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Annals of Cardiothoracic Surgery Jul 2018Coronary surgery performed on an arrested heart, using one internal mammary artery and a saphenous vein carries two main potential drawbacks: the known failure rate of... (Review)
Review
Coronary surgery performed on an arrested heart, using one internal mammary artery and a saphenous vein carries two main potential drawbacks: the known failure rate of vein grafts and the relatively high rate of neurologic injury. To address these concerns, we describe a technique that achieves complete revascularization without manipulating the ascending aorta (anaortic, off-pump) and utilizing total arterial grafts. All patients undergo thorough preoperative investigation, including bilateral carotid, vertebral and subclavian artery Duplex ultrasounds. A pulmonary artery catheter, transoesophageal echocardiography, and point-of-care coagulation testing are used in each case. The left and right internal mammary arteries and non-dominant radial artery are harvested using a fully skeletonised technique. Wide bilateral extrapleural retrothymic tunnels are developed and the pericardium is opened widely to facilitate cardiac positioning. A tandem graft is constructed with the right internal mammary artery (RIMA) and radial artery using an end-to-end anastomosis. This graft is brought into the pericardium and through the transverse sinus in order to graft the lateral and inferior walls with multiple sequential distal anastomoses. The left internal mammary artery (LIMA) is used to graft the anterior wall. Four main cardiac positions (high and low lateral walls, inferior and anterior walls) are obtained using a combination of off-pump stabilizer positioning, alternate tension on pericardial 'heart-strings', table tilting and folded wet sponges. All distal anastomoses are performed using silastic intracoronary shunts and an off-pump myocardial stabilizer. All grafts are checked using transit-flow time measurements. Milrinone is continued overnight and dual antiplatelet therapy is continued for 3 months postoperatively.
PubMed: 30094221
DOI: 10.21037/acs.2018.06.17 -
Cardiovascular Pathology : the Official... 2019The aims of this study were, firstly, to determine the relationship of left ventricular wall thickness (LVWT) measurements between postmortem computed tomography (PMCT)... (Comparative Study)
Comparative Study
PURPOSE
The aims of this study were, firstly, to determine the relationship of left ventricular wall thickness (LVWT) measurements between postmortem computed tomography (PMCT) and postmortem magnetic resonance imaging (PMMR) and, secondly, to assess the utility of postmortem imaging for LVWT measurements compared to autopsy.
MATERIALS AND METHODS
All cases ≥18years old, with postmortem interval ≤4days, cardiac PMCT, PMMR, and full forensic autopsy, were reviewed in our database retrospectively. Exclusion criteria were gas accumulations in the myocardial wall and cardiac trauma. LVWT on PMCT and PMMR was assessed. The measurements were repeated by the same rater after 2months. Autopsy reports were reviewed, and LVWT and pericardial fluid volume measured at autopsy were noted. Pericardial fluid volume >50ml was determined positive for pericardial effusion.
RESULTS
A total of 113 cases were included in the study. Twelve cases had pericardial effusion. Intrarater reliability for imaging based LVWT was excellent. LVWT (free wall) was significantly larger on PMCT (18.3mm) compared to PMMR (17.6mm), but these measurements correlated positively. LVWT (anterior wall) was significantly larger on PMMR (15mm) than at autopsy (14mm), and these measurements also correlated positively. Pericardial effusions led to larger differences between PMMR and autopsy measurements, however without statistical significance.
DISCUSSION
There exist discrepancies between LVWT as measured on postmortem imaging and at autopsy. Specialists should be aware in order to not misinterpret imaging measurements.
Topics: Adult; Aged; Autopsy; Databases, Factual; Female; Heart Ventricles; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Multidetector Computed Tomography; Myocardium; Observer Variation; Pericardial Effusion; Postmortem Changes; Predictive Value of Tests; Reproducibility of Results; Retrospective Studies
PubMed: 31639653
DOI: 10.1016/j.carpath.2019.107149 -
Journal of Veterinary Cardiology : the... Dec 2022An 11-year-old mixed breed dog was presented with exercise intolerance and syncope. At admission, transthoracic echocardiography revealed myxomatous mitral valve disease...
