Infected Cardiac Myxoma: an Updated Review

OBJECTIVE

This study aims to present an updated clinical picture of the infected cardiac myxoma. Revankar & Clark made a systematic review of infected cardiac myxoma based on the literature before 1998. Since then, there has not been any updated information describing its recent changing trends.

METHODS

A comprehensive literature search of infected cardiac myxoma was conducted on MEDLINE, Highwire Press and Google between 1998 and 2014.

RESULTS

In comparison with Revankar & Clark''s series, the present series disclosed a significantly decreased overall mortality. It is believed that refinement of the prompt diagnosis and timely management (use of sensitive antibiotics and surgical resection of the infected myxoma) have resulted in better outcomes of such patients.

CONCLUSION

The present series of infected cardiac myxoma illustrated some aggravated clinical manifestations (relative more occasions of high-grade fever, multiple embolic events and the presence of refractory microorganisms), which should draw enough attention to careful diagnosis and treatment. In general, the prognosis of infected cardiac myxoma is relatively benign and the long-term survival is always promising.     

Cardiac myxoma in pregnancy: a comprehensive review

Objective

Cardiac myxoma in pregnancy is rare and the clinical characteristics of this entity have been insufficiently elucidated. This article aims to describe the treatment options and the risk factors responsible for the maternal and feto-neonatal prognoses.

Methods

A comprehensive search of the literature of cardiac myxoma in pregnancy was conducted and 44 articles with 51 patients were included in the present review.

Results

Transthoracic echocardiography was the most common diagnostic tool for the diagnosis of cardiac myxoma during pregnancy. Cardiac myxoma resection was performed in 95.9% (47/49); while no surgical resection was performed in 4.1% (2/49) patients (P=0.000). More patients had an isolated cardiac myxoma resection in comparison to those with a concurrent or staged additional cardiac operation [87.2% (41/47) vs. 12.8% (6/47), P=0.000]. A voluntary termination of the pregnancy was done in 7 (13.7%) cases. In the remaining 31 (60.8%) pregnant patients, cesarean section was the most common delivery mode representing 61.3% and vaginal delivery was more common accounting for 19.4%. Cardiac surgery was performed in the first, second and third trimester in 5 (13.9%), 14 (38.9%) and 17 (47.2%) patients, respectively. No patients died. In the delivery group, 20 (76.9%) neonates were event-free survivals, 4 (15.4%) were complicated and 2 (7.7%) died. Neonatal prognoses did not differ between the delivery modes, treatment options, timing of cardiac surgery and sequence of cardiac myxoma resection in relation to delivery.

Conclusion

The diagnosis of cardiac myxoma in pregnancy is important. Surgical treatment of cardiac myxoma in the pregnant patients has brought about favorable maternal and feto-neonatal outcomes in the delivery group, which might be attributable to the shorter operation duration and non-emergency nature of the surgical intervention. Proper timing of cardiac surgery and improved cardiopulmonary bypass conditions may result in even better maternal and feto-neonatal survivals.     

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.     

Simultaneous liver resection and double cardiac valve replacement. A case report

INTRODUCTION

We present a rare case in which both a double cardiac valve replacement was performed as well as a hepatic resection.

PRESENTATION OF CASE

We report the case of a 36 year old patient who presented with intra abdominal bleeding thought to have been caused by a liver haemangioma she also had severe autoimmune cardiac valve disease. She underwent a simultaneous right hepatectomy with cardiac valve replacement.

DISCUSSION

Management of this challenging case is discussed.

CONCLUSION

We advocate the possibility of performing combined operations where both valve replacement and hepatic resection is required.     

A giant right atrial villous myxoma with simultaneous pulmonary embolism

INTRODUCTION

Primary cardiac tumors are rare and approximately three quarters of them are benign and up to half of the benign tumors are myxomas. Right atrial villous myxoma with pulmonary embolism is an unusual apparition.

PRESENTATION OF CASE

A 29 year-old male was admitted to our outpatient clinic with progressive exertional dyspnea, chest pain and intermittent feeling faint. A giant right atrial villous mobile mass was detected by means of transthoracic echocardiography. To exclude possible pulmonary embolism, chest computed tomography scan was performed and showed filling defects in the branch of the pulmonary artery. The mass was totally resected.

