Saturday, May 6, 2023: 5:00 PM - Monday, May 8, 2023: 3:45 PM
Los Angeles Convention Center
Posted Room Name: ePoster Area, Exhibit Hall
Track
Multi-Specialty
103rd Annual Meeting
Presentations
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
A 69-year-old male with a history of non-ischemic cardiomyopathy, mild non-obstructive coronary artery disease, an implantable cardiac resynchronization therapy defibrillator (CRT-D) and atrial fibrillation, presented to the emergency room with progressive shortness of breath after recently undergoing atrioventricular node ablation. On physical examination, vital signs were normal with edematous face, basal crackles, elevated jugular venous pressure and lower limb edema. Laboratory tests confirmed increased troponin I, creatinine and brain natriuretic peptide (BNP). Transthoracic echocardiography revealed left ventricular ejection fraction (LVEF) of 15%, preserved right ventricular systolic function, mild mitral regurgitation, and flail anterior leaflet of tricuspid valve attached to a ruptured segment of the anterior papillary muscle resulting in severe tricuspid regurgitation. Coronary angiogram demonstrated chronic total occlusion of the proximal left anterior descending artery (LAD) and non-obstructive lesions in the left circumflex and right coronary arteries. Given the patient's age and minimal comorbidities, a surgical repair was planned with standby mechanical circulatory support. Tricuspid valve repair was performed and consisted of reimplantation of the papillary muscle, placement of a neo-chord to the anterior leaflet, and placement of a size 32 semirigid annuloplasty ring. Two coronary bypass grafts were performed, with left internal mammary artery to LAD and vein graft to the second obtuse marginal. Following slow weaning from cardiopulmonary bypass (CPB), transesophageal echocardiography revealed new central severe mitral regurgitation and dilated mitral annulus, likely resulting from improved forward flow through the tricuspid valve and right ventricle. This necessitated mitral repair with reduction annuloplasty using a size 32 ring, with a good result. Upon weaning off CPB, it was evident that left ventricular function is markedly reduced with minimal right ventricular dysfunction. It was decided that to provide hemodynamic support and be able to wean the patient off CPB, insertion of Impella 5.0 was required. This was performed through a 10mm graft sewn to the right axillary artery with excellent flow. The Impella was weaned and removed on the third postoperative day after which the patient recovered slowly. Finally, a transthoracic echocardiogram demonstrated intact repair and mild improvement in LVEF to 25% upon 6 months follow-up.
View Submission
Poster Presenter
Mohammed Alharbi, McGill University Health Center
-
Contact Me
Montreal, QC
Canada
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Objective: The utilization of temporary mechanical circulatory support (MCS) in high-risk cardiac surgery and acute cardiogenic shock has been rapidly increasing, specifically by the large micro-axial pump (Impella 5.5). Surgical grafting to the axillary artery or the ascending aorta are two most common anatomical approaches for the insertion. However, an alternative approach through the brachiocephalic artery enables the Impella insertion 1) through median sternotomy without fluoroscopy during high-risk cardiac operations, and 2) for patients with small axillary artery and/or short aorta which are contraindications for the conventional Impella 5.5 insertion. In this video presentation we describe two cases of Impella 5.5 implantation through brachiocephalic artery for the two distinct scenarios.
Case 1: A 72-year-old male presented with moderate to severe aortic tissue valve regurgitation (Implanted 12 years ago) due to the recent prosthetic valve endocarditis treated medically. His ejection fraction was <20%. Through the redo-sternotomy, a 10-mm Dacron graft was sewn to the brachiocephalic artery and tunneled to the supraclavicular area. Then, a guidewire was parked into the ascending aorta through this graft using transesophageal echocardiography (TEE) guidance. The AVR was then conducted in standard fashion and the guidewire was manually directed into the left ventricle (LV) before the aortotomy closure. After the cross-clamp was released, the Impella 5.5 was passed over the guidewire under TEE guidance without fluoroscopy to the poorly functioning LV. Postoperatively he was mobilized well and separated from the device on POD 7 by ligating the graft through the supraclavicular counter skin incision.
Case 2: Unlike the first case, the impella implantation was not planned but went well for the second case. A 38-year-old female with congenital mitral valve insufficiency, atrial fibrillation, and ventricular septal defect (VSD) with low normal ejection fraction preoperatively. She underwent mitral valve replacement (MVR) with On-X mechanical valve, MAZE procedure, and VSD closure. The operation was complicated by post cardiotomy cardiogenic shock requiring VA-ECMO support. Due to the predominant LV dysfunction, Impella 5.5 was inserted on POD2 with the intention of weaning from VA ECMO and close the chest. Due to the 5mm right axillary artery and short ascending aorta, the brachiocephalic artery (9mm) was chosen to be grafted for Impella 5.5 insertion to secure the safety length for the Impella 5.5 outflow while the chest was still open under TEE and fluoroscopy guidance. On POD4, she was weaned and decannulated from central VA ECMO and the chest was closed, On POD 14 the Impella was removed at the bedside.
Conclusions: Implantation of the Impella 5.5 via brachiocephalic arterial graft is feasible in situations that the chest is already open, or/ and axillary artery is small and unsuitable, or ascending aorta is short. This technique even facilitates efficient insertion without any other incisions (i.e. axillary incision) or fluoroscopy utilization. Although scheduled implantation of Impella 5.5 may provide a better outcome, the pre- and peri-operative patient assessment should be carefully proceeded. Further considerations in patients' disease profiles and anatomical characteristics will help us choose the optimal approach to improve outcomes in this difficult patient population.
View Submission
Poster Presenter
Farhang Yazdchi, Brigham and Women's Hospital
-
Contact Me
Boston, MA
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Aortoesophageal fistula (AEF) is a rare but life-threatening condition that often presents with Chiari's triad (mid-thoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval). Most AEFs are caused by an aneurysmal aorta and almost always heralded by gastrointestinal bleeding. In emergent cases, thoracic endovascular aortic repair (TEVAR) often serves as a temporizing measure and a bridge to surgery. Here, we report a case of staged AEF management in a 70-year-old patient with a history of hypertension, hyperlipidemia, type II diabetes, hypothyroidism, gastroesophageal reflux disease, chronic obstructive pulmonary disease and a 40 pack-year smoking history who presented with hematemesis and abdominal pain. Imaging showed a descending thoracic aortic aneurysm with concern for AEF. She was taken emergently to the operating room (OR) for aneurysm exclusion and esophageal exploration. The vascular surgery team performed a TEVAR with placement of a Cook Zenith Alpha ZTA-P 32-156 stent graft without coverage of the left subclavian artery. Intra-operatively, the patient had ST segment elevations that were concerning for myocardial infarction, and further surgical procedures to control the likely esophageal perforation were deferred. The following day, after clinical stabilization and cardiology clearance, she was taken back to the OR for exploration and source control. EGD demonstrated an ischemic, partially necrotic segment of the esophagus adjacent to the aortic aneurysm (approximately 24-26 cm from the incisors). Given endoscopic evidence of AEF, we proceeded with esophagectomy via right thoracotomy in order to resect the ischemic segment and divert enteric content from the aortic stent graft. During esophageal debridement, copious bleeding (approximately 1 liter) was noted from the necrotic wall of the aneurysm sac requiring en masse suture repair. The chest was closed, and she underwent cervical esophagostomy, exploratory laparotomy, gastrostomy and jejunostomy tube placement. To relieve left mainstem bronchus compression from the aneurysm sac, the interventional pulmonology team also placed a covered metal stent in the left mainstem bronchus. She was discharged to long-term acute care hospital on post-operative day (POD) 22. Four months later, she underwent retrosternal gastric conduit creation and was discharged home on POD 12. Given the emergent repair with a TEVAR and positive intraoperative cultures, the patient was continued on life-long suppressive antibiotics. Her diet was advanced in an outpatient setting. She is doing well 36 months after initial presentation.