An 11-year-old mixed breed dog was presented with exercise intolerance and syncope. At admission, transthoracic echocardiography revealed myxomatous mitral valve disease (MMVD) associated with severe left atrial (LA) enlargement and moderate anechoic pericardial effusion with a hyperechoic density suggestive of a thrombus. Rupture of the LA free wall secondary to MMVD was suspected, and medical therapy with furosemide and pimobendan was initiated. After one month, recheck echocardiography showed mild anechoic pericardial effusion and an acquired atrial septal defect with a left-to-right intracardiac shunting flow. In light of the dog's history, the latter finding was suspected to be secondary to a further rupture of the LA wall due to MMVD, this time affecting the interatrial septum. The images described here allow us to suspect that sequential LA wall ruptures developed over time in the same subject affected by MMVD, a clinical presentation not previously described in veterinary medicine.
Topics: Dogs; Animals; Mitral Valve; Atrial Fibrillation; Pericardial Effusion; Dog Diseases; Heart Valve Diseases
PubMed: 36252456
DOI: 10.1016/j.jvc.2022.09.001 -
Interactive Cardiovascular and Thoracic... May 2018The development of calcification-resistant bioprosthetic materials is a very important challenge for paediatric surgery. The subcutaneous implantation in rats is the...
OBJECTIVES
The development of calcification-resistant bioprosthetic materials is a very important challenge for paediatric surgery. The subcutaneous implantation in rats is the well-known first-stage model for this kind of research. Using this model, we aimed to compare calcification of the porcine aortic wall and bovine pericardium and jugular vein wall cross-linked with glutaraldehyde (GA) and ethylene glycol diglycidyl ether (DE). We also determined the efficacy of DE-preserved tissue modification with 2-(2-carboxyethylamino)ethylidene-1,1-bisphosphonic acid (CEABA).
METHODS
Three groups of each biomaterial were evaluated: GA-treated, DE-treated and DE + CEABA-treated. The microstructure of non-implanted biomaterials was assessed by light microscopy after Picro Mallory staining; the phosphorus content of the DE and DE + CEABA samples was assessed by atomic emission spectrometry. Samples were implanted subcutaneously into young rats for 10 and 60 days. The explant end-point included quantitative calcification assessment by atomic absorption spectrophotometry and light microscopy examination after von Kossa staining.
RESULTS
All GA-treated biomaterials had a high calcium-binding capacity (>100 μg/mg dry tissue). DE preservation decreased the vein wall and pericardium calcium content by 4- and 40-fold, respectively, but was ineffective for the aortic wall. The calculated CEABA content was almost equal in the vein wall and pericardium (17.7 and 18.5 μM/g) and slightly less in the aortic wall (15 μM/g) (P = 0.011). CEABA effectively reduced mineralization in the DE aortic wall and DE pericardium to 10.1 (7.8-21.1) and 0.95 (0.57-1.38) μg/mg but had no effect in the DE vein wall. Mineralization in the GA- and DE-treated aortic and vein walls was predominantly associated with elastin. CEABA modification decreased elastin calcification but did not block it completely.
CONCLUSIONS
Each xenogeneic material requires individual anticalcification strategy. DE + CEABA pretreatment demonstrates a high mineralization-blocking efficacy for the bovine pericardium and should be employed to further develop the paediatric pericardial conduit. Aortic wall calcification cannot be blocked completely using this strategy.
Topics: Animals; Aorta; Biocompatible Materials; Bioprosthesis; Cattle; Diphosphonates; Elastin; Epoxy Resins; Glutaral; Heart Valve Prosthesis; Jugular Veins; Pericardium; Prosthesis Design; Rats; Swine; Tissue Culture Techniques; Tissue Preservation; Vascular Calcification
PubMed: 29346675
DOI: 10.1093/icvts/ivx445 -
Proceedings of the Institution of... Mar 2015Pericardial effusion is a pathological accumulation of fluid within pericardial cavity, which may compress heart chambers with hemodynamic impairment. We sought to...
