Transcatheter closure of left ventricular pseudoaneurysm

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction, cardiovascular surgery, trauma, or infection. Untreated left ventricular pseudoaneurysm can have significant morbidity and mortality. Surgical treatment has generally been the standard of care. However, with a sicker and older population, surgical risks can sometimes be significant. We report a case of successful percutaneous closure of left ventricular pseudoaneurysm using coils and a vascular plug. We emphasize the role and importance of multimodality imaging for accurate diagnosis and therapy, and briefly review the literature on the various approaches used for percutaneous closure of left ventricular pseudoaneurysms.     

Surgery for arrhythmias, myocardial infarction, pericardial disease, cardiac tumors, and trauma, and intraoperative echocardiography

This brief review highlights some of the advances made in selected areas of cardiac surgery over the past year, including surgery for arrhythmias, complications of myocardial infarction, pericardial disease, cardiac tumors, and trauma. In the treatment of arrhythmias, surgery for supraventricular arrhythmias and ventricular tachycardias is discussed, as is the role of the automatic implantable cardioverter-defibrillator in the surgical treatment of ventricular tachycardias. The usefulness of intraoperative echocardiography in evaluating valve disease, valve defects, and the results of surgical repair of atrioventricular septal defects is also discussed. The impact of these exciting developments can be expected to continue over the next several years.     

Acquired coronary fistula after left ventricular de-airing by apical needle aspiration.

Acquired coronary fistula is uncommon, but has been reported to occur after several surgical procedures, acute myocardial infarction, endomyocardial biopsy, coronary angioplasty, and thoracic trauma. We describe the occurrence of a left coronary to left ventricular cavity fistula following resection of a left atrial myxoma, with spontaneous closure in the following weeks. The fistula was likely caused by a needle inserted into the left ventricular apex, a procedure routinely used to ensure left ventricular de-airing.     

Novel approach for the percutaneous treatment of left ventricular pseudoaneurysms

Left ventricular pseudoaneurysm (LVPA) is a rare yet serious complication that may follow cardiac surgery, myocardial infarction, trauma, or infection. If left untreated, reported rates of rupture and sudden cardiac death are high. Although surgical intervention has traditionally been the standard treatment for LVPA, percutaneous closure is now an attractive alternative in the high‐risk patient. We report a case of a successful percutaneous LVPA closure using direct chest wall entry into the pseudoaneurysm. This novel approach can be useful when access to the LVPA is a challenge, especially in the setting of small ostial size, dense left ventricular trabeculations, angulated serpiginous tract, and presence of mechanical prostheses. © 2014 Wiley Periodicals, Inc.     

Pseudoaneurisma gigante da via de saída do ventrículo esquerdo: uma patologia rara

Pseudoaneurysm of the left ventricular outflow tract (LVOT) is a rare disease with high morbidity and mortality, resulting from left ventricular damage due to myocardial infarction, infective endocarditis or surgical trauma. A case of giant pseudoaneurysm of the LVOT, even more rarely reported in the literature, is described. The lesion was detected 12 years after aortic valve replacement for infective endocarditis in a young patient, a former intravenous drug user. As it is an uncommon disease, little is known about its clinical presentation and treatment.     

Broken bodies, broken hearts? Limitations of the trauma system as a model for regionalizing care for ST-elevation myocardial infarction in the United States

Many cardiovascular experts have called for the creation of specialized myocardial infarction centers and networks in the United States analogous to the current model for major trauma. Patients suffering ST-elevation myocardial infarction (STEMI) and trauma share an essential feature that makes the argument for regionalization persuasive: rapid triage and treatment by highly trained personnel improve survival in both conditions. Despite this similarity, however, the trauma system may be limited as a model for regionalizing STEMI care. First, the development of trauma systems has been hindered by the struggle for sufficient and stable funding, competing interests among individual stakeholders, and the overall lack of desire for state-sponsored healthcare planning in the United States. These same obstacles would need to be overcome if STEMI care is regionalized. Second, unique characteristics related to STEMI care, such as its varied clinical presentation and more lucrative reimbursement, will create new challenges. In this article, we briefly review the current status of trauma systems in the United States and describe why the regionalization of STEMI care may require different methods of healthcare organization.     