AEF is a rare, life-threatening condition that can often be managed with a staged surgical approach. In this case, TEVAR was a successful temporizing measure prior to partial esophagectomy with cervical esophagostomy before gastric conduit creation four months later. Aortic graft replacement is pursued in certain patients and may contribute to slightly better long-term outcomes compared with TEVAR alone. Esophagectomy contributed to better overall prognosis for AEF compared with no esophageal intervention, esophageal repair, and esophageal stent. More work is needed to determine which patients should be offered aortic graft replacement following emergently placed TEVAR.
View Submission
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Here we report our experience in managing a large iatrogenic tracheoesophageal fistula (TEF) in a 13-yr-old boy likely related to prior tracheostomy. One year prior to presentation to us, he had suffered from Dengue shock in Antigua with subsequent multisystem organ failure. He required tracheostomy and gastrostomy and ultimately recovered allowing for decannulation. Several months following his discharge, he was readmitted with recurrent pneumonias and failure to thrive, at which time an extensive TEF was identified. He was subsequently transferred to our center for further management.
He underwent bronchoscopy and esophagoscopy for initial evaluation. This identified a large, but mature defect, 4cm in length(Figure 1A) that was 7cm from the vocal cards proximally, and 4cm from the carina distally. On the esophageal side, the TEF was 17cm from the incisors. His case was discussed in multidisciplinary fashion with evaluation by thoracic surgery, plastic, and pediatric surgery. Multiple options for reconstruction were considered as the fistula spanning the neck and upper thorax made repair and reconstruction challenging. Tracheal resection with primary repair of the esophageal defect was discussed, but length of the TEF was a concern. We also considered division of the trachea and esophagus followed by primary repair of the esophagus and muscle-flap reconstruction of membranous portion of the trachea. The proximal esophagus was quite dilated making primary repair feasible, and we believed a radial forearm free-flap would provide the necessary rigidity to reconstitute airway anatomy.
Following treatment of pneumonia with antibiotics and several weeks of nutrition repletion, he was taken to the operating room for TEF repair with primary closure of esophageal defect and free-flap tracheal reconstruction. We began with a right sternocleidomastoid(SCM) incision carried down to the upper sternum, and we began our dissection with identification of the anterior wall of the trachea. We quickly identified the need for further exposure to isolate the length of the defect, and performed an upper sternal split down to the second interspace. The innominate vein and artery along with the aorta were mobilized inferiorly in order to create space for exposure of the distal airway. Following dissection of the length of the trachea, we identified the esophagus posteriorly. Once the proximal and distal areas of the fistula were fully mobilized we encircled both with umbilical tapes for further traction. We then sharply opened the fistula, thereby separating the esophagus and trachea. The dilated esophagus was amenable to primary repair with running absorbable suture. A radial myofascial cutaneous free-flap, harvested by plastic surgery team, was then used to cover the posterior tracheal defect with the skin side facing into the tracheal lumen using interrupted PDS sutures and ensuring to maintain a taught closure. The flap was then microvascular anastomosed to the right internal mammary vessels with the vascular pedicle brought underneath the sternum and brought out through the second interspace. Once completed, a saline leak test was performed with no evidence of an air leak. A Jackson-Pratt drain was left by the repair sites.
The patient recovered well with repeat bronchoscopy demonstrating an intact repair with viable graft(Figure 1B). His diet was advanced and he has been discharged following successful multidisciplinary repair of his extensive TEF.
Poster Presenter
Anne Montal, NYC Health + Hospitals
-
Contact Me
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
The innominate vein may be injured during redo or initial median sternotomy due to the anatomical location of the vessel crossing from the left side of the body to the right. It courses anteriorly to the aortic arch and is usually protected by thymic and pericardial adipose tissue. In the case of redo sternotomy,this tissue has usually been violated and the innominate vein may have little distance from the posterior shelf of the sternum. Can also be tethered due to indwelling pacing leads. In first-time sternotomy, the risk is decreased but still present if perfect technique is not followed. We have developed a technique for repair utilizing autologous saphenous vein tissue to create a spiral vein graft.
The most important step in repairing an injury to the innominate vein is first recognizing that the injury has occurred and to control the bleeding. This can often be accomplished without significantly disrupting the flow of the planned procedure. Once on cardiopulmonary bypass, the right sided aspect of the innominate vein will be controlled by venous drainage, but the left side may require a field sucker. We prefer to use a pediatric vent for this purpose. At this point, the remainder of the planned operation may be completed. Approximately 2 standard lengths of saphenous vein are harvested and marked as usual. The vein is split along the midline in the direction of blood flow. We then wrap the vein around a 5cc syringe with the intimal layer towards the plastic, envisioning a barber pole, and suture it together along the edges using 6-0 prolene continuous sutures. We perform the anastomoses with our spiral vein graft using 5-0 prolene continuous sutures. The right side of the innominate vein is completed first while on cardiopulmonary bypass with vacuum assisted drainage. Then the left side of the anastomosis using the pediatric vent for clearing the field. The anastomoses may be performed during rewarming allowing for weaning off cardiopulmonary bypass once complete.
Innominate vein injury is a known complication of median sternotomy, and while avoidance is the best practice, this technique allows for repair using the patient's own tissue. Close attention to pre-operative imaging can help avoid injury in re-operations by planning for alternative strategies prior to sternotomy.
View Submission
Poster Presenter
Andrew Gorton
-
Contact Me
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
An 80-year-old female was referred to our thoracic surgery service with a one-year history of progressive dysphagia and ten-pound weight loss.
Low-dose CT imaging was obtained which noted a soft tissue mass, likely intraluminal, measuring 3.1 x 2.6 x 5.5 cm. Bronchoscopy revealed extrinsic compression, but no airway involvement, and EGD confirmed the presence of a large tumour spanning the proximal-esophagus from 21 to 29 cm from the incisors.
Multiple tissue biopsies were obtained during EGD, which demonstrated histological findings in keeping with melanoma. Pathology noted that this specimen may represent a primary esophageal malignant melanoma but could represent metastatic disease from skin or mucosal surfaces. As such, investigations to locate a primary source involved full skin surveillance exam, consultation with ophthalmology to rule out an ocular melanoma and a PET study.
Each of the aforementioned diagnostic management steps yielded normal results. The PET scan revealed an uptake in the left cavernous sinus; however, subsequent MRI of brain revealed no concerning focal lesions. Unexpectedly, despite attempts to locate a primary melanoma source, no such source could be found, leaving primary esophageal melanoma as the diagnosis.