Pericardial effusion is a pathological accumulation of fluid within pericardial cavity, which may compress heart chambers with hemodynamic impairment. We sought to determine the mechanics underlying the physiology of the hemodynamic impairment due to pericardial effusion using patient-specific computational modeling. Computational models of left ventricle and right ventricle were based on magnetic resonance images obtained from patients with pericardial effusion and controls. Myocardial material parameters were adjusted, so that volumes of ventricular chambers and pericardial effusion agreed with magnetic resonance imaging data. End-diastolic and end-systolic pressure-volume relationships as well as stroke volume were determined to evaluate impaired cardiac function of biventricular model. Distributions of myocardial fiber stresses and their regional variation along left ventricular wall were compared between patient groups. Both end-diastolic and end-systolic pressure-volume relationships shifted to the left for patients with pericardial effusion, with right ventricle diastolic filling particularly restricted. Left ventricle function as estimated by Starling curve was reduced by pericardial effusion. End-systolic fiber stress of left ventricle was significantly reduced as compared to that found for healthy patients. Myocardial stress was found increased at interventricular septum when compared to that exerted at lateral wall of left ventricle. Right ventricular myocardial stress was reduced as a consequence of the pressure equalization between right ventricle and pericardial effusion. Diastolic right ventricle collapse in patients with pericardial effusion is related to higher myocardial fiber stress on interventricular septum and to an extensible pericardium reducing motion of ventricular chambers, with right ventricle particularly restrained. These findings likely portend progression of pericardial effusion to cardiac tamponade.
Topics: Adult; Aged; Aged, 80 and over; Cardiac Tamponade; Female; Finite Element Analysis; Humans; Male; Models, Cardiovascular; Pericardial Effusion; Young Adult
PubMed: 25833996
DOI: 10.1177/0954411915574012 -
Journal of Cardiovascular Computed... 2020Infected coronary artery aneurysms (ICAA) represent a rare but potentially fatal complication of pre-existent atherosclerotic or non-atherosclerotic coronary artery...
BACKGROUND
Infected coronary artery aneurysms (ICAA) represent a rare but potentially fatal complication of pre-existent atherosclerotic or non-atherosclerotic coronary artery disease, percutaneous coronary artery intervention, endocarditis or extracardiac infection.
METHODS
A retrospective analysis of four cases in addition to 51 infected coronary artery aneurysms from the literature, for a total of 55 ICAA was performed. Clinical and morphological information including age, sex, clinical presentation, microbial cultures, size, location and associated abnormalities as well as patient outcome was reviewed.
RESULTS
83% of affected patients were adult males, with an average age of 55.24 years. The right coronary artery was the most commonly affected vessel (40%). In nearly 80% of the time, the responsible organism was either Staphylococcus aureus (53.3%), or Streptococcus (20%) infection. ICAA are typically large, on average 3.4 cm in diameter and can measure up to 9 cm. On contrast enhanced CT, imaging features include lobulated contour or saccular shape (54.2%) with thick wall or mural thrombus (87.5%). Associated abnormal appearance of the pericardium with either pericardial fluid, thickening or loculation is common (79.2%).
CONCLUSION
ICAA are typically large, and characterized by a thick wall with a lobulated or saccular shape. Association with mediastinal, chest wall or pericardial abnormalities are common. This combination of findings, in the setting of fever, known infection, or recent coronary intervention should raise concern for ICAA.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aneurysm, Infected; Computed Tomography Angiography; Coronary Aneurysm; Coronary Angiography; Female; Humans; Infant; Male; Middle Aged; Risk Factors; Young Adult
PubMed: 30711513
DOI: 10.1016/j.jcct.2019.01.018 -
BMC Medical Imaging May 2021Pericardial hematoma is blood accumulation in the pericardial space. Although rare, it could arise in various conditions, such as after cardiac surgery. Clinical... (Review)
Review
BACKGROUND
Pericardial hematoma is blood accumulation in the pericardial space. Although rare, it could arise in various conditions, such as after cardiac surgery. Clinical diagnosis of pericardial hematoma is implausible; thus, cardiac imaging plays a pivotal role in identifying this condition. We presented a case of multiple pericardial hematomas, which was found as an incidental finding in post-cardiac surgery evaluation. We highlighted the diagnostic challenge and the key features of multi-modality cardiac imaging in pericardial hematoma evaluation.