Post-traumatic pseudoaneurysm of the common hepatic artery with duodenal fistula

BackgroundPost-traumatic pseudoaneurysm of the hepatic artery is rare, especially after blunt abdominal trauma; an even more rare occurrence is enteric fistulisation.Case outlineA 29-year-old man was admitted with an acute episode of upper gastrointestinal bleeding three months after blunt abdominal trauma and was found to have an hepatic artery pseudoaneurysm with duodenal fistula. Surgical treatment was by ligature of the artery and duodenal closure with omental patch.DiscussionThere is one previous case report of hepatic artery pseudoaneurysm as a delayed complication of blunt abdominal trauma. The presence of a haematoma in the hepatoduodenal ligament after blunt trauma should raise the suspicion of hepatic artery injury, and surgical exploration may prevent the subsequent development of pseudoaneurysm. CT scan has become an important instrument both in diagnosis and in surgical planning.     

Myocardial Revascularization for the Elderly: Current Options, Role of Off-pump Coronary Artery Bypass Grafting and Outcomes

The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coronary artery bypass surgery in the elderly.     

New treatment strategies for hypertrophic obstructive cardiomyopathy: alcohol ablation of the septum: the new gold standard?

Hypertrophic cardiomyopathy is a primary myocardial disorder with an autosomal pattern of inheritance characterized by inappropriate myocardial hypertrophy. Annual mortality has been reported to be 1% to 2% and sudden death represents the most common cause. Treatment strategies are 1) medical therapy in patients with mild to moderate symptoms, 2) reduction of septal hypertrophy by surgical myectomy or alcohol ablation, and 3) implantation of an automatic cardioverter-defibrillator in the presence of non-sustained ventricular tachyarrhythmias. A debate has been started on whether surgical myectomy or alcohol ablation of the septum is the appropriate treatment for hypertrophic obstructive cardiomyopathy. Surgical (transaortic) myectomy has been the gold standard in the past 20 to 30 years for treatment of symptomatic patients with significant hemodynamic outflow tract obstruction. However, modern interventional technologies allow reduction of the myocardial septum by injection of alcohol into the first or second septal branch under guidance of two-dimensional (2D)-contrast echocardiography. This percutaneous technique not only has a lower morbidity than surgical myectomy but can be guided precisely by 2D echocardiography. One potential complication is transient (<30%) or permanent (<10%) atrioventricular block III; however, this complication is relatively rare. A randomized trial comparing the two treatment modalities is lacking, and the chance is small that such a trial will be performed because alcohol ablation can be done with high success and low complication rates, leaving only complex interventions (with valvular reconstructions and so on) for surgical myectomy.     

Coronary occlusion secondary to blunt chest trauma: a first attempt at balloon angioplasty

There have been only 58 angiographically documented reports of transmural myocardial infarction due to closed-chest trauma. None of these cases has been treated by percutaneous transluminal coronary angioplasty. We report the case of a 40-year-old man who developed an anterior-wall myocardial infarction secondary to blunt chest trauma suffered in an automobile accident. Angiographic study performed 2 months after the injury revealed an isolated total obstruction of the left anterior descending coronary artery. The patient was judged a good candidate for balloon angioplasty, but total reocclusion occurred within 24 hours of the procedure and a 2nd attempt did not restore patency. Surgical revascularization was performed a week later. A year after his injury, the patient remains asymptomatic and is back at work. Despite the failure of percutaneous transluminal coronary angioplasty in its 1st application to coronary artery repair after blunt chest trauma, we believe it to be the treatment of choice in young patients and in single-vessel disease.     

微创外科消融治疗心房颤动的进展

心房颤动是临床中最常见的心律失常之一,外科治疗心房颤动已有近30年的历史。近10年来,微创外科消融手术作为一种创伤小的、治愈率高的治疗手段在治疗心房颤动方面取得了长足的进展。心房线性消融和自主神经节消融的具体手术策略因尚无统一的标准术式而倍受关注;微创外科用于治疗心房颤动,在应用中也暴露了其自身的缺点和不足,也正因如此,近年来一些新的技术方法和创新理念被融入微创外科消融手术中来,并日渐加以改进和完善。相信伴随着手术方式的改良、手术设备的改进以及理念的创新,微创消融手术治疗心房颤动会不断拓展其手术适应证并会被更多的人接受。     

Transcatheter closure of ventricular septal defect: a nonsurgical approach to the care of the patient with acute ventricular septal rupture.

Acute ventricular septal rupture is a potentially fatal complication of myocardial infarction. In the past, surgical repair was the only treatment option for this life-threatening event. However, not all patients are good surgical candidates. Transcatheter closure of a ventricular septal defect (VSD) with a prosthesis called the Rashkind Patent Ductus Arteriosis Occluder System allows closure of the VSD without the possible complications associated with open-heart surgery. This treatment has potential as a temporary measure for patients awaiting surgical repair of VSD. Transcatheter closure may also be used as a permanent treatment for those patients considered to be poor surgical candidates. This case presentation addresses the use of a state-of-the-art nonsurgical approach to VSD closure. The focus is on the unique medical and nursing interventions used in caring for the patient suffering from a myocardial infarction complicated with postinfarction ventricular septal defect.     

