Category: Case Study

A 49-year-old male, known case of hypertension, hyperlipidemia and diabetes mellitus, presented with history of unstable angina. Transthoracic echocardiogram showed left atrial myxoma. His coronary angiogram showed critical left main stenosis with triple vessel disease. There was total occlusion of LAD and first diagonal 1. He was referred for an emergency cardiac surgery.

Surgical Procedure

Under cardiopulmonary bypass and cardioplegic arrest, left atrial myxoma was excised and removed in toto through biatrial approach. Left atrial myxoma was 7 cm x 3 cm in size. Atrial septum was directly closed. He also had CABG x4 where left IMA was anastomosed to mid LAD and SVG was anastomosed to first diagonal, OM2 and PDA. The patient came off bypass with stable hemodynamics. .

Conclusion

Atrial myxomas are the most benign primary tumors of the heart with a majority arising in the left atrium. Approximately 10 to 15% of patients with atrial myxo-mas may be completely asymptomatic. Most often a thorough preoperative evaluation detects the underlying pathology in these patients.

This particular patient was having predominantly symptoms of ischemic heart disease. Routine cardiology evaluation with transthoracic echocardiogram detected the presence of a left atrial mass. This patient had successful removal of left atrial myxoma and coronary bypass surgery.

Aortic valve replacement in post-op mitral valve surgery after 28 years

A 50-year-old male, known post-operative mitral valve replacement, was admitted with shortness of breath. He was on meticulous anticoagulation, even though he worked at a desert farm. On evaluation, he was diagnosed to have severe aortic stenosis. Previous mitral valve replacement was done 28 years prior with On-x valve by the same surgeon. At that time, aortic valve did not have significant gradient. The mitral prosthetic valve was functioning well with minimal gradient. It was decided to proceed with aortic valve replacement.

Surgical Procedure

After induction, left femoral vessels were exposed and isolated for emergency cannulation and to go on cardiopulmonary bypass. Sternotomy was uneventful. Patient underwent aortic valve replacement with 21 mm Sorin Carbomedics Supra-annular top hat valve. Transfusion was minimized by the use of cell-saver, antifibrinolytics and meticulous attention to hemostasis.

Discussion

Patients who need cardiac surgery have become increasingly more complex, and an increasing proportion of them require reoperative cardiac surgery. Surgical techniques have significantly improved in recent times. However redo cardiac surgery has several inherent challenges that can increase mortality and also morbidity to the patient. With the use of imaging, the risk of sternal opening is now better assessed. Preparedness, in case of an injury induced emergency, increases in intensity from having the perfusionist in the room (for the lowest-risk patients), to exposing the axillary artery or groin vessels, to establishing cardiopulmonary bypass (CPB) before opening, to performing hypothermic circulatory arrest (for the highest-risk patients). Early CPB results in a longer pump run, increased risk of bleeding due to coagulopathy, and higher risk of end-organ dysfunction. For these reasons, we believe that CPB or circulatory arrest (or both) should be established before opening only in patients who are at the highest risk of injury upon opening.

Reoperation does present increased risk in selected patients. However, systematic protocol-based approach, and use of checklists help in decreasing the risks of redo surgery.

Young patient with left ventricular thrombus tumor

A 32-year-old male, was referred for Cardiac Surgery from another hospital.

He presented to another hospital with history of acute onset of severe headache, nausea and vomiting, associated with extensive heat exposure. There was no history of chest pain or any other cardiac symptoms. ECG was reported as normal. Chest X-ray showed mild to moderate left pleural effusion. He was taken up for CT scan of brain which confirmed acute infarct left posterior parietal territory. He never had any focal neurological deficit. His transthoracic echocardiogram showed a firm mass attached to the lateral wall of left ventricle (LV) with no regional wall motion abnormality but high cardiac markers.

He was referred for emergency cardiac surgery. Before transferring this patient, we requested to do a coronary angiogram. But due to CT brain findings CT coronary angiogram was done in that hospital and reported as normal. In view of the CT scan finding and echocardiogram, it was decided to remove the LV mass, with provisional diagnosis of LV thrombus/tumor causing embolization to brain, on emergency basis.

Surgical Procedure

Intra Operative transesophageal echocardiogram showed normal LV function with no Regional Wall Motion Abnormalities. Transmitral complete resection of the LV mass was done under cardio pulmonary bypass. Thoracoscopic inspection of the left ventricle done through the mitral orifice to make sure that complete resection of the mass was done. Transaortic inspection was also done to exclude any residual debris. Patient made an uneventful post-op recovery.

