Severe cardiogenic shock due to acute onset of an aorto-to-right atrial shunt in a patient with aortic valve endocarditis

INTRODUCTION

Heart failure is the most common cause of death due to infective endocarditis. We report a case of a patient presenting with severe shock due to an infection-associated left-to-right cardiac shunt.

PRESENTATION OF CASE

A 62-year-old man, who underwent aortic valve replacement five years previously, was admitted to ICU due to acute hemodynamic deterioration. A few days earlier, he had a septic episode with blood cultures positive for Staphylococcus aureus and clinical features of infective endocarditis. In ICU, transthoracic echocardiography revealed shunting from the aortic root to the right atrium resulting in severe cardiogenic shock.

DISCUSSION

This case report describes a near fatal complication of infective endocarditis, detected by routine use of transthoracic echocardiography.

CONCLUSION

Our case outlines the relevance of early cardiac surgery strategies in patients with infective endocarditis and we briefly discuss the current literature.     

Ileocecal Valve Lipoma With Refractory Hemorrhage

Background:

Lipomas are the most common benign mesenchymal tumors of the gastrointestinal tract, with the colon being the most prevalent site. Intestinal lipomas are usually asymptomatic. Tumors >2 cm in diameter may occasionally cause nonspecific symptoms, including change in bowel habits, abdominal pain, or rectal bleeding, but with resection the prognosis is excellent. Herein, we describe the case of an elderly male who presented with painless hematochezia.

Methods:

Both colonoscopy and computed tomography of the abdomen and pelvis confirmed the presence of a mass near the ileocecal valve. Because of continuing bleeding, the patient required laparoscopic-assisted right hemicolectomy to resect the mass.

Results:

Both gross and microscopic pathology were consistent with lipoma at the ileocecal valve.

Conclusion:

Previous cases of ileocecal valve lipomas have been reported in the English literature, with the majority presenting as intussusception or volvulus. We present a rare case of an ulcerated ileocecal valve lipoma presenting as lower gastrointestinal bleeding that was treated successfully with laparoscopic resection.     

Ministernotomy for aortic valve replacement: a study of the preliminary experience.

Objective

The aim of the study was to evaluate the technical feasibility and the postoperative course of aortic valve replacement through a ministernotomy.

Setting

The Montreal Heart Institute and the Hôpital Lariboisière, Paris, France.

Design

A case series from 2 institutions.

Patients

Fifty-one patients who underwent aortic valve replacement through a ministernotomy. The sternal incision was started at the level of the sternal notch extending down to the third or fourth intercostal space with a transverse section of the sternum at this level on both sides or limited to the right side (inverted T or L incision). Thirty-nine patients had aortic stenoses, 6 patients were operated for aortic insufficiency and 6 had mixed disease. The mean (and standard deviation) preoperative left ventricular ejection fraction was 0.56 (0.17).

Main outcome measures

Cardiac bypass time, complications and outcome.

Results

The patients received Carbomedics and St. Jude mechanical valves, Hancock and Carpentier–Edwards bioprostheses. Thirty-eight patients were administered antegrade and retrograde cardioplegia, 10 patients ante-grade and 3 retrograde blood cardioplegia only. The mean (and standard error) cardiopulmonary bypass time and aortic cross-clamp time were 104 (38) minutes and 72 (16) minutes respectively. Two patients (4%) died and 2 patients (4%) showed evidence of a stroke after the procedure. Hospital stay averaged 8 (5) days.

Conclusion

We conclude that aortic valve replacement can be done through a ministernotomy approach with perioperative results similar to those obtained through a conventional sternotomy.     

Laparoscopic Management of Massive Hemobilia From an Intrahepatic Aneurysm

Background:

Intrahepatic arterial aneurysms are rare and typically related to trauma, transplantation, iatrogenic injury, or infection. They account for approximately 10% of clinically significant hemobilia.

Case Report:

We present the case of a 49-year-old man with an intraparenchymal hepatic artery aneurysm that presented as massive hemobilia following a laparoscopic cholecystectomy. The aneurysm could not be managed by interventional embolization and required a left hepatic lobectomy, which was performed laparoscopically.

Discussion:

Evaluation of hemobilia requires a multidisciplinary team approach. The diagnosis of hepatic artery aneurysm can be most readily made by MRI or CT scan. Interventional embolization of the aneurysm may be effective treatment but is not always possible due to anatomic considerations. Where indicated, surgical resection in a manner that preserves a maximal amount of normal hepatic parenchyma is the treatment of choice.

