsuccessful. RESULTS There were no early or late deaths. The peak-to-peak gradients between the upper limb and the lower limb decreased from 59.3 ± 16.3 mm Hg to 2.0 ± 2.8 mm Hg (p < 0.0001). The mean follow-up was 96.6 ± 92.6 months (range, 1 to 240 months; median, 54 months). Doppler interrogation of the lower limb arterial system after a mean follow-up of 86.4 ± 85.2 months showed an unobstructed flow pattern. The ankle-brachial pressure index improved from a preoperative value of 0.60 ± 0.07 to 1.04 ± 0.11 (p < 0.0001). Systolic blood pressure decreased significantly compared with preoperative values (153.9 ± 18.9 vs 122.8 ± 10.2, p < 0.0001). Three patients continued to receive antihypertensive medication due to persistent mild hypertension. CONCLUSIONS Extraanatomic bypass to the supraceliac abdominal aorta provides effective palliation for complex aortic obstructions. It is easy and quick to perform, avoids fatal complications, and is well tolerated in all age groups.

Immunohistochemical characterization of glandular elements in glandular cardiac myxoma: Study of six cases

Back ground: Glandular cardiac myxoma has varying clinical presentation with uncertain histogenesis and debatable immunohistochemical profile. Glandular epithelial differentiations are rare phenomenon known to be present as an intrinsic component of the tumor. The origin of the glands has been attributed to epithelial differentiation of a totipotent cardiomyogenic precursor cells or the entrapped foregut rests in the tumor. Materials and Methods: Retrospective study includes six cases of glandular cardiac myxoma collected over a perior of 4 years. Sections were examined to define the histogenesis, histological and immunohistochemical profile of the glandular elements. Results: Incidence of glandular cardiac myxoma was 6.6% with a male to female ratio of 1:2.Mean age was 49.9 years. Left atrium was the commonest site. Five were sporadic and one was familial. Chest pain and dyspnea were the commonest clinical symptoms. Histologically all myxoma showed well formed glandular structures with typical myxomatous area. No atypia, mitosis or necrosis was identified in the glandular elements. Markers in six cases of glandular cardiac myxoma were immunopositive for CK7, CK 19, EMA, CEA, focally for E-cadherin while immunonegative for CK20, Chromogranin, Synaptophysin, calretenin, vimentin, B-catenin, TTF-1 and GCDFP-15 favoring enteric differentiation. Conclusion: Glandular cardiac myxoma is a rare entity which shows characteristics similar to those of classical cardiac myxoma with benign glandular elements showing enteric differentiation. Complete surgical excision is the treatment of choice with good prognosis. It is important to recognize this entity to avoid an erroneous diagnosis of metastatic adenocarcinoma.

Thrombus in the Proximal Aorta: Cardiopulmonary Bypass Strategy and Surgical Management.

De novo noninfective thrombus formation in the ascending aorta is rare. We report two cases of ascending aortic thrombus, their surgical management, and cardiopulmonary bypass strategy.

Familial biatrial cardiac myxoma with glandular elements: A Rare entity with review of literature

Cardiac myxomas are benign neoplasm of the heart with an incidence of 0.3%. Glandular cardiac myxomas are very rare and accounts for less than 3% of all cardiac myxomas. Here, we report a case of familial glandular cardiac myxoma in a 35 year old male who complained of exertional dyspneoa and weakness of right side of body on clinical presentation. Associated features of Carneys complex were not present. Family history revealed presence of cardiac myxoma in younger brother and sister. Transthoracic echocardiography detected biatrial myxoma. Excision of both lesions was done under cardiopulmonary bypass. Histopathology confirmed myxoma with glandular elements. Postoperative course was uneventful.

Repair of Concomitant Double Orifice Mitral and Tricuspid Valves

The coexistence of double orifice mitral and tricuspid valves is rare. We report a five-year-old boy with double orifice mitral and tricuspid valves requiring surgical correction of hemodynamically significant mitral and tricuspid stenosis.

Surgical Challenges of Familial Hypercholesterolemia

A 21-year-old patient with familial hypercholesterolemia presented with angina caused by ostial stenosis of the left internal mammary artery and severe calcific aortic stenosis with small aortic root 9 years after coronary revascularization. The ostium of the left internal mammary artery was enlarged using a saphenous vein patch through a left supraclavicular incision, which improved left ventricular function. Successful aortic valve replacement with posterior aortic root enlargement was subsequently performed. The surgical management of this condition is discussed briefly.

Giant Left Atrial Myxoma

A 45-year-old female presented with increasing dyspnea, ascites, and pitting edema. A chest X-ray showed left atrial enlargement, an ill-defined right heart border, and splaying of the carina (Fig. 1). A computed tomographic angiogram showed an 11 12.5cm left atrial intracavitary mass (Fig. 2). Transesophageal echocardiography confirmed the presence of the left atrial mass and revealed a 16mmHg gradient across themitral valvewith moderate tricuspid regurgitation (Fig. 3). At the time of surgery, cardiopulmonary bypass was initiated with an ascending aortic cannula and venous cannulae in the superior and inferior vena cavae. Following cardioplegic arrest, transverse biatrial incisions were performed and the entire fossa ovalis was removed revealing the bulging mass (Fig. 4). The tumor extended from the inter atrial septum along the left atrial wall up to the right inferior pulmonary veins. It was completely removed in two pieces. The atrial septumwasclosedprimarily and themitral valve remained competent. The patient had an uneventful postoperative course. The histopathology revealed an atrial myxoma.