Routine post-op echocardiogram done on post-operative day 3, showed moderate LV dysfunction (RWMA corresponding with the resected mass territory). Meanwhile, histopathology report of the mass was reported as thrombus. Transradial, coronary angiogram was done which showed re-canalized left circumflex with residual stenosis. He was subjected for stenting on left circumflex artery and had a smooth outcome. He was discharged on 10th post-operative day. Follow up 2D Echo at OPD revealed normal LV function with no RWMA.

Discussion

Young patient with no history of cardiac symptoms presented with CVA and on echocardiogram showed thrombus in LV. It was not easy to exclude a tumor mass in the echocardiogram. In view of acute CVA on CT scan and further to avoid more neurological problems, it was decided to remove the mass/thrombus. Transmitral approach was used aided by thoracoscope for complete clearance. Left ventriculotomy was avoided.

Conclusion

Young patient, with LV thrombus and history of CVA, should be subjected to LV mass thrombus removal and short term anticoagulation to get a good recovery.

Surgical correction in re-do mitral valve surgery

Rheumatic heart disease (RHD) is the only preventable cardiovascular disease which causes significant morbidity and mortality particularly in low- and middle-income countries. The need for surgery for severe RHD is clear with a significant lack of access to surgical and percutaneous intervention in regions of the greatest global need. Surgery for RHD should be timeous to result in the best possible outcome. In advanced RHD, heart failure, atrial fibrillation and endocarditis can add to the complexity of the surgery.

History

A 45-year-old Sudanese lady, with history of mitral valve repair done 20 years prior, presented with dyspnea on exertion, chest pain and severe pulmonary artery hypertension. Echocardiogram showed severe mitral stenosis, moderate mitral regurgitation, moderate tricuspid regurgitation, severe pulmonary artery hypertension, enlarged right atrium and giant left atrium. Coronary angiogram showed normal coronaries.

Surgical Procedure

Under cardiopulmonary bypass and cardioplegic arrest, she underwent redo mitral valve replacement (29mm carbomedics standard mechanical valve), tricuspid valve repair with Annuloplasty (32mm Edwards MC3 Annuloplas-ty ring), left atrial appendage closure from left atrium, left atrial size reduction with plication, and right atrial size reduction. Came off CPB in the first attempt, in sinus rhythm. Patient made a gradual uneventful recovery post-op and was discharged home on the tenth post-operative day.

Discussion

RHD remains a neglected cardiovascular disease, which causes significant morbidity and mortality in low- and middle-income countries. Timing of surgical intervention is crucial for a favorable outcome. Our patient with history of previous mitral valve repair, presented relatively late with compounding risk factors of cardiac failure, atrial fibrillation, pulmonary artery hypertension, tricuspid regurgitation and giant left atrium, in addition to the primary pathology of mitral valve disease. Giant left atrium (GLA) is a condition defined when the left atrial diameter exceeds 65 mm. It is commonly associated with mitral valve regurgitation due to excess intracavitary pressure resulting in strain and dilation of the left atrial chamber. The enlarged left atrium leads to expansion of left atrial volume, which in turn can place pressure on the main bronchus, lung and left ventricle with corresponding cardiopulmonary embarrassment. Because GLA can increase the risk of sudden death, its existence merits surgical intervention. Partial resection of inferior and or superior left atrial wall, is the most common surgical technique. With the evolution of atrial fibrillation surgery, atrial size matters and is determinant of long term performance following successful ablation. Surgical management of GLA achieves good clinical outcome with respect to cardiopulmonary performance including restoration of sinus rhythm among patients suffering from atrial fibrillation.

In patients who undergo mitral valve surgery with tricuspid regurgitation or tricuspid annular dilation, performing concomitant tricuspid valve repair lowered risk for progression of tricuspid regurgitation. There is broad agreement that when a patient has severe tricuspid regurgitation, then that valve should be repaired. However, there is significant uncertainty in how to manage moderate or less tricuspid regurgitation. There are some data from observational studies that failure to manage less than severe tricuspid regurgitation is associated with decreased survival and heart failure. It is a common debate among surgical team members as to what to do with leaking tricuspid valve during mitral valve surgery. It is recommended that the tricuspid valve annulus be intervened based on function (i.e., degree of tricuspid valve regurgitation), diameter size, significant right ventricular dilation or dysfunction. This patient presented all the difficulties associated with rheumatic valve surgery including cardiac failure, atrial fibrillation, associated valve lesion, pulmonary artery hypertension and giant left atrium. Careful assessment, pre-operative optimization, meticulous surgical technique and optimal post-operative management played an important role in successful outcome.