Does Totally Endoscopic Access for Off-pump Cardiac Surgery Influence the Incidence of Postoperative Atrial Fibrillation in Coronary Artery Bypass Grafting? A Preliminary Report

Background The occurrence rate of atrial fibrillation (AF) after coronary artery bypass grafting, quoted in the literature, is wide ranging from 5% to over 40%. It is speculated that, off-pump coronary artery bypass grafting (OPCAB) and also minimally invasive cardiac surgery reduces the incidence of postoperative AF due to reduced trauma, ischemia, and inflammation. Current data, however, do not clearly answer the question, whether the incidence of postoperative AF is reduced in using minimally invasive techniques, ideally resulting in the combination of both small access and off-pump surgery. The aim of this study was to evaluate the incidence of postoperative AF in patients undergoing totally endoscopic off-pump coronary artery bypass grafting (TECAB).Methods A retrospective analysis of 72 patients undergoing myocardial revascularization was performed. Early postoperative incidence of AF was compared between three groups of patients: 24 after conventional coronary artery bypass grafting (CABG), 24 after OPCAB, and 24 after totally endoscopic off-pump CABG. Clinical profile of the patients, including factors having potential influence on postoperative AF was matched for groups.Results Postoperative AF occurred in 25% of the patients in the CABG group, in 16% of the patients in the OPCAB group, and in 16% of the patients in the TECAB group. This difference has no statistical significance. Risk factors and incidence of postoperative complications were comparable in all groups excepting the number of distal anastomoses. There was a statistical significance between CABG group and TECAB group.Conclusion Avoiding cardiopulmonary bypass and minimizing surgical trauma did not reduce the incidence of postoperative AF in this patient collective. It remains an attractive hypothesis that postoperative AF is reduced by off-pump myocardial revascularisation and minimizing surgical trauma but more robust data are required.     

晚期糖基化终产物引起老年小鼠创伤后继发心脏损伤加重的机制研究

目的 探讨衰老个体创伤后心肌损伤加重的机制,尤其是晚期糖基化终产物（AGEs）在其中发挥的作用。方法 C57雄性小鼠使用Noble-Collip创伤仪制备小鼠创伤模型。将成年C57小鼠（2月龄18只）和老年C57小鼠（20月龄18只）随机分为:非创伤组、创伤组、创伤干预组。采用彩色多普勒超声诊断仪检测左室射血分数(EF)和左室短轴缩短率(FS)。取心肌组织予Western blot检测磷酸化的AMP蛋白激酶（pAMPK）、AMP蛋白激酶（AMPK）、p16和p53 蛋白表达水平,使用ELISA 试剂盒检测血清可溶性晚期糖基化终产物受体（sRAGE）和羧甲基赖氨酸（CML）的水平。结果 与成年创伤小鼠对比,老年小鼠创伤后心肌损伤明显加重,表现为左室EF和左室FS显著减低（均P<0.01）。血MG-AGEs显著升高（P<0.05）以及AMPK活性下降（P<0.05）。预先采用sRAGE对AGEs进行干预,可显著改善老年小鼠创伤后心功能,表现为心肌AMPK活性显著提高（P<0.01）,心脏功能EF和FS值显著提高（P<0.01）。结论 衰老个体创伤后心肌损伤加重的机制与MG-AGEs系统有关,该系统可能是提高老年个体临床救治的有效靶点之一。     

Current status of MIDCAB procedure

The advent of cardiopulmonary bypass in the early 1960s allowed surgeons to safely perform complex reconstructions on the heart. Since then, the field of cardiac surgery has progressed to where surgical myocardial revascularization, or coronary artery bypass grafting (CABG), has become the most exhaustively studied operation in the history of surgery, and it has achieved widespread use because its benefits have been so thoroughly documented. The paradoxical fact is that more elderly and debilitated patients benefit the most from cardiac surgery compared with medical therapy, yet they sustain greater risk of morbidity and mortality after cardiac surgery. Most of the recent innovations and refinements in the treatment of coronary artery disease aim toward reduction of trauma without deviating much from the safety and efficacy of the conventional procedures. As a consequence, a greater number of high-risk elderly patients have become candidates for coronary artery bypass grafting (CABG). All of the amendments are caused by changing clinical scenarios brought on by an increased number of aging patients, a greater number of patients requiring re-operations, cost containment, increased discernment about outcome assessment, and also the dominance of coronary bypass being threatened by the success of interventional cardiology.     