DISCUSSION

RA villous myxoma is a rare subtype in an unusual location with high potential of pulmonary embolism. Early surgery for villous myxoma has a great importance in order to reduce the risk of pulmonary embolism.

CONCLUSION

3D TEE should be a sufficient technique for diagnosis and evoluation of shape, size and origin of the cardiac mass an adequate guide to surgical treatment.     

Small-bowel resection for metastatic melanoma

Objective

To determine whether complete resection of small-bowel metastases from melanoma improves patient survival.

Design

A computer-aided chart review.

Setting

Hospitals associated with McGill University.

Patients

Twenty patients (17 men, 3 women), identified from 1524 patients with melanoma, who underwent surgery to the small bowel for metastases. Patient age and clinical presentation, tumour site and stage were recorded.

Intervention

Exploratory laparotomy with complete or partial resection of involved small bowel.

Main Outcome Measures

Operative morbidity, mortality and length of survival related to the extent of small-bowel resection.

Results

Eleven patients had complete resection, 8 patients had partial resection and 1 patient had a palliative bypass only. Long-term survival (ranging from 2 to 10 years) was 36% in those who had complete resection and 0% in those who had partial resection; operative morbidity and mortality were 20% and 15% respectively.

Conclusion

Complete resection of small-bowel metastases in patients with metastatic melanoma can result in long-term survival.     

Adaptive Cerebral Neovascularization in a Model of Type 2 Diabetes: Relevance to Focal Cerebral Ischemia

OBJECTIVE

The effect of diabetes on neovascularization varies between different organ systems. While excessive angiogenesis complicates diabetic retinopathy, impaired neovascularization contributes to coronary and peripheral complications of diabetes. However, how diabetes influences cerebral neovascularization is not clear. Our aim was to determine diabetes-mediated changes in the cerebrovasculature and its impact on the short-term outcome of cerebral ischemia.

RESEARCH DESIGN AND METHODS

Angiogenesis (capillary density) and arteriogenesis (number of collaterals and intratree anostomoses) were determined as indexes of neovascularization in the brain of control and type 2 diabetic Goto-Kakizaki (GK) rats. The infarct volume, edema, hemorrhagic transformation, and short-term neurological outcome were assessed after permanent middle–cerebral artery occlusion (MCAO).

RESULTS

The number of collaterals between middle and anterior cerebral arteries, the anastomoses within middle–cerebral artery trees, the vessel density, and the level of brain-derived neurotrophic factor were increased in diabetes. Cerebrovascular permeability, matrix metalloproteinase (MMP)-9 protein level, and total MMP activity were augmented while occludin was decreased in isolated cerebrovessels of the GK group. Following permanent MCAO, infarct size was smaller, edema was greater, and there was no macroscopic hemorrhagic transformation in GK rats.

CONCLUSIONS

The augmented neovascularization in the GK model includes both angiogenesis and arteriogenesis. While adaptive arteriogenesis of the pial vessels and angiogenesis at the capillary level may contribute to smaller infarction, changes in the tight junction proteins may lead to the greater edema following cerebral ischemia in diabetes.Type 2 diabetic patients hold two- to fourfold higher risk for cerebrovascular disease and stroke (1,2), and 70% of patients with a recent stroke have overt diabetes or pre-diabetes distinguished by impaired fasting glucose or impaired glucose tolerance (3). However, the underlying basis of this increased risk remains unclear. Diabetic vascular complications are well studied in diabetic retinopathy, nephropathy, peripheral arterial disease, and coronary artery disease. However, diabetes-induced structural and functional changes in the cerebral vasculature are unknown.It is becoming clear that the integrity of cerebral blood vessels is critical in the pathophysiology of stroke. While type 2 diabetes accounts for ∼90–95% of all diagnosed cases of diabetes in adult patients, most of the experimental studies are focused on type 1 diabetes induced by streptozotocin (STZ) injection, which is associated with high-level and short-term elevations of blood glucose. We have recently shown that diabetic Goto-Kakizaki (GK) rats develop smaller infarct and greater hemorrhagic transformation after stroke. These animals also showed cerebrovascular remodeling characterized by increased vessel tortuosity, vascular endothelial growth factor (VEGF) expression, and matrix metalloproteinase (MMP)-2 and -9 activity (4). Generated from glucose-intolerant Wistar rats, GK rat is a nonobese model of spontaneous type 2 diabetes with moderately elevated glucose levels (5,6). In light of previous reports that showed greater ischemic damage in acute hyperglycemic models of stroke (7–9), we hypothesized that chronic moderate hyperglycemia as seen in the GK model promotes neovascularization that affects the extent of ischemic injury. Considering that neovascularization may originate from new vessel formation as well as functional remodeling of existing vessels, the goals of the current study were 1) to determine the effect of diabetes on capillary density and arteriogenesis, 2) to determine the influence of diabetes on blood-brain barrier (BBB) baseline permeability and expression of proteins important for vascular integrity, and finally 3) to evaluate the effect of ischemic injury on infarct and hemorrhagic transformation development in diabetic rats with preexisting vascular disease, all of which may impact the outcome of ischemic injury.     