A 34-year-old male from Cameroon, with Marfanoid features was referred for aortic root replacement and mitral valve surgery. His echocardiogram showed severe ascending aortic dilatation more than 8 cm and severe mitral regurgitation. Preoperative TEE showed dilated aortic annulus and ascending aorta, dilated mitral annulus, with severe AR and MR. He was planned for Bentall procedure and mitral valve repair.2

Surgical technique

Under cardiopulmonary bypass and cardioplegic arrest, ascending aorta and the aortic valve was replaced with 25 mm Carbomedics valve bearing conduit with coronary implantation. Mitral valve showed normal leaflets with dilated annulus. Mitral annuloplasty was done using a 32 mm Carpentier-Edwards Physio ring. Post-op TEE showed no MR and normally functioning aortic prosthesis. He had a smooth post-op recovery and was discharged on seventh post-op day.

Discussion

Co-existing aortic root and mitral valve pathology is increasingly recognized among patients undergoing cardiac surgery. This combination of pathologies is particularly common in patients with connective tissue disorders such as Marfan syndrome. Aortic root replacement with mitral valve repair or replacement are the surgical options to treat these patients. However, the combination of the mitral valve operation and an aortic root procedure is more demanding than either major operation alone and knowledge regarding the clinical outcome is limited. The most common pathologies are root aneurysm without dissection and degenerative mitral valve disease. Combined aortic root and mitral valve operations are safe and associated with excellent long-term results.

A 43-year-old lady, with history of childhood rheumatic fever, presented with history of gradually progressive dyspnea on exertion, palpitation and recent onset of chest pain. She had undergone percutaneous mitral balloon valvotomy fifteen years back for mitral stenosis. She had no other significant history.

Her clinical examination showed mid-diastolic murmur at the apex. Her echocardiogram showed severe mitral restenosis with mitral valve area of 1.0 cm² with calcified commissures and severely thickened leaflets. Pre-operative coronary angiogram showed intramyocardial left anterior descending (LAD) artery with myocardial bridge causing systolic and diastolic compression. Other coronaries were normal.

Surgical Procedure

She underwent mitral valve replacement with 27 mm bi-leaflet Carbomedics mechanical valve. She also had supracoronary artery myotomy, unroofing and marsupialization of the incised myocardium over LAD. Once the LAD was localized, by identifying the artery near the apex, the proximal LAD was exposed by incising the muscle and fat together with Pott’s scissors, keeping the lower scissor blade exactly on the anterior surface of the artery to minimize the chance of injuring the diagonals and entering into the right ventricular cavity. Each edge, including the full thickness of muscle and fat, was sutured in a running fashion with 6-0 Prolene. The suturing was started from the distal end in a continuous running manner. After reaching the other end, similar suturing was done in an over and over fashion in the reverse direction. This was repeated on the other side also. She came off bypass with normal ECG and stable hemodynamics. She made an uneventful postoperative recovery and was discharged from our care on the 7th postoperative day.

Discussion

Myocardial bridges (MB) are rarely observed, but well known, pathology of the major epicardial coronary arteries which are embedded in the overlying myocardial tissue. They are associated with myocardial ischemia and infarction, cardiac arrhythmias and sudden death. This entity is the cause of myocardial infarction with normal coronaries in some patients. Surgical myotomy reverses local myocardial ischemia and causes an increase in coronary blood flow. Supra-arterial decompressive myotomy treats the physiologic abnormality and corrects the congenital anatomic defect. Many techniques have been described and each has advantages and disadvantages. The problems that can be encountered during exposure of the intramyocardial LAD are (1) injury to the diagonal branches and the LAD itself and (2) entering into the right ventricle cavity. We describe our unique technique, which tackles these dangers effectively. This technique can also be used in conventional CABG with CPB or for off-pump CABG procedures. In addition, it helps to control bleeding from the cut edges.

