Sunil Abrol

Pseudoaneurysms of the Ascending Aorta Following Coronary Artery Bypass Surgery

Abstract  Background: Ascending aortic pseudoaneurysms following prior cardiac procedures are a rare entity. We reviewed our institutional experience given the isolated case reports in the literature. Methods: A 10‐year retrospective review identified 5 patients who underwent ascending aorta pseudoaneurysm repair. There were 3 women and 2 men with a median age of 70 years (range 63 to 79 years). Median duration from initial CABG to pseudoaneurysm repair was 5 years (range 5 months to 18 years). The clinical presentations included dyspnoea (2 patients), chest pain, fever of unknown origin, and a pulsatile mass. Four patients underwent urgent investigation and surgery. Diagnosis was established via CT scan (3 patients), transesophageal echocardiogram (1 patient), and MRA (1 patient). Two patients had a prior history of sternal wound infection. Results: Mortality was 60%. One survivor experienced a stroke. The etiology was prior cannulation site in 4 cases and vein graft anastamotic site in 1. Necrotic aortic tissue was noticed in 2 cases. Aortic tissue cultures were negative in all the patients. Cardiopulmonary bypass was established prior to sternotomy in 4 cases and 1 case was performed off‐pump. Inadvertent rupture of the pseudoaneurysm (without exsanguination) occurred in 2 cases following sternotomy. Repair was performed with bovine pericardial patch in 2 cases and plication in 3 cases. Conclusion: This highlights the varied presentation, necessity for urgent diagnosis and repair with a high operative mortality due to the late presentation. Aggressive diagnosis should be sought and consideration should be given to catheter‐based interventions for initial treatment.

Expedient pulmonary embolectomy for acute pulmonary embolism: improved outcomes.

Indications regarding surgical pulmonary embolectomy for treatment of submassive/massive acute pulmonary embolism remain controversial. An institutional experience with pulmonary embolectomy for acute pulmonary embolism (APE) was reviewed. A retrospective analysis of all patients undergoing pulmonary embolectomy for APE from September 2004 to January 2007 was conducted. Demographic data, clinical presentation and outcomes were analyzed. Fifteen patients underwent surgery for APE over a period of 27 months [average age 59.6 (range 35-89) years, (seven male, eight female)]. Six (40%) patients were admitted with known APE and nine patients exhibited post admission APE (seven - after surgical procedures, two - after cerebrovascular accident). Clinical presentation included dyspnea (86.67%), hemodynamic instability requiring continuous vasopressor support (40%), echocardiographic evidence of right ventricular dilatation (80%). Ten patients undergoing early/expedient embolectomy all survived while delayed surgery in the other five patients (>24 h) was associated with 60% mortality. Expanding indications for early surgical pulmonary embolectomy has stemmed from reliable echocardiographic identification of right ventricular compromise and recognition of these findings as harbingers of subsequent hemodynamic embarrassment. Our series underscores the benefit of early consideration and performance of pulmonary embolectomy in these critically ill patients.

Isolated and Significant Left Main Coronary Artery Disease: Demographics, Hemodynamics and Angiographic Features

Left main coronary artery disease carries a poor prognosis. The etiology of isolated and significant left main coronary artery (ILMCA) disease is not well understood. Studies so far were limited by small numbers. The authors identified 46 patients with ILMCA disease from their database over 10 years (group I) and compared them with 83 consecutive patients undergoing catheterization (group II). They also compared patients with ostial vs distal ILMCA disease. Group I represented 0.1% of catheterization patients. The demographic profile and atherosclerotic risk factor profile of the 2 groups as well as ostial and distal ILMCA disease were compared. This is the largest study of ILMCA disease. Risk factors for atherosclerosis were commonly seen. Nonatherosclerotic causes of ILMCA disease were not seen. This study suggests coronary atherosclerosis as the predominant cause of ILMCA disease. ILMCA disease is more common in women. Diabetes is more commonly associated with distal ILMCA lesion. There is a trend suggesting that ostial ILMCA lesion is more common in smokers and women.

Prosthetic Valve Endocarditis Caused by Gemella sanguinis: A Consequence of Persistent Dental Infection

Late prosthetic valve endocarditis is usually caused by streptococci, staphylococci, gram-negative bacilli and candida. The authors report the first case of prosthetic valve endocarditis caused by Gemella sanguinis. The patients risk factors for the development of Gemella endocarditis were the persistent severe dental caries and the presence of prosthetic valves. The patient required surgical replacement of the infected valve but had a good outcome with preservation of cardiac and valvular function. Evaluation and treatment of the persistent dental infection before initial valvular surgery may have prevented secondary infection of the prosthetic valve.