Medical oncology considered targetable tumour markers from the detailed pathology assessment, but the tumour lacked mutated BRAF expression. The case was discussed at the multi-disciplinary tumor board. Systemic treatment options other than systemic immunotherapy in the adjuvant setting were not recommended. Radiation oncology indicated that their role would be limited to a palliative setting. Given the patient's limited comorbidities, the consensus was that an esophagectomy would be the preferred treatment modality.
The patient was agreeable to surgical resection and underwent a minimally invasive 3-hole esophagectomy with gastric pull-up and pyloromyotomy. The procedure was uncomplicated and the specimen along with station 7, 8 and 9R lymph nodes were sent for histological analysis.
On pathology, the tumor was located entirely within the tubular esophagus, not involving the gastroesophageal junction and measured 7.2 x 6.5 x 2.0 cm. No lymphovascular or perineural invasion was identified. All lymph nodes (0/8) and margins were uninvolved.
The patient's post-operative course in hospital was complicated by a short two-day intensive care unit stay where she required vasopressor support and supplemental oxygen. The remainder of her hospital stay was otherwise unremarkable.
Beyond her initial discharge from hospital, she has required upper endoscopies every one to two months for dilations of an anastomotic stricture 16 cm from the incisors that caused her dysphasia. It was felt that this was an ischemic stricture related to a proximal anastomosis.
18 months after surgery, the patient developed worsening headaches. This prompted a CT head which was negative. A CT chest/abdomen/pelvis was also completed to assess for recurrence and an irregularly shaped subsolid nodule in the right upper lobe measuring 16 x 11 x 15 mm was found. Mild uptake of this lesion was seen on PET scan. Core biopsy of the lesion revealed moderately differentiated adenocarcinoma, KRAS positive and PD-L1 negative. She was treated with 3400 cGy in a single fraction by the Radiation Oncology team.
The patient is now 26 months from surgery without evidence of melanoma recurrence.
View Submission
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Background: In the past, some surgeons advocated for the use of sutureless ring grafts for repair of acute aortic dissection to mitigate anastomotic complications when suturing to friable tissue and prolonged ischemic times when performing multiple anastomoses. Over the years, there has been limited uptake of this procedure, and there remains a paucity of data regarding its long-term durability.
Case Summary: We present the case of a 54 year old male patient with an ACTA2 pathogenic variant and strong family history of aortic aneurysmal disease who presented to our center for evaluation and management of a chronic DeBakey type I aortic dissection. A decade prior, he presented to an outside hospital with chest pain and syncope, was found to have an acute DeBakey type I aortic dissection involving the bilateral common carotid arteries and extending distally to the left common iliac artery, and promptly underwent emergency repair with aortic valve resuspension and a limited supracoronary ascending aortic replacement. Intraoperative course was complicated by right hemispheric stroke with minimal residual left-sided sensorimotor deficits. After, he remained active and asymptomatic from a cardiovascular standpoint, however, surveillance CTA scans revealed a mildly dilated aortic root at 4.5 cm along with aneurysmal degeneration of the chronic dissection with a maximal diameter of 5.4 cm in the aortic arch/proximal descending thoracic aorta. After initial consultation, he elected to pursue surgical treatment, and underwent redo sternotomy with cardiopulmonary bypass established via a side graft to the right axillary artery and dual stage venous cannulation through the right atrium. Under deep hypothermic circulatory arrest with selective antegrade cerebral perfusion, the aorta was incised above and below the previous repair. On inspection, we observed extensive BioGlue and felt around the previous anastomoses along with two rigid plastic rings consistent with a previous Lemole sutureless ring graft. After careful dissection and excision of the prostheses, we performed a zone 1 branched stented anastomosis frozen elephant trunk repair (B-SAFER) with a stent graft deployed under direct vision in the descending thoracic aorta, another stent graft deployed in the left subclavian artery, and a multi-branch graft to reconstruct the aortic arch with reimplantation of the left common carotid and innominate arteries. Last, a valve sparring aortic root reimplantation was performed using a Valsalva graft sewn over a Hegar dilator. Surveillance CTA scans revealed a durable repair and demonstrated a stable maximal aortic diameter of 5.3 cm in the mid descending thoracic aorta distal to the previous repair. After 4 years, he underwent completion endovascular repair of the thoracoabdominal aorta with covered stent grafts in zones 3–5 and bare metal stents in zones 6–9 (PETTICOAT). At last clinical follow-up 18 months after repair, CTA scan revealed a durable repair with stable aortic dimensions and no evidence of aortic insufficiency or left ventricular dysfunction on echocardiogram.
Conclusions: Innovative procedures beget new complications which in turn require innovative solutions. In patients with aortopathy and previous limited repair of acute DeBakey type I aortic dissection with a Lemole sutureless ring graft, total aortic reconstruction with a staged hybrid approach can be performed with acceptable outcomes.
View Submission
Poster Presenter
William Frankel, Cleveland Clinic
-
Contact Me
Cleveland, OH
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
We report a case of post-acute coronary syndrome (ACS) cardiorrhexis repaired off-pump with deep Trendelenburg positioning using felt strips and multiple pledgeted sutures. The patient was an 84-year-old female diagnosed with anterior ST-segment elevation myocardial infarction complicated by cardiorrhexis following percutaneous coronary intervention. Repeated cardiocentesis resulted in transient blood pressure rises and falls necessitating emergent surgery. Upon entry into the thorax, multiple jets of bright red blood from the anterior, apical, and inferior left ventricular wall were apparent. As the patient had received fibrinolytic therapy 6 hours prior to the rupture event resulting in massive coagulopathy, the repair was undertaken off-pump. The operative time (skin-to-skin) was 2 hours 53 minutes. The next day the patient was returned to the operating room for tamponade. Removal of clot in the anterior mediastinum revealed a longitudinal 7-8 cm partial-thickness laceration of the right ventricle directly beneath the sternal halves. A pericardial patch was tacked over the right ventricular erosion with biological adhesives. The chest was easily closed. Postoperatively, the patient remained intubated in the cardiovascular intensive care unit for 7 days. Her postoperative course was complicated by a left pleural effusion resolved with extended chest drainage, postoperative atrial fibrillation cardioverted with amiodarone, and delirium which resolved with orientation and time. She was discharged to her home in stable condition after a postoperative hospital stay of 23 days. Today, she is alive and fully functional 3 years post-op with echocardiographic left ventricle ejection fraction of 55-60%.
Cardiorrhexis is a rare but well-described mechanical complication of ACS affecting between 0.01% and 0.5% of patients in the post-thrombolytic era. Among the most lethal mechanical complications following ACS, risk factors for cardiorrhexis reported from retrospective analyses by Yamaguchi et al. included increased age and first ACS event. Suchil Bernal et al. additionally reported that female patients, hypertension, and those with anterior wall infarcts were at a greater risk for ruptured heart. Furthermore, patients were most likely to experience left ventricular rupture within the first four days after ACS. In a meta-analysis of 11 observational studies, Matteucci et al. reported a summary operative mortality rate of 32%. Described repair techniques include patch and non-patch techniques. In patch-based techniques, a biological (pericardial) or synthetic patch is applied to the rupture site. In non-patch techniques a plication-type repair with felt approximates the two sides of the rupture site and excludes the site of rupture. Moreover, patch repairs can be applied with or without sutures; preference for non-suture techniques are based on poor quality tissue which would prevent effective suture anchoring. Importantly, on-pump and off-pump techniques have been described with the latter being applied for cases with profound coagulopathy.
