Heart, Lung and Circulation

Editorial Board

2012-05-01

Cardiac Surgery in Patients with a History of Malignancy: Increased Complication Rate but Similar Mortality

Justin Chan, Franklin Rosenfeldt, Krishanu Chaudhuri, Silvana Marasco — 2012-05-01

Background: Little is known about the outcome of cardiac surgery in patients with a prior history of malignancy. Our aim was to investigate in our unit the population of patients with a known malignancy and compare their outcomes to a matched population without malignancy.Methods: We identified all patients who underwent cardiac surgery at the Alfred Hospital between February 2002 and December 2009 with malignancy. Cases were matched to 216 controls based on age, gender, major medical comorbidities and type of surgery. A univariate analysis was performed with Fishers exact test and χ2 test.Results: 83/4474 patients were identified with malignancy. Sixty-four (77%) were male. Mean age of the patients with malignancy was 66.7 years, and 67.4 in the control group. 68.7% had a solid organ tumour, and 31.3% had a haematological malignancy. There were no significant between-group differences in hospital or 30-day mortality. However, there were significantly higher rates of transfusion (79.5% vs 49%, p<0.0001), reintubation (8.4% vs 0.9%, p=0.0009), pneumonia (14.5% vs 6%, p=0.035), septicaemia (8.4% vs 1.9%, p=0.018), arrhythmias (42.2% vs. 33.8%, p=0.047) and anticoagulant complications (7.2% vs 0%, p=0.008) in patients with malignancies.Conclusion: Patients who present for cardiac surgery having had prior treatment for cancer are at particular risk for complications. However, these patients can be operated upon with acceptable risk. There is no difference in the short term mortality. Therefore, for selected patients who are undergoing curative treatment for their malignancy, or are in remission, cardiac surgery is not contraindicated.

The Acute Haemodynamic Effect of Nebulised Frusemide in Stable, Advanced Heart Failure

2012-05-01

Purpose: To assess the acute haemodynamic effects of nebulised frusemide in a stable advanced heart failure population.Procedure: In this randomised, double blind, placebo controlled trial, people with stable, advanced heart failure undergoing right heart catheterisation were randomised to receive either 40mg (4ml) of nebulised frusemide or 4ml of normal saline. Following inhalation of the study medication, subjects’ pulmonary pressures were recorded every 15min for 1h.Findings: There were no significant changes in the weighted average time course data of the subjects (n=32) in either group over the study period, in particular no differences were observed in haemodynamic parameters between the two groups. Weighted average pulmonary capillary wedge pressure after 60min in the frusemide group was 22.5 (SD 6.5) mmHg (n=14) compared to the placebo group's 24.0 (SD 7.3) mmHg (n=18), p=0.55. The frusemide group had a significantly greater change in the median volume of urine in the bladder over the study period (186ml IQR 137.8–260.8) compared to the placebo group (76ml IQR 39.0–148.0) p=0.02.Conclusion: This study showed that nebulised frusemide had no significant clinical effect on the haemodynamic characteristics of the subjects.

The Use of Computerised Simulators for Training of Transthoracic and Transoesophageal Echocardiography. The Future of Echocardiographic Training?

2012-05-01

Background: Echocardiography is the commonest form of non-invasive cardiac imaging but due to its methodology, it is operator dependent. Numerous advances in technology have resulted in the development of interactive programs and simulators to teach trainees the skills to perform particular procedures, including transthoracic and transoesophageal echocardiography.Methods: Forty trainee sonographers assessed a computerised mannequin echocardiographic simulator and were taught how to obtain an apical two-chamber (A2C) view and image the superior vena cava (SVC). Forty-two attendees at a TOE simulator workshop assessed its utility and commented on perceived future use, using defined criteria.Results: One hundred percent and 88% of sonographers found the simulator useful in obtaining the SVC or A2C view respectively. All users found it easy to use and the majority found it helped with image acquisition and interpretation. Attendees of the TOE training day assessed the simulator with 100% finding it easy to use, as well as the augmented reality graphics benefiting image acquisition. Ninety percent felt that it was realistic.Conclusions: This study revealed that both trainee sonographers and TOE proceduralists found the simulation process was realistic, helped in image acquisition and improved assessment of spatial relationships. Echocardiographic simulators may play an important role in the future training of echocardiographic skills.