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.     

Posterior Wall Gastric Leiomyoma: Endoscopic Tattooing Facilitates Laparoscopic Resection

Objective:

To demonstrate the application of tattooing for the intraoperative localization of posterior wall gastric leiomyoma during laparoscopic resection. The preoperative injection of Indian ink in the tumor-bearing area of the posterior gastric wall eliminates the need to perform anterior wall gastrostomy or intraoperative upper endoscopic tumor localization.

Methods:

A patient with posterior wall gastric leiomyoma was marked with Indian ink during preoperative upper endoscopy. The dye was visualized intraoperatively facilitating wedge resection of the tumor-bearing area with the Endo GIA.

Results:

The patient had an uneventful surgery and recovery. Complete excision of the tumor was accomplished.

Conclusion:

The preoperative endoscopic marking of gastric lesions, facilitates the intraoperative localization and resection of these lesions.     

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.     

Laparoscopic Resection of Giant Adrenal Cavernous Hemangioma

Background:

Large adrenal tumors were initially believed to be a relative contraindication to laparoscopic adrenalectomy.

Methods:

Here we discuss the case of a 42-year-old female with a 12-cm adrenal mass.

Results:

The patient underwent successful laparoscopic resection, and pathology revealed a cavernous hemangioma, a rare benign tumor of the adrenal gland.

Conclusion:

The following is a discussion of the case, laparoscopic resection technique, and brief review of adrenal hemangiomas. In experienced hands, adrenal mass size should not be considered a contraindication to laparoscopic intervention.     

Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery

INTRODUCTION

There is no clear guidance as to the management of carotid stenotic disease prior to cardiac surgery. We aimed to review the results of a single centre performing carotid endarterectomy (CEA) under local anaesthesia prior to cardiac surgery.

PATIENTS AND METHODS

All patients referred for cardiac surgery in our tertiary referral unit between January 1998 and August 2008 were identified and data relating to those 100 undergoing CEA prior to cardiac surgery were reviewed. Eighty had coronary artery bypass grafting (CABG) alone, 15 combined valve surgery and CABG and three underwent isolated valve surgery. Two patients died prior to cardiac surgery.

RESULTS

One hundred patients were prospectively identified after screening by clinical features and carotid duplex scanning to require CEA from a total of 11,394. The stroke rate was 1% between CEA and cardiac surgery, 2% following cardiac surgery and 3% in total. Ninety-eight patients proceeded to cardiac surgery (two deaths post-CEA). The cumulative event rate (stroke, myocardial infarct [included in view of the nature of the patients in our cohort] and/or death) was 10.2% following all cardiac surgery (CABG and valve). In 80 patients undergoing CABG only, the cumulative event rate was 7.5% after CABG. Including the two deaths pre-cardiac surgery, the rates were 12% and 8%. The risk of peri-operative stroke and 30-day mortality were reduced to that of patients undergoing cardiac surgery without significant carotid arterial disease, 3% versus 3.3% and 5.1% versus 6.5%, respectively.

CONCLUSIONS

This study demonstrates that a policy of selective screening for significant carotid artery disease in cardiac surgical patients combined with a strategy of CEA under local anaesthesia prior to unselected cardiac surgery (CABG with or without valve surgery) leads to rates of peri-operative CVA, myocardial infarction and death comparable to rates published for CEA prior to isolated CABG surgery. Furthermore, it reduces the risk of peri-operative stroke and 30-day mortality to that observed in patients undergoing cardiac surgery without significant carotid arterial disease.     

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.     