Conclusion:

This is the first report of laparoscopic liver resection performed for bleeding from a hepatic artery aneurysm and adds an effective treatment modality to the surgical armamentarium.     

Cardiac metastases and tumor embolization: A rare sequelae of primary undifferentiated liver sarcoma

INTRODUCTION

Primary hepatic sarcomas are uncommon malignant neoplasms; prognostic features, natural history, and optimal management of these tumors are not well characterized.

PRESENTATION OF CASE

This report describes the management of a 51-year-old patient that underwent a right trisectionectomy for a large hepatic mass found to be a liver sarcoma on pathology. He subsequently developed tumor emboli to his lungs and was discovered to have cardiac intracavitary metastases from his primary tumor. The patient underwent cardiopulmonary bypass and resection of the right-sided heart metastases to prevent further pulmonary sequela of tumor embolization.

DISCUSSION

The lack of distinguishing symptoms or imaging characteristics that clearly define hepatic sarcomas makes it challenging to achieve a diagnosis prior to pathologic examination. Metastatic spread is frequently to the lung or pleura, but very rarely seen within the heart. Failure to recognize cardiac metastatic disease will ultimately lead to progressive tumor embolization and cardiac failure if left untreated.

CONCLUSION

The most effective therapy for primary liver sarcomas is surgery; radical resection should be performed if possible given the aggressive nature of these tumors to progress and metastasize.     

The risk of cerebrovascular accident in patients with asymptomatic critical carotid artery stenosis who undergo open-heart surgery

Objective

To investigate whether the presence of asymptomatic critical carotid stenosis (ASCCS) increases the risk of perioperative stroke during open-heart surgery, which carries a well-established risk of cerebrovascular accidents.

Design

A case series.

Setting

A university-affiliated hospital that is a major referral centre for cardiovascular surgery.

Patients

Forty-six patients with ASCCS who underwent open-heart surgery between January 1992 and January 1996. Of this group, 27 had bilateral and 19 had unilateral critical carotid artery stenosis.

Interventions

Various cardiac procedures were performed on the 46 patients: 33 underwent coronary bypass grafting, 12 had valve replacement and 1 had heart transplantation.

Main outcome measure

Neurologic deficit.

Results

None of the patients had any perioperative neurologic deficit up to the date of discharge.

Conclusions

Cardiac procedures, without prior carotid artery surgery, can be done in patients with AS-CCS with no significant added risk of stroke. To achieve this, blood pressure should be kept stable intraoperatively, at slightly higher than normal pressure.     

Three Dimensional CT-based Virtual Patellar Resection in Female Patients Undergoing Total Knee Replacement: A Comparison between Tendon and Subchondral Method

Background

Due to its small size, variable shape, and lack of distinct anatomical landmarks, osteoarthritic knees make a precise patellar resection extremely difficult.

Methods

We performed virtual patellar resection with digital software using three dimensional computed tomography scans of knees from 49 patients who underwent primary total knee replacement at our hospital. We compared 2 commonly used resection methods, the tendon method (TM) and the subchondral method, to determine an ideal resection plane with respect to the symmetry and thickness of the patellar remnant.

Results

The TM gave a thicker resected patella, and a less oval cut surface shape, which gives better coverage for a domed prosthesis. Both methods, however, gave a symmetric resection both superior-inferiorly, as well as mediolaterally.

Conclusions

Although TM appears statistically better with respect to the thickness and cut surface shape, only further intraoperative studies with long-term clinical follow-up may provide us with the most appropriate patellar resection method.     

Right ventricular myxoma in a patient with tetralogy of Fallot

INTRODUCTION

Cardiac myxoma is the most common primary cardiac tumour in adulthood and may present in the context of Carney''s complex.

PRESENTATION OF CASE

A 32-year-old male with a history of repaired tetralogy of Fallot in childhood was admitted with severe pulmonary valve regurgitation and a mobile mass in the right ventricle. The patient underwent pulmonary valve replacement and mass excision. Pathology examination showed myxoma.

DISCUSSION

In the majority of cases myxomas originate in the atria, nevertheless they can also be found in a ventricular cavity. Myxoma is a prevalent feature of Carney''s complex, an inherited, autosomal disease, characterised by multiple tumours in several organs. Tetralogy of Fallot has also been described in association with Carney''s complex.