Occlusion of Both Caval Veins by an Endovascular Occluder

Fabrizio Sansone, Cristina Barbero, Mauro Rinaldi — 2012-05-01

Minimally invasive surgery (MIS) for redo mitral/tricuspidal surgery is going to increase, offering good results for early and late mortality and morbidity. In a case of redo surgery through a right thoracotomy (RT), when tricuspid surgery is planned, the superior (SVC) and inferior caval veins (IVC) are usually isolated and snared in order to prevent air embolism and significant blood regurgitation. We describe our experience in eight redo patients, operated for combined mitral/tricuspid or isolated tricuspid surgery, where the endovascular occlusion of the SVC and IVC was obtained by means of an endovascular occluder (Equalizer).

Textiloma mimicking a pericardial hydatid cyst: A case report

Alaae Boutayeb, Lahcen Marmade, Mohammed Laaroussi, Adil Bensouda, Said Moughil — 2012-05-01

Textiloma is unusual and uncommon diagnosis which is rarely considered. We report the case of a 13 year-old patient with Holt-Oram syndrome. He was operated on in 2006 for ostium secundum atrial septal defect. The postoperative course was uneventful until 2010 when the child presented paroxysmal dyspnoea. Investigations revealed para-cardiac mass which was thought to be a hydatid cyst, but operative findings showed textiloma.

Prevalence of Bacteria in the Circulation of Cardiovascular Disease Patients, Madurai, India

2012-05-01

Cardiovascular diseases (CVDs) have a complex aetiology determined by risk factors, which include genetic and environmental factors. Chronic infection and inflammation is reported to be a pathogenic determinant for the development of CVDs. Here, we report the prevalence of bacterial pathogens in the circulation of CVD patients in Madurai, India. Blood culturing was performed using BD BACTEC automated culture system and organisms were identified by16S rRNA gene sequence analysis. From a total of 133 samples screened, 47 samples showed culture positive which indicates a high level of bacteraemia in CVD patients. From the 47 samples that showed growth, we have identified 57 bacterial isolates comprising 35 different species. Coagulase negative Staphylococci (CoNS) was the most predominant group of bacteria and other notable bacterial species isolated in this study are discussed.

Multimodality Imaging of the Mitral Paravalvular Abscess Cavity with Left Ventriculo-atrial Fistula

2012-05-01

Paravalvular complications may occur in patients with infective endocarditis. Paravalvular abscess formation rarely occurs and if so it generally involves the aortic valve. Herein we present a case of left ventriculo-atrial fistula formation through mitral paravalvular abscess cavity shown by multimodality imaging including two- and real-time three-dimensional transoesophageal echocardiography (RT 3-D TEE), cardiac magnetic resonance imaging (CMRI), multislice computed tomography (MSCT) and ventriculography in a patient with a mechanical prosthetic mitral valve. This is the first case in the literature of a mechanical prosthetic mitral valve complicated by a left ventriculo-atrial fistula formation in a healed abscess cavity that is demonstrated with RT-3D TEE, cardiac MRI and MSCT.

Right atrial mass after open heart surgery: tumour or thrombus?

2011-10-17

Detection of a rapidly growing mass in the right atrium during routine inter-echocardiogram follow-up period in two patients after corrective open-heart surgery raises concerns about nature of the mass and the probable cause. One turned out to be an atrial myxoma that grew rapidly over a eight month period and the other a well encapsulate thrombus in a fully anticoagulated patient. Preoperative transthoracic echocardiogram had reported both the cases to be a myxoma. This article highlights the importance of considering rare causes in the face of a seemingly obvious diagnosis and possible use of imaging modalities in the management of these cases.

Anterior Mediastinal Lymphangioma in an Infant: Diagnosis and Surgical Management

2012-05-01

Cystic lymphangioma is a rare lesion of the mediastinum. We present a patient with an antenatally detected mediastinal mass that appeared to regress during foetal life and was not demonstrated on early postnatal imaging. Acute severe respiratory distress at two months of age precipitated surgery with subsequent diagnosis of lymphangioma.

Staged Management of a Primary Aortobronchial Fistula: A Novel Approach Using a Trapezius Flap Repair

Tam Nguyen, Paul Peters, Tim McGahan, Pallav Shah — 2012-05-01

There have been few reported cases of management of an aortobronchial fistula. We describe the case of a 68 year-old male with a very high operative risk who had a successful staged management of a primary aortobronchial fistula. An endovascular stent was placed initially, however due to recurrence of the fistula a second stent was deployed within the first one some three months after. Fifteen months later he represented with massive haemoptysis, severe cachexia and at this stage the best course of surgical management was thought to be lobectomy via thoracotomy followed by trapezius flap overlay covering the exposed stent and separating it from the remaining lung.