Penetrating Nail-Gun Injury of the Heart Managed by Adenosine-Induced Asystole in the Absence of a Heart-Lung Machine

During his work, an 18-year-old carpenter-in-training overbalanced and shot himself in the left median thorax with a nail gun. The patient was delivered to our thoracic surgery unit with a tentative diagnosis of penetrating lung trauma. An emergent computed tomogram showed a heart-penetrating nail injury. The patient was taken to the operating room, where he underwent emergency surgery that included sternotomy, pericardiotomy, extraction of the nail, and trauma treatment of the heart injury. The surgery was performed in a unit without a heart-lung machine. For that reason, asystole was chemically induced by the intravenous administration of adenosine. The surgery was successful, and the patient was discharged from the hospital on the 10th postoperative day.In cases of penetrating injuries of the heart, especially those with a foreign body retained in situ, we believe that the intravenous administration of adenosine is an elegant solution for the rapid provocation of asystole. In contrast to other methods, adenosine-induced asystole enables relatively safe myocardial manipulation in the absence of a cardiac surgical unit and a heart-lung machine.     

Role of catheter and surgical ablation in congenital heart disease

The role of surgery and radiofrequency current ablation for the treatment of tachycardias in patients with congenital heart disease The use of radiofrequency current application as a treatment strategy has stimulated a revolution in our understanding of tachycardia mechanisms. The extension of its use to patients with congenital heart defects and tachyarrhythmias has opened the door to new treatments with known success rates and known risks for mortality and morbidity. Antiarrhythmic surgery aims to dissect or excavate a responsible substrate and is especially worth considering if cardiac surgery is being undertaken for other reasons. With suitable surgical skill and interest, and with strong electrophysiologic support, high success rates have been documented. Antiarrhythmic surgical incisions have the advantage of being visually controllable regarding the extent and location of damage to myocardial tissue. In other situations, radiofrequency current ablation is preferred because of its less-invasive character, its use of local anesthesia, and the avoidance of surgical trauma. Both surgery and catheter ablation require precise clarification of the tachycardia mechanism and precise localization of the underlying substrate. The importation of such techniques into the realm of open chest surgery would be difficult in light of the need for multiple intracardiac catheters and repeated fluoroscopically guided catheter positioning. Electrophysiologic studies performed during the antiarrhythmic surgical procedure cannot provide complete information, and their use is thus restricted to the arrhythmogenic myocardial target only [32,45]. In contrast, catheter-mediated electrophysiologic studies offer the option of exact diagnosis, precise substrate localization, and interventional treatment in a single session. Moreover, validation of the linear lesion's completeness has become a reliable predictor for mid- and long-term success in avoiding recurrences. As a result, the application of catheter-mediated ablation has exploded within the past 15 years. Antiarrhythmic surgery has survived as a discipline in a decreasing number of experienced hands [43,44]. As a result of recent experiences and modern technology, success rates above 90% [74-76, 81,88] for the interventional treatment of congenital tachycardias have become comparable to those reported in patients with "normal" hearts. For acquired tachycardias, acute success rates today range about 80% at the atrial level. The rate of recurrence is still relatively high at about 10-25% [73,76,77,79,91,96,102]. Further improvements are being pursued. Data on the treatment of acquired tachycardias at the ventricular level is largely anecdotal. Good early success rates are combined with a tendency to recurrence in longer-term follow-up [50,76,103-108]. Some of the late VT ablation recurrences may be explained by the fact that fibrotic, scarred, and hypertrophic myocardial tissue at the targeted site often prevents effective radiofrequency current application and lesion generation. In order to improve RF lesion depth and continuity, newly designed technologies for radiofrequency current ("cooled tip electrode", Cordis Webster, Baldwin Park, CA), and alternative energy sources (cryo-ablation, micro-wave, or ultrasound) are being readied for introduction in the very near future. For patients suffering from recurrent tachycardias and having other reasons for open-heart surgery, a hybrid concept can be created, utilizing modern 3-D electro-anatomical reconstruction as a basis for an electrophysiologically informed surgical procedure. Following such a concept, a hemodynamic catheterization can be combined with an electrophysiologic study to define critical myocardial zones for induced macro-re-entry tachycardias, or of those zones expected to play an arrhythmogenic role in the future. With such information, surgical incisions for cardiac access and repair can be planned and performed. The role of surgery in antiarrhythmic treatment can become preventive. Myocardial tissue is incised for cannulation and repair in a way that can reduce the chance of later scar-associated tachycardias [109]. The extension of surgical cuts to physiologic barriers of electrical conduction is a major strategy for the primary prevention of postsurgical or incisional arrhythmias. In addition, the simultaneous treatment at heart surgery of already existing tachycardias can be offered within the same session as a secondary preventive concept. Despite the immense growth of knowledge and experience in recent years, there is still a need for more knowledge about the factors causing arrhythmogenesis and their interactions. Prospective and randomized studies are needed to show the most effective strategies to prevent arrhythmia-mediated death. The future of antiarrhythmic treatment will less be directed by the limitations of current interventional tools, which will be improved, and more by an evolutionary process in philosophy regarding the understanding of arrhythmogenesis in these patients as the basis for new concepts of arrhythmia prevention and treatment.     