CASE PRESENTATION
An asymptomatic, 35-years old male, who underwent surgical closure of secundum atrial septal defect (ASD) one month ago, came for routine transthoracic echocardiography evaluation. An intrapericardiac hematoma was visualized at the right ventricle (RV) 's free wall side. Another mass with an indistinct border was visualized near the right atrium (RA). This mass was suspected as pericardial hematoma differential diagnosed with intracardiac thrombus. Cardiac computed tomography (CT) scan showed both masses have an attenuation of 30-40 HU; however, the mass's border at the RA side was still not clearly delineated. Mild superior vena cava (SVC) compression and multiple mediastinal lymphadenopathies were also detected. These findings are not typical for pericardial hematomas nor intracardiac thrombus; hence another additional differential diagnosis of pericardial neoplasm was considered. We pursued further cardiac imaging modalities because the patient refused to undergo an open biopsy. Single-photon emission computer tomography (SPECT)/CT with Technetium-99 m (Tc-99 m) macro-aggregated albumin (MAA) and Sestamibi showed filling defect without increased radioactivity, thus exclude the intracardiac thrombus. Cardiac magnetic resonance imaging (MRI) reveals intrapericardial masses with low intensity of T1 signal and heterogeneously high intensity on T2 signal weighted imaged and no evidence of gadolinium enhancement, which concluded the diagnosis as subacute pericardial hematomas. During follow-up, the patient remains asymptomatic, and after six months, the pericardial hematomas were resolved.
CONCLUSION
Pericardial hematoma should be considered as a cause of pericardial masses after cardiac surgery. When imaging findings are atypical, further multi-modality cardiac imaging must be pursued to establish the diagnosis. Careful and meticulous follow-up should be considered for an asymptomatic patient with stable hemodynamic.
Topics: Adult; Diagnosis, Differential; Heart Atria; Heart Neoplasms; Heart Septal Defects, Atrial; Heart Ventricles; Hematoma; Humans; Incidental Findings; Magnetic Resonance Imaging; Male; Multimodal Imaging; Pericardium; Postoperative Complications; Single Photon Emission Computed Tomography Computed Tomography; Thrombosis; Tomography, X-Ray Computed
PubMed: 34006236
DOI: 10.1186/s12880-021-00617-0 -
Journal of Cardiovascular Imaging Jun 2018Interpretation of cardiac uptake on 18-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) is often confounded by intense physiological...
BACKGROUND
Interpretation of cardiac uptake on 18-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) is often confounded by intense physiological FDG uptake and numerous benign conditions. The aim of the study was to describe the echocardiographic features in concordance with cardiac and pericardial F-FDG uptake on whole-body oncology PET/CT.
METHODS
We enrolled 43 consecutive patients (34 solid tumors, 8 lymphomas and 1 leukemia) who were newly diagnosed with non-cardiac malignancy showing incidental cardiac or pericardial F-FDG uptake on PET/CT and underwent transthoracic Doppler echocardiography (TTE) within 1 month of PET/CT. The maximum standardized uptake (SUV) of all lesions was measured.