In summary, because of hemodynamic instability associated with cardiac rupture, the off-pump technique is rarely performed. This report emphasizes the importance of considering stabilization with deep Trendelenburg positioning and off-pump repair for this high mortality complication of ACS.
*References provided separately.
View Submission
Poster Presenter
Ameen Basha, University of Calgary
-
Contact Me
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Abstract
Primary cardiac lymphomas are rare and subvariants like fibrin-associated diffuse large B-cell lymphoma (FA-DLBCL) are even more uncommon. They are mostly found within cardiac myxomas or associated with cardiac prosthesis. They do no tend to form a mass making the diagnosis challenging. Symptoms are unspecific and their behaviour is indolent. Surgical resection alone seems to offer promising results without the need of adjuvant therapy.
We present a 24-year-old female with FA-DLBCL located within an SVC thrombus causing SVC syndrome.
TTE revealed the presence of a large mass filling the entire right atrium, extending from the SVC. Subsequently she underwent a successful removal of the SVC and RA mass.
To our knowledge this is the first case of a FA-DLBCL located in the SVC causing SVC syndrome.
Patient and methods
A 24 year-old immunocompetent female who presented with SVC obstruction symptoms was referred to our cardiac surgery service for debulking of an SVC and RA mass.
She presented initially with dyspnoea, headaches and chest tightness. A CT revealed bilateral pulmonary embolism and she received anticoagulation therapy. However, over the following months she developed facial, neck, upper limb and upper chest swelling, mostly when bending forward. She underwent a biopsy of the mass that revealed a FA-DBLCL. Chemotherapy was initially offered but her symptoms continued to deteriorate rapidly with increasing facial swelling and cyanosis. A transthoracic echocardiography showed a 4.7x 5.5cm mass filling the entire right atrium, extending from the SVC (completely blocked) and causing severe TV obstruction. The patient was immediately admitted from the clinic. Following a multidisciplinary team meeting decision was made to perform urgent surgery to remove the mass. The preoperative planning considered the need for deep hypothermic circulatory arrest due to the localization of the tumour obstructing the RA and SVC.
Median sternotomy was performed. The right atrium was distended and hard on palpation. Ascending aorta cannulation was performed. A two-stage venous cannula was carefully inserted in the the right atrium after initial digital palpation of the mass to ascertain if there was space available for the cannula. Full cardiopulmonary bypass was commenced and the patient was cooled to 18 degrees Celsius. The venous cannula was removed and the right atrium was opened revealing an atrial mass measuring 7x4 cm occupying almost the entire chamber. The SVC was hard on palpation and completely obliterated by the tumour. The right atrial mass was resected en-bloc. The SVC was partially freed from the tumour obtaining a mass measuring 6x4 cm. We removed as much of the mass as possible to guarantee that the SVC lumen was not obstructed. This part of the procedure was the most challenging as we were aiming to remove the mass in an expeditious manner without causing injury and considering the DHCA time to keep it to a minimum. The procedure was uneventful, the patient recovered well and was discharged home after 1 cycle of chemotherapy. During follow up there has been no signs of recurrence.
We present a unique case of a young female immunocompetent adult with a FA-DLBCL arising from an SVC thrombus presenting with SVC syndrome. She underwent a successful resection of the mass under a brief period of deep hypothermic circulatory arrest and made an uneventful recovery. Clinical outcome seems favourable after surgical resection
View Submission
Poster Presenter
Andres Diaz
-
Contact Me
United Kingdom
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Introduction
Mitral valve repair (MVr) in degenerative or ischaemic mitral regurgitation is a common cardiac surgical procedure. Depending on valve pathology annuloplasty ring, neochord implantation, leaflet resection and leaflet augmentation techniques are used to achieve mitral valve competence. Here we are reporting a case of "delayed right ventricular dissection" 19 days after mitral valve repair. We did not find this complication of mitral valve surgery previously reported in the literature.
Case Report
A 77-year-old gentleman with progressively worsening shortness of breath (NYHA class III) was diagnosed with severe mitral regurgitation. Transoesophageal echocardiography showed bi-leaflet mitral prolapse with impaired left ventricular function. They underwent a mitral valve repair using two Gore-Tex neo chords and a 33 mm annuloplasty ring. Post-operative echocardiogram demonstrated a competent mitral valve with trivial regurgitation. 12 days post discharge, the patient re-presented to their local hospital with presyncopal symptoms. They were found to have a retrosternal collection and a right pleural effusion. CT scan and echocardiogram were reported as suspected contained rupture of RV free wall. The patient was transferred back to our institution for further management. At re-exploration we found that the right ventricular free wall had dissected, separating the endocardium from myocardium and epicardium. The entry point was in the infundubular region and remote from any surgical sites. Successful repair was accomplished by using mechanical circulatory support in the immediate post repair period.
Conclusion
With careful planning and use of MCS a successful repair of RV free wall dissection was accomplished.
View Submission
Poster Presenter
Fadi Al-Zubaidi
-
Contact Me
United Kingdom
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
A 37-year-old male presented with supra-ventricular tachycardia, exercise intolerance and lower limb edema. He reported a 2-year history of dyspnea and palpitations with signs of SVC-Syndrome. Computed tomography angiography (CTA) showed a gigantic 15cm fistula aneurysm caused almost complete obstruction of the superior vena cava (SVC), inferior vena cava (IVC), right pulmonary veins and right pulmonary artery (RPA).
The Achilles heel of surgical coronary arteriovenous fistula (CAVF) ligation is myocardial protection. A hybrid approach was utilized to overcome this issue. The fistula was occluded using a percutaneous plug device and subsequently resecting the aneurysm on cardio-pulmonary bypass (in order to ensure adequate myocardial protection). Using a telescoping technique, the 14mm plug was deployed proximal to the fistula aneurysm, angiographically occluding flow through the fistula and aneurysm.
Subsequently, sternotomy was performed on cardiopulmonary bypass (CPB) via peripheral cannulation as the aneurysm was adjacent to the sternum. Successful antegrade cardioplegic arrest occurred without the need to manually occlude the fistula (plug resistance to flow). The fistula aneurysm was opened between the SVC and aorta. All accessible aneurysmal free wall tissue was resected. The fistula inlet and outlet were identified and primarily closed. The patient was weaned off CPB with normal biventricular function.
The patient was discharged on warfarin and ASA for embolic prophylaxis. Eight-month postoperative CTA showed resolution of all obstruction and normalization of heart size. The patient was completely asymptomatic at follow up with no further palpitations.