A 54-year-old male came with history of chest pain of 3 weeks duration. He was a known diabetic and hypertensive. He was not on any treatment at that time. His symptoms worsened after three weeks, when he presented to the hospital. On evaluation, he was detected to have ventricular septal rupture following acute coronary syndrome. He had features of pulmonary edema and congestive heart failure. Echocardiogram showed moderate LV dysfunction with ejection fraction of 35%, mild MR and 18mm ventricular septal rupture at the apex with dyskinetic apex. Coronary angiogram showed severe triple vessel dis-ease. After initial stabilization, he was taken up for surgery after a week when his renal function started deteriorating.

Surgical Procedure

He underwent ventricular septal repair using Gore-Tex patch and coronary artery bypass grafting (CABG x5) under cardiopulmonary bypass and intra-aortic balloon pump counter-pulsation. His post-operative period was stormy with repeat episodes of cardiac failure requiring prolonged inotropic support and ICU care, which was further complicated by renal dysfunction that was managed conservatively.

Discussion

Ventricular septal rupture repair is a rare surgical intervention with a high complication and mortality rate. On the other hand, if it is left untreated, it has a high mortality. In the acute phase, because the remaining septum is mushy necrotic muscle, they are not receptive to sutures. The hospital survival after ventricular septal rupture repair varies between 30–47%. These high mortalities have to be set against the mortality without surgery which is 94%.

Surgical principles of VSR closure include hypothermic cardiopulmonary bypass with myocardial protection, trans-infarction approach to the VSR, trimming of infarcted muscle around the VSR, closure of the VSR with a patch to avoid tension and closure of the ventricle without tension, with Teflon felt using buttressed sutures. Closure of ventricular septal rupture following myocardial infarction is an infrequent operation with a very high operative risk. Nonetheless, early surgical intervention offers the only realistic chance of survival and this opportunity should not be denied to patients. Immediate intra-aortic balloon counterpulsation provides some haemodynamic optimization while preparations are made for surgery.

The good long term outcome for survivors makes the high early mortality worthwhile. Transcatheter closure of ventricular septal rupture in the acute setting has been reported. This may provide temporary hemodynamic relief and therefore allow surgical closure after the infarcted myocardium around the rupture has had time to fibrose. With the current devices, closure can be very difficult

Discussion

Ventricular septal rupture repair is a rare surgical intervention with a high complication and mortality rate.

In the acute phase, because the remaining septum is mushy necrotic muscle, they are not receptive to sutures. The hospital survival after ventricular septal rupture repair varies between 30–47%. These high mortalities have to be set against the morality without surgery, which is 94%. Surgical principles of VSR closure include hypothermic cardiopulmonary bypass with myocardial protection, trans-infarction approach to the VSR, trimming of infarcted muscle around the VSR, closure of the VSR with a patch to avoid tension and closure of the ventricle without tension, with Teflon felt using buttressed sutures.

Closure of ventricular septal rupture following myocardial infarction is an infrequent operation with a very high operative risk. Nonetheless, early surgical intervention offers the only realistic chance of survival and this opportunity should not be denied to patients. Immediate intra-aortic balloon counterpulsation provides some haemodynamic optimisation while preparations are made for surgery. Another adjunct for those patients who are severely hemodynamically compromised are ventricular assist devices. As the technology of devices advances they should become increasingly available and increasingly adaptable; one can imagine the situation where a temporary device will maintain a patient’s haemodynamics while the edges of the septal rupture fibrose sufficiently to allow a definitive surgical closure later.

An 82-year-old UAE national, who underwent cardiac catheterization procedure at Al Ain Hospital, developed coronary artery perforation during cardiac catheterization. Emergency covered stent grafting was done and perforation was closed. But unfortunately, the patient developed acute cardiac tamponade and needed resuscitation. Initially 100 ml of blood was drained from the pericardium percutaneously, but the patient’s condition did not improve and he went into cardiogenic shock. He was intubated and IABP was introduced with heavy inotropic support.

