Taranpreet Singh

A simple technique for aortic valve replacement in patients with a patent left internal mammary artery bypass graft

Aortic valve replacement in patients with a patent left internal mammary artery graft is often a challenge because of the difficulties with dissection of the left internal mammary artery and optimum myocardial protection. We describe a simple technique of aortic valve replacement with a beating heart and continuous coronary perfusion for this difficult group of patients.

Mitral Valve Annular Dilatation Caused by Left Atrial Myxoma

We report a case of mitral valve annular dilatation caused by a large left atrial myxoma. A 69-year-old woman presented in pulmonary oedema. She was found to have a large left atrial myxoma prolapsing into the left ventricle in diastole causing severe functional mitral stenosis. At operation, the myxoma was completely excised from its attachment to the atrial septum. The mitral valve looked anatomically normal but the mitral annulus was dilated. The intraoperative Trans Oesophageal Echocardiogram (TOE) on weaning from cardiopulmonary bypass confirmed a dilated mitral annulus with moderate mitral regurgitation (MR). We elected not to place an annuloplasty ring in anticipation of improvement with postoperative remodelling. However, mitral regurgitation worsened after discharge becoming moderately severe and remains so after 1 year follow-up despite optimal medical treatment. This case suggests that annular dilatation can result from mechanical dilatation by a large left atrial myxoma. Intraoperative mitral valve annuloplasty should be considered in the presence of moderate MR as postoperative remodelling does not occur.

Intravenous Leiomyomatosis with Intracardiac Extension: First Reported Case in Australia

Intravenous leiomyomatosis (IVL) with cardiac extension is a rare uterine tumour. We present an unusual case of uterine leiomyoma that progressed along the inferior vena cava into the right atrium. Complete one stage removal of the tumour was performed using cardiopulmonary bypass and circulatory arrest. The literature review reveals that this is the first reported case in Australia of IVL with intracardiac extension which was successfully removed with a single stage procedure.

Simplified cerebral protection using unilateral antegrade cerebral perfusion and moderate hypothermic circulatory arrest.

BACKGROUND Antegrade cerebral perfusion is one of the most reliable methods of organ protection during hypothermic circulatory arrest for aortic arch surgery. We used a simplified antegrade cerebral perfusion technique with low mortality and morbidity. METHODS Between January 2005 and August 2008, 21 patients underwent aortic arch surgery with unilateral antegrade selective cerebral perfusion through the brachiocephalic artery and moderate hypothermic circulatory arrest. The mean age for patients was 58.0+/-11.1 (27-82) years. Cardiopulmonary bypass was commenced and the ascending aorta was cross-clamped. Patients were cooled to 22-28 degrees C, whilst the proximal anastomosis was performed. The brachiochephalic artery was cannulated using a balloon tipped 15Fr catheter used for retrograde cardioplegia. Antegrade cerebral perfusion was established at the rate of 10 ml//kg/min. The perfusion pressure was controlled between 50 and 70 mm Hg whilst the distal anastomosis was completed. RESULTS There were no operative deaths and no permanent neurological deficits. Four patients had temporary confusion. Mean antegrade cerebral perfusion time was 21.6+/-8.0 (12-48)min. Eight out of 20 patients had circulatory arrest at 28 degrees C and their mean circulatory arrest time was 22.8+/-4.7 (16-32)min. DISCUSSION The mortality and neurological outcomes of aortic surgery using unilateral antegrade cerebral perfusion with moderate hypothermic circulatory arrest produced satisfactory results. Bilateral cannulation and deep hypothermia appear to be unnecessary in most cases. The coagulopathy from deep hypothermia is thereby avoided.

Fatty Infiltration of an Aortic Valve

Adipose tissue is a normal constituent of the heart, but not a normal anatomic finding of cardiac valves. Fatty infiltration of the aortic valve is rare, with unknown significance on valve function. We report a case of fatty infiltration and replacement of the spongiosa layer in an incompetent aortic valve. The mechanism of fat infiltration is unknown, but may be explained by differentiation of preexisting valve interstitial cells secondary to valvular injury.

Mitral Valve Repair on the Beating Perfused Heart

It is difficult to assess the success of mitral valve repair in the arrested heart. Various techniques have been described. Transesophageal echocardiogram (TEE) provides excellent two-dimensional evaluation of the repair, but three-dimensional anatomic characteristics are limited. We describe a simple technique for performing mitral valve repair on the beating heart. This allows accurate evaluation of valvular competence and three-dimensional anatomic characteristics prior to closure of the atriotomy.

Redo Sternotomy and Cardiopulmonary Bypass to Repair a Right Ventricular Penetrating Injury

A 61-year-old female with a history of major depression and previous suicide attempts was admitted with a self-inflicted knife wound to the chest. She had undergone coronary artery bypass surgery 13 years ago. On arrival, she was hemodynamically stable with a 20-cm kitchen knife penetrating her chest through the lower sternum (Fig. 1). A chest computed tomogram with contrast showed the knife embedded in the right ventricle (Fig. 2). At the time of surgery, cardiopulmonary bypass was established through the femoral vessels and a redo-sternotomy revealed a 3-cm right ventricular laceration, which was repaired with Prolene sutures. All the bypass grafts including the left internal mammary artery graft to the left anterior descending artery were patent and uninjured. The patient had an uneventful postoperative course and was discharged to a psychiatric hospital for further mental care. Figure 1. A 20-cm kitchen knife, secured with tapes, penetrating the lower part of the sternum.