View Submission
Poster Presenter
Muhammed Mashat, King Abdulaziz University
-
Contact Me
Canada
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Introduction: Left ventricular assist devices (LVAD) are life-prolonging therapy for end stage heart failure. Risks of these devices include thrombosis and stroke, but few cases of acute perioperative pump thrombosis have been reported. Here, we describe a case of pump thrombosis at time of index operation requiring emergent pump exchange.
Case Summary: A 57-year-old woman with history of non-ischemic cardiomyopathy, acute on chronic systolic heart failure with inotrope dependence, and factor V Leiden heterozygosity underwent LVAD implantation via bilateral thoracotomies. The case was performed without initiating cardiopulmonary bypass and no intra-operative complications were initially encountered. According to pre-operative hematology recommendations, surgery was performed using our standard anticoagulation protocol and heparin was reversed at case conclusion. The LVAD was set to 5400 RPM and flowing 4.4 LPM.
A dramatic decrease in calculated LVAD flows occurred just prior to transport, prompting a ramp transthoracic echo. Speeds were increased to 7000 RPM without any resulting change in flow, hemodynamics, or left ventricular end diastolic diameter. The decision was made to re-open. Epicardial echo demonstrated thrombotic burden within the outflow graft, confirming acute pump thrombosis. The patient underwent immediate CT angiography which showed no evidence of large vessel occlusion or major cerebrovascular accident. The patient returned to the operating room for emergent LVAD pump exchange. Heparin was not reversed and the patient underwent delayed closure two days later. The patient's overall course was complicated by frontal lobe stroke, gastrointestinal bleeding, and left thoracotomy infection. She made an excellent functional recovery and was discharged home 54 days after implantation.
Discussion: Among the possible etiologies for post-operative LVAD low-flow, pump thrombosis is one of the most difficult to manage. Diagnosis can be made by assessing the patient's hemodynamic monitoring, chest tube output, LVAD parameters, and echocardiography. Once the diagnosis is made, it is critical to rule out thromboembolic events to large vessels in the brain amenable to endovascular retrieval in order to mitigate major neurologic injury. The presence of infarcted brain may also influence management decisions and risk stratification of hemorrhagic conversion with anticoagulation.
The patient was hemodynamically stable with significant vasopressor support, allowing for diagnostic work-up and return to the operating room without initiating extracorporeal membrane oxygenation (ECMO). Had she decompensated further, this would have been the next intervention as a bridge to pump exchange. Post-operative anticoagulation was aggressively managed in collaboration with hematology. Systemic heparin was not reversed after the pump exchange and the patient was maintained on therapeutic anticoagulation.
Conclusion: Acute pump thrombosis is a rare but potentially catastrophic event following LVAD implantation. Although the only device currently available has an improved hemocompatibility profile compared to earlier pumps, it is important to maintain acute pump thrombosis in the differential. A high index of suspicion and expeditious management are critical to successful patient outcome. Thrombolytic therapy is contraindicated in the acute post-operative period, and ECMO may be indicated for temporary support.
View Submission
Poster Presenter
Madeline Fryer
-
Contact Me
Paris, IL
France
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
A membranous structure that divides the right atrium (RA) into two distinct chambers represents a congenital cardiac anomaly known as cor triatriatum dexter (CTD). Normal embryological development involves the regression of the right valve of the sinus venosus (SV); however, failure of regression can lead to CTD with varying clinical manifestations. Another embryological remnant that usually regresses after birth is the Eustachian valve (EV). Here, we present a case of an iatrogenic CTD, where the right atrium was divided into two chambers from a prior atrial septal defect (ASD) repair with persistent EV leading to liver cirrhosis.
A 55-year-old male presented with a history of a congenital ASD and no family history of prior congenital heart disease. He reported a cardiac murmur but was grossly asymptomatic and no further workup was obtained. At 15 he was diagnosed with an ASD. Right heart catherization showed an elevated Qp/Qs suggestive of left to right shunting. The patient underwent surgical repair by a world-renowned surgeon in Houston, TX. However, the details of the operation are unavailable. At age 45, he was found to have elevated liver enzymes, and his pathology suggested liver fibrosis due to venous congestion. His symptoms continued to progress. Imaging showed normal biventricular function and a possible obstructive membrane at the IVC/right atrium (RA) junction, consistent with CTD + SV defect versus a small residual ASD. Right heart catheterization and intracardiac echo (ICE) showed a thick band of tissue at the IVC/RA junction suggesting a prominent EV leading to CTD. ICE color doppler demonstrated flow acceleration at the opening of the CTD. An SV versus residual ASD was noted, with an agitated saline study confirming shunting.
A redo sternotomy was safely performed. No cannulation sites were identified, suggesting that the initial operation was likely completed under inflow occlusion. The RA was opened away from the prior transverse incision. There was a very thick EV, which had been sewn to the inferior edge of a sinus venosus ASD with near occlusion of the IVC orifice. A residual ASD at the top end of this lesion was seen. The thickened EV tissue was excised to expose the entire IVC orifice. The foramen ovale was opened, and the ASD was enlarged such that an adequately sized patch could be approximated without encroachment of the IVC orifice. A bovine pericardial patch was fashioned and sewn. TEE demonstrated no residual turbulence through the IVC opening, and the bubble study was negative.
The patient recovered well after surgery. Post-op echo showed no evidence of intracardiac shunting, as detected by Doppler and agitated saline. The remainder of his recovery was without complications, and the patient was discharged home on POD 5.
The rare nature of CTD due to iatrogenic causes can make the diagnosis difficult. This case report adds to the dearth of literature on this anomaly and demonstrates the complexities of managing patients with adult congenital heart disease – many of whom had early era repair techniques but have no operative records to inform future intervention. Symptoms of right-sided heart failure, including hepatic cirrhosis, and history of cardiac intervention may suggest a diagnosis of iatrogenic CTD. Although rare, clinicians should be aware of the causes and clinical manifestations of this cardiac pathology to facilitate earlier recognition, avoid delayed diagnosis
View Submission
Poster Presenter
Rachel NeMoyer, Cleveland Clinic
-
Contact Me
Cleveland, OH
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Objective: To share a new technique in complex primary MV repair using an inverted basal triangular P2 resection plus neo-chordae in a symptomatic patient with severe MR secondary to P2 prolapse with chordal rupture.