CONCLUSION

Coexistence of tetralogy of Fallot with a cardiac ventricular myxoma in a patient not affected from Carney''s complex or other familial syndrome.     

Hepatic angio-sarcoma: An unusual source of intra-hepatic bleeding

INTRODUCTION

Hepatic angio-sarcoma represents an uncommon malignant tumor of the liver with a poor prognosis and a high rate of bleeding complications.

PRESENTATION OF CASE

We report a case of hepatic angio-sarcoma with a multi-nodular pattern complicated by intra-hepatic bleeding. The diagnosis was performed by computed tomography (CT). Angiographic procedure was unsuccessfully attempted as a treatment option. Autoptic examination confirmed the vascular nature of the malignant tumor.

DISCUSSION

Hepatic angio-sarcoma represents the most common malignant mesenchymal tumor of the liver. The diagnosis is provided by the histological examination and by specific endothelial markers. However, CT examination allows to recognize the disease and to detect intra-abdominal bleeding occurring in one-fourth of cases. Surgical resection represents the only definitive treatment of hepatic angio-sarcoma. In case of haemoperitoneum, trans-catheter arterial embolization represents the primary procedure used to stop the acute arterial bleeding.

CONCLUSION

CT represents the reference technique for the diagnosis of hepatic angio-sarcoma and allows to recognize the intra-abdominal bleeding which represents its most common complication. This condition always requires an immediate therapeutic approach.     

Abnormal heart rate variability and atrial fibrillation after aortic surgery

Introduction

Complete denervation of transplanted heart exerts protective effect against postoperative atrial fibrillation; various degrees of autonomic denervation appear also after transection of ascending aorta during surgery for aortic aneurysm.

Objective

This study aimed to evaluate if the level of cardiac denervation obtained by resection of ascending aorta could exert any effect on postoperative atrial fibrillation incidence.

Methods

We retrospectively analysed the clinical records of 67 patients submitted to graft replacement of ascending aorta (group A) and 132 with aortic valve replacement (group B); all episodes of postoperative atrial fibrillation occurred during the 1-month follow-up have been reported. Heart Rate Variability parameters were obtained from a 24-h Holter recording; clinical, echocardiographic and treatment data were also evaluated.

Results

Overall, 45% of patients (group A 43%, group B 46%) presented at least one episode of postoperative atrial fibrillation. Older age (but not gender, abnormal glucose tolerance, ejection fraction, left atrial diameter) was correlated with incidence of postoperative atrial fibrillation. Only among a subgroup of patients with aortic transection and signs of greater autonomic derangement (heart rate variability parameters below the median and mean heart rate over the 75^th percentile), possibly indicating more profound autonomic denervation, a lower incidence of postoperative atrial fibrillation was observed (22% vs. 54%).

Conclusion

Transection of ascending aorta for repair of an aortic aneurysm did not confer any significant protective effect from postoperative atrial fibrillation in comparison to patients with intact ascending aorta. It could be speculated that a limited and heterogeneous cardiac denervation was produced by the intervention, creating an eletrophysiological substrate for the high incidence of postoperative atrial fibrillation observed.     

Long-term survival after hepatic cryosurgery versus surgical resection for metastatic colorectal carcinoma: a critical review of the literature

Objective

To critically assess the evidence for long-term survival after hepatic resection and hepatic cryosurgery for metastatic colorectal cancer. The purpose of this review is to determine if a randomized controlled trial comparing these two treatment modalities is justified.

Data sources

A review of the medical literature from 1973 to 1995 using the MEDLINE and CAN-CERLIT databases. References were also retrieved from the bibliographies of identified articles and from experts in the field of hepatobiliary and pancreatic surgery.

Study selection

One hundred and seventy-eight studies were reviewed. Studies presenting original data on the results of hepatic resection or cryotherapy for colorectal liver metastases were selected. Studies were excluded if they did not present survival data longer than 2 years. Studies pertaining to resection for fewer than 60 patients with colorectal metastases to the liver were excluded.

Data extraction

Data forms were designed before studies were examined in detail. All studies that met the inclusion and exclusion criteria were reviewed and the identified data extracted and tabulated.