One-stage repair using a frozen elephant trunk technique for acute type A intramural hematoma with an ulcer-like projection in the dilated proximal descending aorta

An 82-year-old female was admitted with an acute type A intramural hematoma (IMH) following treatment for a type B IMH. Computed tomography angiography showed a large IMH extending from the ascending aorta to the proximal descending aorta which contained an intimal tear with an ulcer-like projection and was 6 cm in diameter (Fig. 1A,B). In addition, the innominate and left carotid arteries had a common trunk consistent with a bovine arch. At the time of surgery following a mediansternotomy, the innominate artery was cannulated and subsequently clamped at 26°C at which time circulatory arrestwas initiated and antegrade cerebral perfusion (10mg/kg) was instituted. The ascending aorta and transverse arch were excised and the left subclavian artery was transected with an endovascular stapler. A 28-mmHemashield graft was used to construct the elephant trunk and was anastomosed to the descending aorta with a 4-0 Prolene running suture (Fig. 2A-1) and then extracted from the descending aorta (Fig. 2A-2). Under fluoroscopy, a guidewire was placed in the descending aorta through which a #34-mm Gore TAG graft (W L Gore & Associates Inc., Sunnyvale, CA) was inserted (Fig. 2A-3). The proximal portion of the 28-mm Hemashield graft was anastomosed to the proximal ascending aorta using a running 4-0 Prolene suture. A 22-mm Hemashield graft was anastomosed end to side from the bovine trunk to the ascending aortic graft (Fig. 2A-4). The left subclavian artery was not reconstructed. The total circulatory arrest time was 77min. The patient tolerated the procedure well and had an uncomplicated postoperative course. A follow up computed tomography scan at 10 months showed no further aneurysmal dilation of the aorta and no endoleaks (Fig. 2B,C).

Adult Onset Dysphagia: Right Sided Aortic Arch, Ductus Diverticulum, and Retroesophageal Ligamentum Arteriosum Comprising an Obstructing Vascular Ring

A 49-year-old African American male patient with no past medical history was admitted because of 3 months of difficulty swallowing solid and liquid foods. He had constant retrosternal discomfort and appeared malnourished. The chest radiograph revealed a right sided aortic arch with tracheal deviation to the left. A swallow study confirmed a fixed esophageal narrowing at the level of T6. Contrast enhanced Computed Tomography (CT) angiogram of the chest and neck revealed a mirror image right aortic arch with a left sided cardiac apex and a prominent ductus diverticulum (measuring 1.7 × 1.8 cm). This structure extended posterior to and indented the mid esophagus. A left posterolateral thoracotomy was performed and the ductus diverticulum was resected. A retroesophageal ligamentum arteriosum was found during surgery and divided. This rare combination of congenital anatomical aberrations led to severe dysphagia in our patient. Successful surgical correction in the form of resection of the ductus diverticulum and division of the retroesophageal ligamentum arteriosum led to complete resolution of our patients symptoms.

Selective use of the intra-aortic filter in high-risk cardiac surgical patients leads to better postoperative outcomes

OBJECTIVES: The objective of this study was to evaluate the effect of an intra-aortic filter on postoperative outcomes in high-risk cardiac surgical patients. METHODS: An intra-aortic filter was used in 316 (4.9%) of 6442 cardiac surgical cases from 2003 to 2013. A retrospective analysis of the Society of Thoracic Surgeons (STS) registry data was performed for 204 patients with filter placement who underwent coronary artery bypass grafting (CABG) (n = 89), valve replacement (n = 63) or combined CABG and valve replacement (n = 52), matched with 1224 patients without filter placement by STS mortality scores based on propensity scores. Generalized linear modelling was used to compare rates of complications as well as the length of stay and time in the intensive care unit (ICU). A P-value < 0.05 was considered significant. RESULTS: Overall, patients with filters before matching had a significantly higher risk of death than did the patients without filters: 12.0% of patients with filters had an STS mortality risk score ≥4 vs 7.7% of patients without filters (P = 0.027). After analysis of the composite endpoint of all STS major morbidities, the matched filter group had fewer overall complications (6.8 vs 13.2%, P = 0.02). The rate of postoperative respiratory failure was lower in the filter group (2.5 vs 7.0%, P = 0.01). Rates of stroke and new-onset haemodialysis, while not statistically different, were almost 50% lower in the filter group. Length of stay in the hospital and in the ICU was not significantly different; however, in patients with postoperative complications, time in the ICU (163 vs 189 h, P = 0.02) was shorter for the filter patients. CONCLUSIONS: The use of the intra-aortic filter reduces postoperative complications after cardiac surgery and should be considered for use in high-risk cases.