Methods: A video presentation of a new technique of P2 prolapse MV repair. Pre-operative echo was scrutinised to establish the mechanism of MR and the risk of SAM as well as LV function and presence of TR. Operation: Median sternotomy approach. Bicaval cannulation instituted for CPB with access to the MV via Sondergaard's groove. The patient was cooled to 28 degrees. Annuloplasty sutures are placed initially to gain adequate exposure for valve inspection. The valve is fully assessed and interrogated for the assessment of the mechanism of MV regurgitation prior to choosing a repair technique. The Mitral Valve Repair technique chosen in this case combines posterior leaflet resection with neo-chordae. Basal inverted triangular resection is performed centred on the annular aspect of P2 leaflet to reduce P2 height. The leaflet is extended to its full length by temporarily anchoring the free margin of the leaflet to the anterior annulus with a sliding stay suture. This slight tension extending the leaflet aids with the resection of myxomatous tissue whilst preserving the main body of the MV leaflet tissue anteriorly. The width and height of the triangular resection can be adjusted accordingly and adapted to the requirements of the repair. Leaflet continuity is restored by approximating the 2 sides of the to base of the triangle at the annular leaflet attachment. In this case the leaflet height is reduced to 15mm as the sides of the triangle are approximated to the base of the triangle. A 5/0 Prolene running suture is used to close the defect and the deep cleft between P1 and P2 noted on the initial interrogation of the valve is also closed. We can now turn our attention to the neo-chordae. In this particular complex repair case three Goretex neo-chord to P2, A1 and A2 were inserted. This is followed by stabilisation of the annulus with a 36mm Annuloplasty Ring secured using CorKnot device. Saline test confirms a satisfactory repair and fine adjustment to the neo-chordae lengths complete the repair. The atrium is then closed, with a running suture. The heart is filled the X-clamp removed following de-airing techniques and the operation is completed. The patient came off CPB easily with no support and our post operative echo confirms absence of mitral regurgitation.
Results: We were able to achieve a stable MV repair using this newly described technique. Systolic anterior motion was avoided by reducing the leaflet height and a stable repair was achieved with no MR.
Conclusions: Our reproducible technique has inverted the classic French correction with the base of the triangle on the annular aspect of the leaflet attachment rather than the free margin. Using this technique, the main body of the leaflet is absent of a suture line and a stable repair is achieved. This reproducible technique can be added to the armamentarium of Primary MV repair achieving an excellent result whilst following the '10 commandments of MV repair' as described by the Cleveland Clinic group. We will continue to apply this technique in selected cases.
View Submission
Poster Presenter
Ian Cummings, Royal Sussex County Hospital, Brighton
-
Contact Me
London, UK
United Kingdom
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Behcet's disease is a recurrent inflammatory multi-organ illness characterized by ulcers and skin lesions. Cardiac involvement is estimated to range from 7% to 46%, but its onset before adulthood is extremely rare. We present a case of a school-age boy with aortic valve insufficiency with later prosthetic aortic valve dehiscence caused by Behcet's disease.
This patient presented with fever and an incidental finding of bicuspid aortic valve with severe insufficiency at the age of 7 at the outside hospital. Infective endocarditis was suspected, but the blood culture was negative. Perforation of the anterior cusp was seen intraoperatively, and single-leaflet aortic valve reconstruction utilizing the Ozaki technique was performed. Severe aortic valve insufficiency occurred shortly after the procedure with deteriorating left ventricular function, and the patient was transferred to our hospital three months later. The pericardial patch used for leaflet reconstruction was found detached from the aortic annulus during reoperation, and mechanical aortic valve replacement was performed. Follow-up echocardiograms revealed a normally functioning prosthetic valve with reduced left ventricular systolic function.
One year later, at 8 years old, he presented with a fever of unknown origin, with ineffective antibiotic therapy. Laboratory tests showed elevated leucocyte count, C-responsive protein of 73 mg/L, and erythrocyte sedimentation rate (ESR) of 83 mm/h. Blood culture tested negative for microorganisms. Echocardiogram revealed a surprising rocking motion of the prosthetic aortic valve indicating prosthetic dehiscence (Figure A). Cardiac CT demonstrated a large paravalvular pseudo-aneurysm (Figure B). With no evidence of infection, the patient was highly suspected of cardiac involvement of a systematic inflammatory disease. Although the patient had recurrent oral ulcers, there was no history of skin lesions or genital ulcers, with a negative pathergy test. Human leukocyte antigen-B*15 was positive. Both clinical presentation and imaging findings strongly suggested cardiac involvement of Behcet's disease despite failure to meet the diagnostic criteria. Pediatric rheumatologists initiated the immunosuppressant with methylprednisolone. The patient was afebrile two days later with gradually decreasing ESR, which returned to normal after two weeks.
Another two weeks later, modified Bentall procedure was performed. Consistent with the preoperative imaging findings, the prosthetic aortic valve was partially detached from the aortic annulus (Figure C) with no signs of infective endocarditis. After removing the prosthesis, the pseudo-aneurysm was closed using the bovine pericardial patch. The valved conduit was sutured to the left ventricular outflow tract using interrupted mattress stitches with imbrication suture from the outside in and was fixed with felt. The postoperative course was uneventful. Histological analysis of the thickened aortic wall showed a disrupted myofibroblast arrangement with no significant inflammatory cell infiltration (Figure D). The patient was on oral prednisone therapy with Adalimumab after discharge. He has done well with no postoperative complications at three months of follow-up.
To our knowledge, it is the youngest patient with Behcet's disease requiring aortic valve surgery. Timely diagnosis is essential, and immunosuppressive therapy with modified Bentall procedure may be effective. Long-term follow-up is needed.
View Submission
Poster Presenter
Wen Zhang, Shanghai Children's Medical Center
-
Contact Me
Shanghai, Shanghai
China
A 55-year-old male with history of mechanical aortic and mitral valve replacement for endocarditis nine years prior presented to our institution with chest pain and dyspnea in cardiogenic shock. He quickly decompensated requiring high doses of vasopressors and he developed respiratory and renal failure requiring mechanical ventilation and continuous renal replacement therapy. Transesophageal echocardiography demonstrated severe aortic regurgitation, but was unable to reasonably visualize the mechanical aortic valve leaflets due to shielding from the mitral prothesis. On fluoroscopy, the entire aortic prosthesis was missing from the its annulus and was found to have migrated distally in the descending thoracic aorta with position adequate for distal blood flow in systole.
The patient was taken to the operating room from the cath lab for redo aortic valve replacement with a 23 mm mechanical aortic valve. Since there were no concerns for distal ischemia, the migratory aortic prosthesis was left in situ for retrieval at a later time after recovery from acute shock and multisystem organ failure.
The post-operative course was prolonged, but the patient recovered respiratory and kidney function. At discharge, he had decreased cardiac function with an ejection fraction of 19%. He was sent home on post-operative day fourteen with the migratory aortic valve in situ on therapeutic anticoagulation with a life vest defibrillator.
The patient was followed closely and eventually underwent removal of the migratory valve seven months later by our aortic specialist through a thoracoabdominal approach. This was done under cardiopulmonary bypass with cannulation in the descending thoracic aorta, left common femoral artery, and left common femoral vein. The prosthesis was palpated in the supra celiac aorta. The aorta was clamped at T10 and infrarenally, it was then opened and the valve was removed along with some adherent old clot. The prosthesis eroded into the media of the aorta so an interposition graft was used to replace this portion.
On review of the case, the valve was clearly visible on chest x-ray in the emergency room in a migratory position (Figure), but this was overlooked due to this uncommon presentation. Also, in a retrospective analysis of this patient's cath, performed three years prior to evaluate for coronary disease, the aortic valve prothesis is seen moving up and down or "rocking" within the aortic annulus. Rocking is consistent with dehiscence which is a rare complication in itself, but complete dehiscence and migration of the prosthetic valve is very unusual. Careful review of valve prostheses is essential during any heart catheterization as it may demonstrate issues that could be intervened upon prior to serious complications.
