Zaw Lin

Penetrating atheromatous ulcer of ascending aorta: a case report and review of literature.

Penetrating atherormatous ulcer (PAU) is the condition in which ulceration of an aortic atherosclerotic lesion penetrates the internal elastic lamina into the media. Penetrating atheromatous ulcers usually involve the descending thoracic aorta and are very uncommon in ascending aorta. Differentiation of PAU from other causes of Acute Aortic Syndrome (AAS) such as intramural haematoma (IMH) and aortic dissection is difficult. The diagnosis of these ulcers is made on computerised tomography (CT) scan, magnetic resonance imaging (MRI), or transoesophageal echocardiography (TOE). Once diagnosed, PAU of ascending aorta should be treated surgically on emergency basis. We report on a patient of penetrating atherosclerotic aortic ulcer in ascending aorta with a review of the natural history, imaging diagnosis and management of the condition. She underwent ascending aortic interposition graft using 26mm Dacron graft successfully.

Chylotamponade: An Unusual Manifestation of Gorham-Stout Syndrome

Gorham-Stout syndrome is a rare disorder that leads to extensive lymphangiomatosis in bones with resorption of adjacent bone matrix. As a result, the disease is also known as massive osteolysis or “vanishing bone disease.” Although the disease primarily occurs in bone, it may also involve adjacent soft tissues. We report a case of Gorham-Stout syndrome presented with chylotamponade as a result of extensive intrathoracic lymphatic hyperproliferation. A 50-year-old woman, who is known to have Gorham-Stout syndrome, presented with progressively worsening dyspnea for 1 week. She was hemodynamically stable and her cardiorespiratory examination was unremarkable except for elevated jugular venous pressure. Chest radiography revealed an enlarged cardiac silhouette and a small left pleural effusion. Transthoracic echocardiography confirmed a large pericardial effusion with evidence of tamponade. Urgent pericardiocentesis was performed, and ≈1.2 L of milky fluid, identified a s chyle on biochemistry, was drained. She became asymptomatic soon after pericardiocentesis; however, pericardial fluid reaccumulated over the next few days. She had been diagnosed as having Gorham-Stout syndrome from the age of 12 years. Massive osteolysis of the mandible developed, which required reconstruction. Osteolysis subsequently recurred in the reconstructed mandible. Also, bone involvement in the skull base had …

Coagulase-negative staphylococcus endocarditis: staphylococcus lugdunensis

Staphylococcus lugdunensis is an infrequent cause of native valve endocarditis. A case of triple-valve involvement of Staphylococcus lugdunensis with intracardiac fistula formation in a 47-year-old woman was managed successfully with surgery. The importance of early diagnosis and prompt referral for surgical treatment is highlighted.

Assessment of the EuroSCORE II in a New Zealand Tertiary Centre

BACKGROUND The updated European System for Cardiac Operative Risk Evaluation (EuroSCORE II) is a well-established cardiac surgery risk scoring tool for estimating operative mortality. This risk stratification system was derived from a predominantly European patient cohort. No validation analysis of this risk model has been undertaken for the New Zealand population across all major cardiac surgery procedures. We aim to assess the efficacy (discrimination and calibration) of the EuroSCORE II for predicting mortality in cardiac surgical patients at a large New Zealand tertiary centre. METHODS Data was prospectively collected on patients undergoing cardiac surgery from September 2014 to September 2017 at Waikato Hospital, New Zealand. Patient demographic information, preoperative clinical risk factors and outcome data were entered into a national database. Included patients received either isolated coronary artery bypass grafting (CABG), isolated valve surgery, isolated thoracic aortic surgery, or a combination of these procedures. The primary outcome was the discrimination and calibration of predicted EuroSCORE II risk scores compared with observed 30-day mortality events. RESULTS 1666 cardiac surgery patients were included during the study period, with an average EuroSCORE II of 2.97% (95% confidence interval (CI): 2.76-3.18). 933 patients underwent isolated CABG, 384 underwent isolated valve surgery, 48 received isolated thoracic aortic surgery and 301 received combination procedures. Thirty-day mortality events in each of these groups was 7, 4, 2 and 13 deaths respectively. There were 26 deaths across the total cohort at 30-days (observed mortality rate 1.56%). Discrimination analysis using receiver operating characteristic curves demonstrated the area under the curve (AUC) of the EuroSCORE II in each of these groups as 93.4% (95% CI: 91.6-94.9, p<0.0001), 66.3% (95% CI: 61.3-71.0, p=0.37), 37.0% (95% CI: 15.7-58.2, p=0.23) and 74.8% (95% CI: 69.5-79.6, p<0.0001) respectively. The total cohort AUC was 83.1% (95% CI: 81.2-84.9, p<0.0001). Calibration analysis using Hosmer-Lemeshow tests for the subgroups revealed p-values of 0.848, 0.114, 0.638 and 0.2 respectively. The total cohort Hosmer-Lemeshow p-value was 0.317. CONCLUSIONS EuroSCORE II showed a strong discriminative ability for isolated CABG 30-day mortality in a New Zealand patient cohort. However, the scoring system discriminated poorly across valvular, thoracic aortic or complex combination cardiac surgical procedures. Good calibration of the EuroSCORE II was achieved across both the total cohort and subgroups. It is important to consider the performance of other cardiac surgery risk stratification models for the New Zealand population.

CT12 SURGICAL MANAGEMENT OF DESCENDING NECROTIZING MEDIASTINITIS

Descending necrotizing mediastinitis is a form of mediastinitis caused by odontogenic infection or deep cervical infections, which spreads to the mediastinum via the cervical facial planes. Criteria adopted for the diagnosis of Descending Necrotizing mediastinitis are clinical manifestations of severe infection, demonstration of characteristic roentgenographic features, documentation of the necrotizing mediastinal infection and establishment of oropharyngeal or cervical infection with the development of the necrotizing mediastinal process. Most of the published reports in literature are single case report. The largest series published is of 17 patients over 15 years. Despite the increased use of CT scan as a diagnostic aid and the improvement in antibiotics, mortality in patients with descending necrotizing mediastinitis remains high, reported between 25–40% in the literature.