Spontaneous spinal epidural hematoma with hemiparesis mimicking acute cerebral infarction: two case reports

Context

Acute hemiparesis is a common initial presentation of ischemic stroke. Although hemiparesis due to spontaneous spinal epidural hematoma (SSEH) is an uncommon symptom, a few cases have been reported and misdiagnosed as cerebral infarction.

Design

Case reports of SSEH with acute hemiparesis.

Findings

In these two cases, acute stroke was suspected initially and administration of intravenous alteplase therapy was considered. In one case, the presentation was neck pain and in the other case, it was Lhermitte''s sign; brain magnetic resonance imaging (MRI) and magnetic resonance angiography were negative for signs of ischemic infarction, hemorrhage, or arterial dissection. Cervical MRI was performed and demonstrated SSEH.

Conclusion

Clinicians who perform intravenous thrombolytic treatment with alteplase need to be aware of this possible contraindication.     

Is prophylactic resection valid as an indication for elective surgery in diverticular disease?

Objective

To determine whether interval resection in asymptomatic patients after 1 or 2 episodes of acute diverticulitis (prophylactic resection) is justified as a means of preventing late inflammatory complications of diverticular disease.

Design

A retrospective analysis.

Setting

A university-affiliated tertiary care hospital.

Patients

Those requiring hospitalization from 1987 to 1995 for treatment of acquired diverticular disease of the colon. Twenty-eight patients underwent elective resection and 154 were treated for inflammatory complications (perforation, fistula, complete large-bowel obstruction).

Interventions

Standard surgical management for diverticular disease, but only 3 prophylactic resections were undertaken during this period.

Outcome measures

Type of operation, stoma creation and closure, hospital death. In those treated for complicated disease, the effects on outcome of all previous outpatient treatment and hospitalizations.

Results

Only 10% of those presenting with complications had been treated conservatively for acute diverticulitis and only 5% had been hospitalized for this reason.

Conclusions

Prophylactic resection is unlikely to prevent late major complications of diverticular disease; therefore, as an elective indication for surgery in this disease its use is questionable.     

Indications for intensive care unit care after carotid endarterectomy

Objectives

To describe the complications of carotid endarterectomy and the interventions performed in the intensive care unit (ICU) after carotid endarterectomy. To identify preoperative and recovery room (RR) risk markers for these complications and interventions.

Design

A retrospective case study.

Setting

The ICU of a university hospital.

Patients

One hundred and one patients who required carotid endarterectomy over a 15-month period.

Intervention

Carotid endarterectomy (bilateral procedures in 11 patients).

Outcome Measures

Demographic data including Goldman’s cardiac risk index and the therapeutic intervention scoring system (TISS) score to measure the risk of complications.

Results

Most of interventions conducted in the RR and ICU were to control high blood pressure. In the RR, three patients experienced a neurologic event, one patient was reintubated for vocal cord paralysis and one had electrocardiographic abnormalities. Overall, 5 of the 101 patients had neurologic complications and 2 suffered a myocardial infarction. Two patients died, one as a result of a massive stroke and the other of myocardial infarction with cardiogenic shock. The mean (and standard deviation ) TISS score in the ICU was 12.6 (3.8). Analysis of all events in the RR was not predictive of events in the ICU. However, the absence of major complications in the RR had a negative predictive value of 97%.

Conclusions

The decision to admit patients to the ICU after carotid endarterectomy should be based on major complications occurring in the RR. A low TISS score and low incidence of complications does not warrant routine admission.     

Salpingo-ureteric fistula—A rare complication following laparoscopic surgery for colorectal cancer: A case report and literature review

INTRODUCTION

We report the management and outcome of the case of a 57-year old woman with adenocarcinoma of the rectum. Following neo-adjuvant chemo-radiotherapy and laparoscopic-assisted anterior resection of her tumour she developed a right salpingo-ureteric fistula.

PRESENTATION OF CASE

Three weeks following laparoscopic anterior resection of the tumour she presented with urinary frequency and incontinence. A ureteric stent was inserted and left in-situ for five months but the fistula did not heal. The patient underwent exploration and open repair of the salpingo-ureteric fistula which resolved her symptoms.

DISCUSSION

There have not been many reported cases in the literature of salpingo-ureteric fistulae but after initial trial of management with ureteric stents all eventually required open exploration and repair.

CONCLUSION

we advocate open repair of salpingo-ureteric fistulae as the definitive management following intra-operative injury.