Gunshot wounds: causing myocardial infarction, delayed ventricular septal defect, and congestive heart failure

Penetrating chest trauma can cause a wide variety of cardiac injuries, including myocardial contusion, damage to the interventricular septum, laceration of the coronary arteries, and free-wall rupture. Herein, we describe the case of a 21-year-old man who presented with congestive heart failure, which was secondary to an old myocardial infarction and complicated by the delayed formation of a ventricular septal defect. All of these conditions were attributable to multiple gunshot wounds that the patient had sustained 6 months earlier. Left ventricular angiography showed an apical aneurysm; a large, muscular, ventricular septal defect; and 19 gunshot pellets in the chest wall. Three months after aneurysmectomy and surgical closure of the septal defect, the patient had recovered fully and was asymptomatic.This case reaffirms the fact that substantial cardiac injuries can appear months after chest trauma. The possibility of traumatic ventricular septal defect should be considered in all multiple-trauma patients who develop a new heart murmur, even when overt chest-wall injury is absent.     

New concepts in the pathophysiology of acute myocardial infarction

Recent findings concerning the pathophysiology of acute myocardial infarction are reviewed and related to the potential for myocardial salvage. The myocardial infarction process can be divided into 2 phases, an early evolving phase (the first 6 hours) and a later convalescent phase. An evolving infarction is associated with an occluded coronary artery; in most cases, a thrombotic occlusion occurs. The human coronary artery normally has an intact endothelium, which has protective vasodilatory and antiplatelet-aggregating effects that are lost when the endothelium is damaged. The endothelium is exquisitely sensitive to trauma and can be damaged by high shear stress produced by narrowing of the coronary arteries that is not associated with reduced coronary blood flow. In addition, during this acute endothelial damage, monocellular infiltration of the coronary arteries has the potential to release factors that may cause platelet aggregation, enhance blood coagulation, attract other white blood cells or exert other effects on the coronary tree. Myocardial damage occurring in the early evolving stage is usually responsive to treatment that either restores myocardial oxygen supply or reduces myocardial oxygen demand. However, coronary events occurring after the first 6 hours usually are not responsive to such treatment. Certain clinical variables may shorten or extend the time period within which damaged myocardium can be saved. The findings suggest important approaches for intervention to modify the acute phase.     

Combined percutaneous biosense-guided laser myocardial revascularization and coronary intervention.

Laser myocardial revascularization is a promising new treatment strategy for patients with severe ischemic heart disease who are not candidates for conventional percutaneous or surgical revascularization. The open chest surgical approach to transmyocardial revascularization has been approved by the FDA for the treatment of angina in inoperable patients, but has had limited use as a stand-alone procedure. More recently, use of fiber-optic catheters has made it possible to use a holmium:yttrium aluminum garnet laser to perform percutaneous catheter-based transmyocardial revascularization. To the extent that many patients have a combination of ischemic sources, some amenable to conventional revascularization and some not, combination or hybrid approaches have been considered. We report herein two patients with class IV angina who underwent laser myocardial revascularization using the Biosense system and complex percutaneous coronary intervention during the same procedure. Areas amenable to conventional percutaneous coronary intervention (PCI) were so treated, and viable but ischemic areas were supplied by totally occluded native vessels and bypass grafts underwent Biosense-guided laser myocardial revascularization (LMR). As the results of more controlled and blinded studies of laser myocardial revascularization become available (if results continue to be promising) and a better understanding of the mechanism of action of this treatment modality is achieved, LMR-PTCA hybrid will be performed in increasing frequency. However, even after establishing LMR efficacy, studies of LMR-PTCA hybrid should be conducted to determine the efficacy of this approach.