RESULTS
Fifty-six F-FDG uptake lesions (32 pericardium, 7 myocardium, 9 cardiac chambers and 8 great vessels) were found, and pericardial effusion was the most common echocardiographic finding (22/43, 51.2%) among study population. Pericardial FDG uptake was shown as pericardial effusion (68.8%), intrapericardial echogenic materials (31.3%), pericardial thickening (28.1%), hyperechogenicity of myopericardium (18.8%), and restricted sliding movement or constrictive pericarditis (15.6%) on TTE. Lesions with regional wall motion abnormality ( = 0.004) or constrictive pericarditis ( = 0.021) had significantly higher mean SUV than those without. Myocardial FDG uptake demonstrated pericardial effusion (57.1%), regional wall motion abnormality (57.1%), and increased myocardial wall thickness (42.9%). All cardiac chamber FDG uptakes showed intracardiac mass on TTE.
CONCLUSIONS
Cardiac or pericardial F-FDG uptake on oncology PET/CT shows characteristic echocardiographic features according to which heart sites are involved.
PubMed: 29971271
DOI: 10.4250/jcvi.2018.26.e10 -
Netherlands Heart Journal : Monthly... Feb 2023Cardiac tamponade is a rare but life-threatening complication of cardiac interventions. Despite prompt pericardiocentesis, clinical management can be challenging and...
BACKGROUND
Cardiac tamponade is a rare but life-threatening complication of cardiac interventions. Despite prompt pericardiocentesis, clinical management can be challenging and sometimes haemodynamic stabilisation is difficult to achieve. Intra-pericardial thrombin injection after pericardiocentesis promotes haemostasis and acts as a sealing agent, as previously described for left ventricular free-wall rupture. We aimed to evaluate intra-pericardial thrombin injection as a bailout strategy for pericardial tamponade following percutaneous cardiac interventions.
METHODS
In a 5-year single-centre retrospective analysis we identified 31 patients with cardiac tamponade due to percutaneous intracardiac procedures. Intra-pericardial thrombin injection as a bailout strategy was administered in 5 of 31 patients (16.1%).
RESULTS
Patients receiving intra-pericardial thrombin were in a more critical state when thrombin was applied, as demonstrated by a higher rate of resuscitation (40% versus 26.9%) and a trend toward a prolonged stay in the intensive care unit (177.6 ± 84.0 vs 98.0 ± 31.4 h). None of the patients with pericardial tamponades treated with intra-pericardial thrombin needed cardiothoracic surgery. Mortality after 30 days was lower with intra-pericardial thrombin injection than with standard treatment (0% vs 15.4%). We observed no complications using intra-pericardial thrombin.
CONCLUSION
Intra-pericardial thrombin injection could be considered as a bailout strategy for patients with iatrogenic pericardial tamponade due to percutaneous procedures. We recommend further evaluation of this technique in the clinical management of refractory pericardial tamponade.
PubMed: 35648265
DOI: 10.1007/s12471-022-01701-y -
Transplant Infectious Disease : An... Feb 2018A 60-year-old woman with a history of dilated cardiomyopathy underwent heart transplantation. One month post discharge, she presented to clinic with low-grade fever and...
A 60-year-old woman with a history of dilated cardiomyopathy underwent heart transplantation. One month post discharge, she presented to clinic with low-grade fever and productive cough. Her chest radiograph showed air-fluid levels in the pericardial silhouette. Transthoracic echocardiogram showed a large complex pericardial collection with no evidence of cardiac tamponade. The patient was urgently taken to the operating room for exploration. A large "egg-shaped" mass in the pericardium measuring 10 × 12 cm with gaseous material was aspirated. As the posterior wall of the mass was firmly adhered to the right atrium, the capsule was incompletely excised. We present the case of a potentially life-threatening complication post transplantation that required surgical debridement and life-long antibiotic suppressive therapy. To our knowledge, this is the first report of purulent pericardial collection caused by Enterobacter cancerogenous. Further research is required to better understand the biology of this microorganism and the role it may play as a pathogen in immunocompromised patients following solid organ transplantation.
Topics: Echocardiography; Enterobacter; Enterobacteriaceae Infections; Female; Heart Transplantation; Humans; Immunocompromised Host; Middle Aged; Pericarditis; Pneumopericardium
PubMed: 29105898
DOI: 10.1111/tid.12800