Data synthesis

No controlled studies were identified, only case series. Four reports on hepatic cryosurgery and 9 on hepatic resection met the study criteria. The cryosurgery studies were methodologically poor; the resection studies were larger and more methodologically sound. The median follow-up for cryosurgery ranged from 12 to 28.8 months, that for resection 21 to 69 months. There is clear evidence that hepatic cryosurgery has a role in the management of selected patients with colorectal metastases to the liver. However, valid conclusions cannot be made about the 5-year survival rate. The results of the studies on hepatic resection in patients with colorectal metastases to the liver have greater validity and consistency, with 5-year survival rates of 20% to 40%.

Conclusions

Although hepatic cryosurgery offers some unequivocal and other potential advantages over surgical resection for colorectal metastases to the liver, the published data do not support its use in patients with resectable disease outside a clinical trial, and do not yet justify a randomized trial. A study that collects prospective data on 2 groups of patients (resectable v. unresectable) who differ only in the anatomic location of their metastases within the liver is needed.     

Surgical treatment of aortic valve endocarditis: a 26-year experience

Objective

We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years.

Methods

From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.

Results

Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.

Conclusion

Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.     

A rare case of extensive diffuse nonpigmented villonodular synovitis as a cause of total knee arthroplasty failure

INTRODUCTION

Nonpigmented villonodular synovitis (non-PVNS) is a benign proliferative disease involving the synovium. It is a rare condition that is little recognized. Non-PVNS has been reported as a cause of total knee replacement failure.

PRESENTATION OF CASE

We report a case of extensive diffuse non-PVNS in a patient with tibial component loosening after total knee replacement and review the related literature.

DISCUSSION

It is reported that pigmented villonodular synovitis (PVNS) occurs less frequently than non-PVNS after knee replacement. However, there are many more case reports of PVNS than non-PVNS after knee arthroplasty in the English-language literature.

CONCLUSION

Previously, there were no reported cases of extensive diffuse non-PVNS after total knee arthroplasty (TKA). This case study highlights an unusual case of non-PVNS as a cause of TKA failure. We propose that non-PVNS should be considered as a differential diagnosis in patients after TKA who present with recurrent pain and effusion/hemarthrosis of the knee, and that it is one of the causes of implant loosening after TKA.     

Influence of valve prosthesis type on early mortality in patients undergoing valve surgery

Objective

To evaluate the influence of the type of prosthesis in-hospital mortality in the post-operative period in patients who had valve replacement.

Methods

A cross-sectional data, such as gender, origin, age, etiology, echocardiograph data, the type of surgery performed and the prosthesis used in cases of valve replacement were analyzed retrospectively.

Results

We reviewed 353 charts of patients who underwent valve replacement surgery. The mean age was 41.87±17.9 years. Regarding gender, 52.8% were female. As for the origin, 61.1% came from small cities within the state. Of all patients, 58.5% suffered from rheumatic disease. Assessing the type of prosthesis implanted, 70% held replace by bioprosthesis and 30% metallic. The hospital mortality in this study was 11%, with no significant difference between the types of prosthesis utilized.

Conclusion

The type of implant used had no effect on in-hospital mortality.     

Renal pelvis squamous cell carcinoma with inferior vena cava infiltration: Case report and review of the literature

INTRODUCTION

Renal squamous cell carcinoma (RSCC) is a rare tumor that is usually diagnosed late as a locally advanced malignancy with adjacent structure involvement. Radical surgical resection with negative margins is the mainstay of treatment, as it is correlated with improved survival, while other modalities of treatment have been shown to have limited efficacy.

PRESENTATION OF CASE

We report a case of a 56 year old gentleman with right RSCC with tumor encasing the inferior vena cava (IVC), treated successfully with surgical resection.

DISCUSSION

The surgical management of vascular involvement of similar tumors has not been discussed in-depth in the literature. Surgical resection of the IVC without reconstruction can be done successfully in the circumstance of good collateral circulation; otherwise IVC resection with reconstruction will be necessary.

CONCLUSION

Radical resection with clear margins of RSCC tumors with vascular involvement is feasible in selected circumstances.     

Retroperitoneal lymph node dissection for metastatic germ cell tumours

INTRODUCTION

In the North Trent Cancer Network (NTCN) patients requiring retroperitoneal lymphadenectomy for metastatic testicular cancer have been treated by vascular service since 1990. This paper reviews our experience and considers the case for involvement of vascular surgeons in the management of these tumours.

