Sanjay Cherian

Late Tamponade Secondary to Aortic Root Perforation by BioSTAR Septal Closure Device

We report a patient who presented with pericardial tamponade 9 months after percutaneous closure of a patent foramen ovale using a BioSTAR septal closure device (NMT Medical, Boston, MA). During the operation, bleeding was observed on the posterior aortic root caused by a nonendothelialized strut. The device was explanted, followed by pericardial patch aortoplasty and patch closure of the patent foramen ovale. This report presents a case of late tamponade related to the new-generation bioabsorbable BioSTAR device. Although late complications related with BioSTAR are rare, the presentation may be dramatic. A high index of suspicion and quick intervention is often lifesaving.

Surgical treatment of complications associated with the Angio-Seal vascular closure device.

Vascular closure devices are used to provide quick hemostasis and early ambulation after percutaneous interventions. The Angio-Seal (AS) vascular closure device forms a mechanical seal by closing the puncture site located between a bioabsorbable anchor within the lumen and a collagen sponge on the adventitia. Although morbidities associated with AS are reportedly infrequent, even the slightest inaccuracy in device implantation may result in displacement of these device components, leading to sudden and severe complications. We report the surgical treatment of complications associated with the use of AS in four patients, including acute limb ischemia, pseudoaneurysm formation, significant hemorrhage, and hypovolemic shock. A common factor in all these cases was that the components of the AS device were displaced from their original site of implantation, stressing the importance of proper device placement. All patients underwent successful surgical vascular repair. Our report highlights the need for exercising extreme care during device implantation, and also the requirement for vigilant inspection for any associated vascular complications commencing immediately after device implantation. It is vital that these device components are actively looked for and removed during surgical exploration so as to prevent future complications.

Modified Transseptal Repair for Total Anomalous Pulmonary Venous Connection Repair in All Age Groups

Little data are available in late-presenting children with unobstructed totally anomalous pulmonary venous connection. Eleven patients underwent repair at a median age of 6.5 months using a modified transseptal approach to improve access and avoid circulatory arrest. There were no early or late deaths, and none of the patients presented pulmonary venous stenosis at a median follow-up of 8.7 years.

Primary cardiac lymphoma causing right atrial occlusion.

Primary cardiac lymphomas (PCL) are extremely rare, and diffuse large B-cell lymphoma is a highly aggressive subtype. We report a case that was initially diagnosed as chronic right heart dysfunction. Detailed investigations revealed a large lobulated tumour occluding the right atrium, infiltrating the inter-atrial septum, the roof of the left atrium, and the aortic root. Despite adequate surgical debulking and initial successful tricuspid annuloplasty, the patient succumbed to multi-organ failure. Pathological analysis of the resected tumour confirmed a diffuse large B-cell lymphoma with a proliferation rate of 100%. What is unique about this case is the size of this rare cardiac tumour, which we believe to be one of the largest described in the literature for a purely intra-cardiac PCL, its aggressive growth rate, and the relatively mild symptomatology until a late stage of the disease.

Rapid Progression of Left Main Coronary Disease Causing Acute Coronary Syndrome

A 72-year-old man presented with atypical chest pain in December 2009. Thereafter, he underwent coronary angiography that revealed no significant stenosis and no thrombosis of any coronary arteries (Figs 1A, 1B), with normal left ventricular function. He was a nonsmoker, non-diabetic, with mild hypercholesterolemia, and mild hypertension that was well-controlled by medication. In June 2010, he presented with acute coronary syndrome with an electrocardiogram that showed non-ST elevation myocardial infarction. A repeat coronary angiography demonstrated rapid progression of atherosclerotic disease, resulting in critical stenosis of the left main

Mitral valve replacement using a mitral homograft.

Mitral valve dysfunction is not always amenable to repair, and may necessitate valve replacement. An alternative to standard mechanical and biological prostheses is the use of homografts. The following manuscript and videos describe our surgical approach to mitral valve replacement with a complete mitral homograft in a cadaveric heart model.

Positron emission tomography–computed tomography scan helps decision making in cardiac surgery

A 64-year old male who underwent a mechanical valve Bentall procedure at another institution presented 1 year postoperatively with fever and dyspnoea. Laboratory investigations revealed Candida albicans infection with a periprosthetic collection. Confusion as to whether the collection was infective endocarditis, a periprosthetic transudate or a mass of haemostatic plugs used intraoperatively was clarified by combined positron emission tomography– computed tomography (PET–CT scans; Fig. 1).

Late erosion of an Amplatzer septal occluder device

Patients in our study with heterotaxy and congenital heart disease (CHD) showed high postoperative morbidity/ mortality, with some having respiratory complications. Although this respiratory phenotype is often attributed to the CHD, airway mucus clearance and left-right patterning, abnormal in heterotaxy syndrome, both require motile ciliary function. Thus airway ciliary dysfunction (CD) similar to that of primary ciliary dyskinesia (PCD) may have relevance for increased respiratory complications seen in patientswith heterotaxy. To better characterize the phenotype of a broad spectrum of patients with heterotaxy, 43 patients with CHD were assessed for airway CD. We used videomicroscopy to look for abnormal ciliary motion in nasal tissue and nasal nitric oxide noninvasive testing (typically low with PCD) to assess for CD. A remarkable 42% (18/43) of patients exhibited CD, with one third in the severe PCD range. Patients greater than 6 years old with CD showed increased respiratory disease similar to that seen in PCD. Our studies suggest patients with CHD who have heterotaxy have substantial risk of CD and respiratory disease that complicates their prognosis. The phenotype–genotype–prognosis correlation is also important in that further research may allow future patients and families to correlate gene mutations with phenotype and prognosis. Now families face the very high recurrence risk ratio of 79.1 for heterotaxia (95% confidence interval, 32.9-190). Further study of our patients with heterotaxy who have CD through next-generation sequencing of all 14 known PCD genes in 13 heterotaxy patients with CD identified 10 novel coding variants in 6 PCD genes. Recently, some CD gene mutations have become commercially available. The paradigm of phenotype–genotype–prognosis is beneficial to promote translational research to the patient, family, and medical care team. Our research suggests that patients with CHD and heterotaxy will