The patient was shifted for emergency cardiac surgery and drainage of cardiac tamponade. The patient’s history revealed ischemic heart disease, diabetes, hypertension, past history of smoking, with recent unstable angina. He was admitted with chest pain as NSTEMI at Al Ain Hospital. He had previous coronary angiogram in 2019 which showed double vessel disease and stenting was done to LAD and circumflex arteries. This time, in view of his unstable angina, he was taken up for diagnostic angiography and possible intervention. On admission to our hospital, he was in cardiogenic shock, on heavy inotropic support, ventilated and on IABP with poor hemodynamics. Preoperative transesophageal echocardiogram in the operation theatre revealed significant cardiac tamponade, ejection fraction 25%, dyskinetic apical and septal region, calcified aortic valve and presence of a large atheroma in distal aortic arch. He was taken up for emergency CABG and pericardial drainage was done. On opening the pericardium, almost 200 mL blood was drained and his hemodynamics improved. In view of the large mobile atheroma in the aortic arch, it was decided to do the coronary bypass grafting on OFF PUMP beating heart. On opening the LAD, there were fresh clots in both distal and proximal areas. A size 3 Fogarty balloon catheter was introduced to both proximal and distal LAD to remove the clots. Then single saphenous vein graft was done to mid LAD. He remained in on IABP and inotropic support with stable hemodynamics. All the supports were weaned off on the second post-operative day and IABP was removed. He was discharged on 12th post-operative day with no neurological deficit.

Discussion

Coronary artery perforation during cardiac interventions, is a rare complication in the present era. Advanced hardware, safety measures and highly experienced interventional cardiologists has brought down this complication to less than 0.3%. But when it occurs, if further interventional procedures fail, surgical treatment is the only alternative. For that, surgical team and the facility should be available at short notice to save the life of the patient.

A 45-year-old known patient of Marfan syndrome, presented with history of progressive shortness of breath, palpitations and easy fatigability over a period of 6 months.

Clinical Findings

• Pectus excavatum (since childhood) 6.5 cm depth.
• Early diastolic murmur over aortic area.
• Marfan syndrome features present.

Primary Investigations & Findings

• 2-D transthoracic echo: Severe aortic regurgitation and ascending aortic aneurysmal dilatation of 7 cm
• CT angiogram: Fusiform
• aneurysm of ascending aorta measuring 7 cm
• CT Thorax: Ascending aortic aneurysm and sternal compression of right ventricle. Reduction of right lung volume, mediastinal shift to the left

Diagnoses

Ascending aortic aneurysm with severe aortic regurgitation and pectus excavatum.

Management Plan

Bentall procedure was done for the ascending aortic aneurysm and severe aortic regurgitation. Additional NUSS Bar fi¬xation was done for correction of pectus excavatum.

Aspects of Challenge in the Case

1) Sternotomy posed risk of RV tear due to its compression by the pectus excavatum.

2) Risk of aneurysm rupture during sternotomy.

3) Bentall procedure and its attendant unique risks such as bleeding and neurological sequela, etc.

4) NUSS Bar procedure for pectus excavatum correction, in the back ground of major cardiac surgery, as combined procedure.

5) Modified NUSS Bar fixation with sternal osteotomies.

Follow-up

Chest wall deformity corrected. He is on regular anti-coagulation and doing well.

Dextrocardia with situs inversus is a rare congenital abnormality with an incidence of only 1:10,000. The incidence of coronary artery disease in this condition is similar to that in the general population.

History

A 66-year-old patient with a diagnosis of left main coronary artery disease and triple vessel disease, was referred for coronary bypass surgery. He was a known case of dextrocardia with situs inversus. He presented with unstable angina. He was a known case of stage 3 chronic renal disease, hypertension and diabetes mellitus. Carotid scan showed bilateral carotid artery stenosis with critical block in the left carotid artery. His coronary angiogram revealed triple vessel disease and dextrocardia.

Surgical Procedure

In preparation for coronary artery bypass surgery, he underwent left carotid endarterectomy. He had an uneventful recovery with no neurological deficit. After six weeks, he was taken up for CABG. Chest was opened through median sternotomy approach. Skeletonized right internal mammary artery (RIMA) was harvested and found to be good size and length and three lengths of long saphenous vein were harvested. Heart was stabilized with a tissue stabilizer device and RIMA was anastomosed to the LAD from the right side. Surgeon came on the left side and stabilized the heart for SVG to ramus intermedius, circumflex PDA and right acute marginal. All the distal anastomoses on those vessels were done from the left side and proximal anastomosis from the right side. Intra and post-op period was uneventful. His serum creatinine went up early post-op period and came down to his pre-op levels in five days’ time. Post-op echo showed normal LV function. He was discharged on 10th post-operative day.

Discussion

Performing CABG in dextrocardiac patient is more difficult and technically challenging as it is not routinely performed. There are few reported cases of CABG in dextrocardia and even lesser number had off-pump approach. Myocardial revascularization in dextrocardia can successfully be achieved with RIMA to the LAD and SVG to other vessels.