PATIENTS AND METHODS

Patients referred by the NTCN to the vascular service for retroperitoneal lymphadenectomy between 1990 and 2009 were identified through a germ cell database. Data were supplemented by a review of case notes to record histology, intraoperative and postoperative details.

RESULTS

A total of 64 patients were referred to the vascular service for retroperitoneal lymph node dissection, with a median age of 29 years (16–63 years) and a median follow-up of 4.9 years. Ten patients died: eight from tumour recurrence, one from septicaemia during chemotherapy and one by suicide. Of the 54 who survived, 7 were alive with residual masses and 47 patients were disease-free at the last follow-up. Sixteen patients required vascular procedures: four had aortic repair (fascia), three had aortic replacement (spiral graft), four had inferior vena cava resection, two had iliac artery replacement and two had iliac vein resection.

CONCLUSIONS

Retroperitoneal lymph node dissection often involves mobilisation and/or the resection/replacement of major vessels. We recommend that a vascular surgeon should be a part of testicular germ cell multidisciplinary team.     

Survival after hepatic resection: impact of surgeon training on long-term outcome

Background

Mortality for liver resection has remarkably improved owing to multiple factors. We sought to determine the impact of the various types of fellowship training on patient survival after liver resection.

Methods

Patients who underwent hepatic resection between 1995 and 2004 in either the Calgary or Capital health regions (Edmonton) of Alberta, Canada, were identified using ICD-9 and -10 codes. Primary outcomes included in-hospital mortality and patient survival according to surgeon volume and training type (surgical oncology v. hepatobiliary v. others).

Results

A total of 1033 patients underwent hepatic resection. Surgeon volume was not predictive of either in-hospital mortality (adjusted odds ratio 0.63, 95% confidence interval [CI] 0.32–1.20) or patient survival (unadjusted hazard ratio 1.11, 95% CI 0.82–1.51). Nonsignificance was also demonstrated for a surgeon’s type of fellowship training.

Conclusion

The various modes of fellowship training do not appear to influence inhospital mortality or patient survival after hepatic resection.     

Urological vignette: Satellite lesion in the bladder from urachal enteric adenocarcinoma

INTRODUCTION

We present, to the best of our knowledge, the first published case report of a satellite lesion within the bladder from enteric type urachal adenocarcinoma (UA).

PRESENTATION OF CASE

Our case report involves a 38-year-old man from the Solomon Islands who underwent open partial cystectomy for UA. However, resection margins were positive due to the novel finding of a satellite lesion on histopathological assessment. Salvage cystectomy was subsequently performed and the patient had an uncomplicated post-operative recovery.

DISCUSSION

This case highlights the importance of achieving negative soft tissue and bladder margins on initial resection of UA, as the consequences of incomplete resection can place significant additional morbidity on the patient.

CONCLUSION

We aim to highlight the possibility of satellite lesions within the bladder in UA and suggest that further studies looking at this phenomenon are required to establish its incidence and overall impact on management of UA.     

Analysis of steps adapted protocol in cardiac rehabilitation in the hospital phase

Objective

To analyze a cardiac rehabilitation adapted protocol in physical therapy during the postoperative hospital phase of cardiac surgery in a service of high complexity, in aspects regarded to complications and mortality prevalence and hospitalization days.

Methods

This is an observational cross-sectional, retrospective and analytical study performed by investigating 99 patients who underwent cardiac surgery for coronary artery bypass graft, heart valve replacement or a combination of both. Step program adapted for rehabilitation after cardiac surgery was analyzed under the command of the physiotherapy professional team.

Results

In average, a patient stays for two days in the Intensive Care Unit and three to four days in the hospital room, totalizing six days of hospitalization. Fatalities occurred in a higher percentage during hospitalization (5.1%) and up to two years period (8.6%) when compared to 30 days after hospital discharge (1.1%). Among the postoperative complications, the hemodynamic (63.4%) and respiratory (42.6%) were the most prevalent. 36-42% of complications occurred between the immediate postoperative period and the second postoperative day. The hospital discharge started from the fifth postoperative day. We can observe that in each following day, the patients are evolving in achieving the Steps, where Step 3 was the most used during the rehabilitation phase I.

Conclusion

This evolution program by steps can to guide the physical rehabilitation at the hospital in patients after cardiac surgery.