Successful surgical repair of a giant left main coronary artery aneurysm with arteriovenous fistula draining into a persistent left superior vena cava and coronary sinus: role of intraoperative transesophageal echocardiography

We report the case of a 74-year-old woman with a history of hypertension, hypercholesterolemia, and pacemaker who presented to the hospital with new onset New York Heart Association class IV congestive heart failure. Transthoracic echocardiography revealed a markedly dilated right ventricle with normal right ventricular systolic function. There was moderate pulmonary hypertension with an estimated pulmonary artery systolic pressure of 60 mm Hg. Her echocardiogram 1 year earlier had demonstrated normal right ventricular size and systolic function, and no pulmonary hypertension. Additional transthoracic imaging with saline contrast study through a left peripheral vein demonstrated the presence of a dilated coronary sinus with a persistent left superior vena cava. Color Doppler demonstrated turbulent flow within the coronary sinus with evidence of significant left-to-right shunting. Cardiac catheterization revealed a massively dilated left main coronary artery aneurysm with an arteriovenous fistula into the left superior vena cava and coronary sinus. The calculated Qp/Qs was 2:1. The patient underwent 2 unsuccessful attempts at percutaneous intervention to occlude the arteriovenous fistula. She then underwent successful surgical closure of the coronary arteriovenous fistula. The important role of intraoperative transesophageal echocardiography in guiding this technically challenging surgical case is discussed.     

Surgical repair of candida mycotic pseudoaneurysm with extensive vegetations of the ascending aorta and pulmonary artery after heart and kidney transplant

We report a case of invasive candidiasis causing a mycotic pseudoaneurysm involving the ascending aorta and pulmonary artery. The patient presented two years after heart-kidney transplant with acute limb ischemia resulting from embolization of fungal vegetations. Operative findings included a pseudoaneurysm resulting from near-complete dehiscence of the aortic suture line, and large vegetations within the ascending aorta extended to the aortic arch and pulmonary artery, with localized dehiscence of the pulmonic suture line. The ascending aorta was replaced, and the pulmonary artery was repaired with bovine pericardium. The patient did well, and blood cultures were negative at 6 months follow-up.     

The mechanism of decrease in dynamic mitral regurgitation during heart failure treatment: importance of reduction in the regurgitant orifice size

Objectives. The purpose of this study was to quantify and characterize the regurgitant flow pattern and regurgitant orifice area in patients undergoing therapy for severe heart failure using contemporary echocardiographic techniques.

Background. Mitral regurgitation may be dynamic in patients with heart failure and ultimately correlate with outcome in a group of patients.

Methods. Fourteen patients with severe heart failure felt to require hemodynamic monitoring for the optimization of medical therapy were enrolled. Two-dimensional and Doppler echocardiograms were performed before and following invasively guided therapy. Hemodynamics and standard echocardiographic dimensions were determined as well as regurgitant volume and regurgitant orifice area derived from color M-mode and Doppler measurements.

Results. Invasively guided therapy for heart failure was associated with a reduction in weight, filling pressures of the left and right heart, systemic vascular resistance, and echocardiographic left atrial, left ventricular and mitral annular dimensions. The mitral regurgitant volume decreased from 47 ± 27 ml before therapy to 14 ± 14 ml after therapy; p < 0.001. While therapy for heart failure markedly attenuated the volume of regurgitation, the pattern of regurgitant flow across the mitral valve was not significantly altered. In contrast, there was no difference in the velocity time integral of the continuous-wave Doppler spectra of mitral regurgitation with therapy (128 ± 23 cm to 123 ± 25 cm, p = 0.23). In all patients, the regurgitant orifice area decreased with therapy from 0.55 ± 0.38 cm² to 0.21 ± 0.20 cm² (p < 0.001).

Conclusions. Pharmacologic reduction in filling pressure and systemic vascular resistance leads to a reduction in the dynamic mitral regurgitation of heart failure through a reduction in the regurgitant orifice area but not through a change in the gradient across the mitral valve. Reduction of the regurgitant orifice area is likely related to decreased left ventricular volumes and decreased annular distention.     

Does quantification of myocardial flow reserve using rubidium-82 positron emission tomography facilitate detection of multivessel coronary artery disease?

Background

Relative myocardial perfusion imaging (MPI) is the standard imaging approach for the diagnosis and prognostic work-up of coronary artery disease (CAD). However, this technique may underestimate the extent of disease in patients with 3-vessel CAD. Positron emission tomography (PET) is also able to quantify myocardial blood flow. Rubidium-82 (⁸²Rb) is a valid PET tracer alternative in centers that lack a cyclotron. The aim of this study was to assess whether assessment of myocardial flow reserve (MFR) measured with ⁸²Rb PET is an independent predictor of severe obstructive 3-vessel CAD.

Methods

We enrolled a cohort of 120 consecutive patients referred to a dipyridamole ⁸²Rb PET MPI for evaluation of ischemia neither with prior coronary artery bypass graft nor with recent percutaneous coronary intervention that also underwent coronary angiogram within 6?months of the PET study. Patients with and without 3-vessel CAD were compared.

Results

Among patients with severe 3-vessel CAD, MFR was globally reduced (<2) in 88% (22/25). On the adjusted logistic Cox model, MFR was an independent predictor of 3-vessel CAD [.5 unit decrease, HR: 2.1, 95% CI (1.2-3.8); P?=?.015]. The incremental value of ⁸²Rb MFR over the SSS was also shown by comparing the adjusted SSS models with and without ⁸²Rb MFR (P?=?.005).

Conclusion

⁸²Rb MFR is an independent predictor of 3-vessel CAD and provided added value to relative MPI. Clinical integration of this approach should be considered to enhance detection and risk assessment of patients with known or suspected CAD.