Cardiac Surgery and Heparin Induced Thrombocytopaenia (HIT): A Case Report and Short Review

W.J. McMeniman, R.B. Chard, J. Norrie, J. Posen — 2012-05-01

This patient presented for emergency cardiac surgery following two episodes of thrombocytopaenia, one before and one associated with exposure to unfractionated heparin in a seven-week period of intensive care management.Although the diagnosis of heparin induced thrombocytopaenia (HIT) was uncertain on clinical grounds when assessed by current criteria , the positive antibody status directed management in accordance with the internationally recognised guidelines published by the American College of Chest Physicians (ACCP) Evidence-based Clinical Practice Guidelines .An alternative anticoagulant to unfractionated heparin was indicated for cardiopulmonary bypass. Bivalirudin was selected because of recent literature supporting its safe use .

Type A Aortic Dissection Diagnosed at Coronary Angiography

B. Gray, B.P. Bailey, M.K. Wilson, S. Patel — 2012-05-01

A 64 year-old man presented with severe central chest pain with associated diaphoresis and palpitations with serial ECGs showing transient anterior ST elevation. He was transferred urgently to the cardiac catheterisation laboratory. It proved difficult to engage the left main coronary artery so an aortogram () was performed, revealing a type A aortic dissection with the catheter in the false lumen (a).

Multisite Arterial Thrombosis: Synchronous or Metachronous?

Haris M. Haqqani, Darryl J. Burstow, Darren L. Walters — 2012-05-01

A 35 year-old male smoker was evaluated after a delayed presentation with chest pain and lateral ST-segment elevation. Coronary angiography showed thrombotic occlusion of the first diagonal artery and no other coronary disease. Percutaneous intervention was not attempted in view of the late presentation and aspirin, clopidogrel and heparin were commenced. Troponin I level was 27.8μg/L and creatine kinase was 2528U/L. Transthoracic echocardiography confirmed lateral wall akinesis but also unexpectedly revealed a large (15mm×10mm) pedunculated echodense mobile mass in the distal aortic arch (Panel A, arrow) with a bright, focus seen at the base of its stalk. Computed tomography confirmed a ruptured calcified atheromatous plaque at this site (Panel B). Cardiac magnetic resonance sequences showed low T1 signal with no enhancement, consistent with a thrombotic aetiology (Panel C). Front-loaded alteplase (100mg) was infused without complication. Echocardiography at day 3 showed complete resolution of the mass at the site of the plaque (Panel D, arrow). Generalised inflammation of the vascular tree may have been responsible for both coronary and aortic plaque ruptures and subsequent multisite thrombus formation ().

Localised Ascending Aortic Dissection Managed Conservatively

2012-05-01

A 56 year-old lady presented with central chest pain and later pain in her right arm. She had stable haemodynamics. CT scan showed a small dissection flap in the ascending aorta 5cm proximal to innominate artery. Right upper limb images did not show any filling defect in brachial, radial and ulnar arterial flow. A repeat CT done next day showed no progression of her dissection but right upper limb images revealed a distal occlusion of brachial artery. She underwent a successful brachial embolectomy under local anaesthesia with a patch angioplasty. Her dissection was managed conservatively with strict blood pressure control. A further CT scan done on day 10 showed no evidence of dissection. Patient was asymptomatic at this stage and on good blood pressure control.

Repeat Percutaneous Treatment of a Large Vein Graft Aneurysm with Covered Stents

Timothy J. Glenie, Seif S. El-Jack — 2012-05-01

We present a case of repeat percutaneous intervention on a coronary artery bypass vein graft using polytetrafluoroethylene (PTFE) covered stents. The original intervention was performed using a combination of PTFE covered stents and bare metal stents for a large vein graft aneurysm. Successful exclusion of the aneurysm was demonstrated on follow up angiography. The patient represented six years after the original intervention with a non ST-segment elevation myocardial infarction. Further angiography demonstrated a recurrence of the aneurysm which we presumed to be due to late malapposition and required repeat PTFE covered stent deployment.

Heart Foundation

2012-05-01

The Cardiac Society of Australia and New Zealand

2012-05-01

Instructions to Authors

2012-05-01