Wide open aortic insufficiency places severe stress on the cardiac myocardium from both inadequate coronary perfusion and elevated left ventricular end diastolic pressure. In our patient, this scenario resulted in acute cardiogenic shock and multi-system organ failure. In this case, our primary goal in management was to fix the acute severe aortic insufficiency. Since there were no signs of mesenteric ischemia and angiography showed good renal and distal perfusion, we decided to leave the migratory valve in situ. We feel this decision was paramount to this patient's survival.
View Submission
Poster Presenter
Shane Smith
-
Contact Me
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Objective: Reconstruction of left ventricular (LV) geometry for ischemic cardiomyopathy following myocardial infarction was first described by Vincent Dor in 1984. Here we describe the concomitant management of a LV aneurysm and refractory non-sustained ventricular tachycardia.
Methods: A 50-year-old woman with a history of Noonan syndrome, presented with multiple ST elevation myocardial infarctions requiring stenting to the left anterior descending (LAD) in 2016, then mid-LAD, 1st diagonal, and proximal right coronary artery in 2021, and subsequently to the circumflex artery in 2022. Since then, she has developed non-sustained ventricular tachycardia (VT) requiring two unsuccessful percutaneous VT ablations, and implantable cardioverter defibrillator placement. She presented with shortness of breath, fatigue, lower extremity edema, and poor functional status. Echocardiogram demonstrated a very large apical LV aneurysm. Cardiac magnetic resonance imaging (MRI) confirmed the apical aneurysm with transmural scar. Simulation of the LV aneurysm resection by MRI, showed an increased LV ejection fraction from 36% to 49% with reduction in LV end diastolic volume from 206 cc to 111 cc. LV reconstruction with VT ablation was chosen as intervention, it was determined that there was no need for concomitant revascularization. Cardiopulmonary bypass was initiated via aortic and right atrial cannulation. Mapping was performed on cardiopulmonary bypass noting foci of inducible arrhythmogenic tissue within the aneurysmal LV wall (Figure 1A). In performing LV reconstruction with endoventricular circular plasty, these foci would be preserved. We therefore elected to perform a cryoablation circumferentially at the transitional zone of the LV aneurysm from both the endocardial and epicardial approach to allow for transmural ablation (Figure 1B). Completion of LV reconstruction with endoventricular circular plasty was performed with interrupted pledgeted sutures at the transition zone, the patch was sized, and tied in place. The incised aneurysmal apex was reapproximated with permanent suture and reinforced with felt strips (Figure 1C-D). Post operatively the patient was maintained on home dose antiarrhythmics without any documented arrhythmias. She discharged on post operative day 7 and has been recovering without arrhythmias.
Results: LV reconstruction utilizing exclusion technique of noncontractile aneurysmal regions of LV to restore size and shape has been associated with improved outcomes. The addition of ablation with intraoperative mapping of arrhythmogenic foci allows for transmural cryoablation with both endocardial and epicardial approaches. This patient has been arrhythmia free since the intervention, with two prior failed attempts at percutaneous ablation we feel that transmural ablation is the key to success.
Conclusions: Left ventricular aneurysm with refractory ventricular tachycardia can be treated successfully and safely with concomitant left ventricular reconstruction and transmural cryoablation.
View Submission
Poster Presenter
Kenneth Hassler, Mayo Clinic
-
Contact Me
United States
Congenital absence of tracheal rings is a rare cause of congenital tracheal stenosis, only reported a few times previously. Here we present a case of a neonate with symptomatic tracheal stenosis, treated successfully with a resection and primary anastomosis.
A 3-week-old, ex-31-week, 2.5kg baby with tachypnea and stridor since birth underwent a rigid bronchoscopy which demonstrated significant narrowing of the distal trachea. A CT scan revealed severe localized airway narrowing and no other cardiovascular abnormalities. Patient was taken for bronchoscopy evaluation with possible dilation. She was found to have severe dynamic narrowing at the distal trachea 1 cm above the carina. The stenotic airway measuring 5 mm in length, appeared to be compliant and distensible with positive pressure ventilation without evidence of complete tracheal rings. A 1.9 mm telescope on a 2.5 ETT bypassed this region. Overnight, patient had worsening ventilation and high peak airway pressures, she required reintervention. This was noted to be unsustainable and tracheal resection was planned.
The infant was taken for a median sternotomy with initiation of CPB. Using a flexible scope, the proximal and distal margins of the narrowing were marked. The diseased trachea was completely excised and it was noted to have absence of tracheal rings. A small incision was made anteriorly proximally and a mirror image incision was made posteriorly in the distal trachea at the membranous portion. Then, the two segments were anastomosed using a posterior running 7-0 Prolene suture and interrupted single and horizontal mattress anterior sutures. Post repair bronchoscopy showed no evidence of residual stenosis. Patient was extubated successfully on POD1 and transferred to the NICU for continued care of prematurity. Gross and histologic findings were consistent with congenital absence of tracheal rings. Subsequent bronchoscopy evaluations have shown no granulation, anastomotic contraction or narrowing.
Tracheal rings are normally "C-shaped," with cartilage anterior and lateral, and a membranous posterior wall. Absent tracheal rings is an extremely rare intrinsic tracheal defect that presents as severe focal tracheomalacia. The absence of the cartilaginous rings leads to airway collapse during fluctuations of pressure associated with normal ventilation. Patients will present with stridor and airway compromise, and become symptomatic much earlier in life. A resection with a primary spatulated anastomosis using everting sutures can result in an unobstructed airway and may have a low risk of recurrence.
Here we present a video of a unique case of a premature, low-birth weight neonate that underwent a successful resection of a short segment of tracheal stenosis from absence of tracheal rings with primary anastomosis of the unaffected trachea.
View Submission
Poster Presenter
Clara Angeles
-
Contact Me
United States
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Background
Acute type A aortic dissection (ATAAD) is a life-threatening surgical emergency that requires prompt intervention. However, controversy over the extent of distal repair remains. A conservative approach limiting replacement to the ascending aorta or hemiarch is safer in the short term but may increase long-term complications necessitating late reintervention, especially in patients with heritable thoracic aortic disease (HTAD) and residual dissection. A more aggressive distal approach with total arch replacement can mitigate long-term risks but adds substantial operative complexity, morbidity, and mortality. However, when patient factors preclude a complex operation, the operative plan should be deconstructed prioritizing the aspects that impact immediate survival.
Case Description
We report on a 63-year woman with Loeys-Dietz syndrome, chronic hypotension, and acute onset chest pain who presented elsewhere and was diagnosed with DeBakey type 1 dissection extending from just distal to the coronary ostia to the left iliac artery. After transfer, she was hemodynamically stable and had no evidence of malperfusion but had ongoing back and chest pain. Given her heritable aortopathy, the initial operative strategy was an extended repair replacing the aortic root, ascending aorta, and the entire arch using hypothermic circulatory arrest. However, the patient did not consent for transfusion of blood products due to her religious observance. Both an extended repair and hypothermic circulatory arrest are associated with increased risk of bleeding and transfusion. With these challenges in mind, we decided to prioritize coronary protection and valve repair, limiting the extent of operative intervention as much as possible. Cardiopulmonary bypass was performed using right axillary artery cannulation, and the heart arrested with retrograde cardioplegia. An intimal tear was visualized distal to the right coronary ostium with retrograde dissection into the sinuses destabilizing the commissures and compromising the valve (severe aortic regurgitation [AR] on intraoperative echocardiography). We transected the involved aorta, resected the originating tear, and obliterated the false lumen using surgical adhesive while protecting the coronary ostia. Using inner and outer felt strips, we resuspended the commissures and provided additional support at the sinotubular junction. A 30-mm graft was used to replace the ascending aorta. Possibly because of her chronic hypotension, the aortic arch was of normal diameter without aneurysmal dilatation, reducing immediate need for intervention on the arch. The patient tolerated the procedure well, with post-repair echocardiography showing restored valvular function. She was discharged home on postoperative day 8 and has remained well in the 3 months since operation.
Conclusion
Patients with HTAD and ATAAD should be considered for total arch replacement at the time of repair to reduce the risk of subsequent dilatation of residual aortic tissue. In complex cases where the risks may outweigh the benefits of this preferred approach, alternative options for intervention should be considered. Deconstructing the surgical approach to prioritize those repairs which offer an immediate survival advantage is warranted in patients with religious considerations.
View Submission
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
We present the case of a 46-year-old male who presented with chest pain for nine days, intermittent fevers, and dyspnea. The patient underwent computed tomography (CT) angiography of his chest that showed a moderate sized pericardial effusion with high density concerning for hemopericardium, along with an outpouching on the right atrial wall with a narrow neck concerning for a pseudoaneurysm. Transesophageal echocardiogram (TEE) redemonstrated the pericardial effusion and right atrial pseudoaneurysm. Given the concern for rupture into the pericardial space, the patient was taken to the operating room for resection of the pseudoaneurysm. The operation was performed via median sternotomy with cardiopulmonary bypass. After meticulous lysis of dense pericardial adhesions, central cannulation was performed, and the aorta and right atrium were cannulated. Right atrial pseudoaneurysm was identified and excised with the surrounding atrial wall. The defect in the atrial wall was closed using a bovine pericardial patch. The patient's post-operative course was unremarkable, and he was discharged home on post operative day 4. Histopathology report initially demonstrated perivascular lymphocyte infiltrate. Six weeks later, the patient represented with chest pain and new word finding difficulty. Workup revealed multiple solid lung, pericardial, brain, and bone nodules. Biopsy of a cardiophrenic nodule demonstrated angiosarcoma, and rereview of the original pathology slides confirmed the diagnosis of primary cardiac angiosarcoma. The patient is currently undergoing chemotherapy for metastatic cardiac angiosarcoma.
Cardiac angiosarcomas are a rare but aggressive form of malignancy. They most commonly arise from the right atrium, and patients often present with nonspecific symptoms such as chest pain, dyspnea, and weight loss. Over half of patients present with metastatic disease, with spread to the lungs or pleura being most common. CT scan often shows a large multilobular mass that comprises the majority of the right atrium. Transthoracic echocardiography (TTE) often shows a large echogenic mass with poorly defined borders. Without surgical resection, average survival is about 4 months. With surgical resection, median post-operative survival is 14 months. A multidisciplinary treatment approach involving local resection, systemic chemotherapy, and radiation therapy is the most favorable strategy.
Our case represented a diagnostic challenge and initially presented on imaging as a right atrial pseudoaneurysm with a narrow neck, as opposed to a large multilobular mass with broad-based attachment. Cardiac angiosarcoma presenting initially on imaging as a right atrial pseudoaneurysm has only been reported in a handful of cases. Diagnosis was further delayed by the challenging histologic presentation in the context of low clinical suspicion, with malignant cells being obscured by extensive fibrin, granulation tissue, and organizing thrombus. Given these difficulties, diagnosis was not made until after distant metastatic spread. The unique presentation of this case demonstrates that clinical suspicion for cardiac angiosarcoma should be maintained for spontaneous pseudoaneurysm originating from the right atrium. With an aggressive disease course, early diagnosis is vital and allows for multidisciplinary care with medical and radiation oncology to offer patients the best chances of survival.
View Submission
Poster Presenter
Salman Zaheer
-
Contact Me
United States
Monday, May 8, 2023: 3:45 PM
Objective: To demonstrate the feasibility and advantages of the robotic approach to the mitral valve in patients with severe pectus excavatum.
Case Video Summary: We present the case of robotic mitral valve repair with left atrial appendage exclusion and cryoMAZE in a patient with pectus excavatum. Our patient is a 69-year-old man with severely restricting chest anatomy due to pectus excavatum with New York Heart Association Class II symptoms of dyspnea on exertion. Pectus excavatum is a relative contraindication to robotic approach to the mitral valve, but surgery is also challenging through sternotomy. Pre-operative imaging showed thickened leaflets with anterior leaflet prolapse causing severe posteriorly directed mitral regurgitation jet. Percutaneous cannulation with 21Fr arterial cannula and 23Fr venous cannula were performed and endoaortic balloon pump was deployed into the aorta. The camera port was placed in the 3rd intercostal space, a left arm port in the 2nd intercostal space and the right arm port in the 5th intercostal space. An additional retractor port was placed in the 4th intercostal space more medially under direct vision.
Exposure was challenging due to the depressed sternum. The low chest height in our patient would have made a non-robotic approach very challenging and the advantage of the robotic approach in this kind of anatomy can be appreciated in the video. After going on bypass and cooling, the pericardium was opened, and retraction sutures were placed. We then inflated the endoaortic balloon, fibrillated the heart and gave 1.2L of antegrade cardioplegia. There was good myocardial arrest. We entered the left atrium through the interatrial groove and used the retractor to expose the mitral valve. The mitral valve was noted to have myxomatous degenerative changes and prolapse of A1 and A2. We placed retraction sutures in the posterior pericardium to the posterior wall of the left atrium, and then proceed to close the left atrial appendage using running Gore-Tex sutures. A left sided cryoMAZE was performed with 2min freezes. The lines were made at the epicardial coronary sinus, mitral line, bilateral pulmonary veins, and base of left atrial appendage. The mitral valve was repaired by placing three separate neochords to A2x2, A1x1. We then placed a 32mm annuloplasty band. Height adjustment of the neochords was performed and the leaflets appeared to coapt nicely on saline testing.
We removed the retractor, closed the atriotomy using Gore-Tex sutures from either side. The heart was deaired and the endoaortic balloon cross-clamp was removed. We placed a bipolar ventricular wire and two 24Fr Blake chest tubes. The patient was weaned off bypass without any problems. There was no mitral regurgitation at the end of the operation with a mean gradient of 1 mmHg.
Conclusions: In summary, with experience, robotic mitral is safe and feasible in select patients with pectus excavatum. It can help avoid sternotomy-related intra- and post-operative complications and provide superior exposure. Compared to right mini-thoracotomy, robotic mitral valve repair also provides three-dimensional instrumentation to the mitral valve with greater flexibility in tight spaces.
View Submission
Poster Presenter
Irbaz Hameed, Yale University School of Medicine
-
Contact Me
Hamden, CT
United States