Category: English

A 61-year-old gentleman, known as hypertensive, diabetic and dyslipidemic, presented with chest pain and was diagnosed as Non ST Elevation Myocardial Infarction. His coronary angiogram revealed left main stenosis and chronic total occlusion of left circumflex and mid right coronary artery. His echocardiogram showed moderate left ventricular dysfunction and mild mitral regurgitation. He was taken up for urgent coronary artery bypass grafting.

Surgical Procedure

On cardiopulmonary bypass, he underwent CABG x 9 grafting. Left internal mammary artery anastomosed as a sequential graft to mid and distal left anterior descending artery. Additionally, he had 7 vein grafts anastomosed to two diagonals, two obtuse marginal and three grafts to posterolateral, posterior descending and ventricular branch of right coronary artery. Patient underwent an uneventful recovery postoperatively and was discharged on the seventh post-operative day.

Discussion

This case report highlights the advantages of the often maligned cardiopulmonary bypass in ensuring a complete revascularization in a patient with multiple severe diffuse triple vessel coronary artery disease. Revascularization of all the occluded coronary artery vessels, with as many as nine distal anastomosis, in diffuse coronary artery disease, is highly demanding. With high attrition rates of vein grafts, the utility of complete vascularization cannot be stressed enough. Off-pump revascularization is limited by quality of anastomosis and number of anastomosis.

A 40-year-old male presented with fever and cough of two weeks duration which did not settle with conservative management. CT chest revealed benign appearing large mediastinal non enhancing cyst of 7 x 8 x 9 cm causing pressure effect over the adjacent mediastinal vascular structures, esophagus, left bronchus and extending below and above aortic arch and occupying space between superior vena cava and ascending aorta.

Surgical Procedure

As a precaution, left femoral artery and vein was exposed and looped under local anesthesia. Airway was secured and lung isolation was achieved with double lumen tube under inhalation anesthesia. The patient underwent complete removal of posterior mediastinal tumor through left posterolateral thoracotomy in right lateral position. Complete excision of the mass was achieved without any damage to the surrounding structures. Lymph node masses were also removed. Patient had an uneventful postoperative recovery.

Conclusion

This case highlights some of the difficulties associated with the management of large mediastinal mass. Though rare, they cause compression of vital structures causing respiratory insufficiency or hemodynamic compromise. Detailed preoperative evaluation and planning is required to ensure a successful outcome. We were prepared to go on emergency cardiopulmonary bypass in case there was a loss of airway or hemodynamic collapse at induction. Additionally, postoperative evaluation of airway for bronchomalacia was done on spontaneous breathing prior to extubation.

Noninvasive intervention / CABG / hybrid procedure

A 40-year-old expatriate presented with unstable angina. At the age of 31, he had stenting in LAD, obtuse marginal 1, obtuse marginal 2 and RCA. Repeat angiogram showed stent stenosis and progressive disease.

Surgical Procedure

He was taken up for coronary bypass surgery under cardiopulmonary bypass. He had CABG x 5 grafts. He had LIMA anastomosed distal to the stent in LAD and SVG anastomosed to first diagonal, OM1, OM2 and precrux RCA. There was no area in PDA or PLB to do the grafting. There were multiple stents in precrux RCA, PDA and posterolateral right. Long arteriotomy was done in RCA and all the stent with atheromatous material were pulled out distally and proximally. Coronary lumen was washed and grafting done. The patient had a smooth post-op recovery and was discharged on 7th post-op day.

Discussion

Diffuse coronary artery disease is a well-known fact in young Asian patients. Noninvasive coronary intervention is the treatment of choice in this group of patients. Total arterial grafting is not an easy task in diffuse distal disease. The cardiology team who treated him at the age of 35 did a good job. Later the disease progress and all the stents had progressive atheromatous lesions. Removal of a stent from the coronary is not without morbidity. In this patient, there was no alternative to find out a portion of a coronary artery for grafting. Hence, the stent was removed, cleaned the coronary and grafting done. It is advocated that surgery is possible even if all the coronaries are occupied with blocked stents.

Mitral valve repair with CABG

A 55-year-old male with severe non-rheumatic mitral regurgitation, severe pulmonary hypertension, diabetes and coronary artery disease, was admitted for mitral valve repair and coronary bypass surgery. In view of his severe pulmonary artery hypertension, he was admitted and treated with Sildenafil (phosphodiesterase inhibitor) before taken up for surgery. His coronary angiogram showed critical occlusion in circumflex artery.

Surgical Procedure

Under cardiopulmonary bypass and cardioplegic arrest, mitral valve was inspected. He had prolapse of P2-P3 segments and chordae rupture at P2 segment. Quadrangular resection and repair of PML was done. Mitral annuloplasty was done using 30 mm Carpentier-Edwards Physio annuloplasty ring. SVG graft was done to OM2 circumflex artery. Came off bypass with stable rhythm and mild mitral regurgitation (MR) on TEE. De-cannulation done. While securing complete hemostasis, his blood pressure improved and then TEE showed moderate MR at P3 segment.

The question was whether to leave it and accept this MR or go back and get a perfect repair. The team decided to re-do the repair. Hence the patient was re-heparinized, cannulated, went on CPB, cardioplegia was given, left atrium was opened. P3 segment was found to be further prolapsed. This segment was re-fixed with neo-chordae and additional Alfieri stitch. Came off bypass. Post-op TEE showed no MR.

The patient became COVID positive in the post-op period and had an extended stay for further 10 days. Post-op follow-up showed no MR and the patient is now back at work.

Discussion

Degenerative mitral valve disease is the most common organic mitral valve pathology. Usually degenerative mitral valve pathology does not progress to clinically significant. But patients who develop symptoms attributable to MR have adverse prognosis and they need timely surgery. With surgery, essentially unavoidable in these patients, mitral valve repair has demonstrated superior short and long-term outcomes. We should try to avoid mitral valve replacement in these patients. Mitral valve repair has been consistently associated with lower risk of thromboembolism and improved survival. The method of mitral valve repair was evolved and improved. On the basis of operative findings, we resect and repair, consider neochordae insertion, placing an Alfieri stich, or doing a combination of these procedures. Once repair is attempted, we must almost always try to reach 100% perfection. At any cost, these patients should not have residual MR as this may progress and the patient may need re-do surgery.

In this case, we partially agreed to accept the mild MR in post-repair period, but within no time, TEE showed worsening MR. There should not be any hesitation to put the patient back on CPB and re-repair the mitral valve to get best results.

A 23-year-old female, was admitted to the hospital, with progressive shortness of breath on exertion, chest pain, palpitation, and fatigability over the last four years. Six months back she had undergone cesarean section (LSCS). During pregnancy, she had severe shortness of breath and it worsened as the pregnancy progressed. During LSCS she collapsed and had a cardiac arrest which was successfully resuscitated. Cardiology evaluation showed large PDA.

On clinical examination, she had continuous murmur over the upper part of the left chest. Her chest x-ray showed bilateral prominent bronchovascular marking. CT angiogram revealed large PDA with shunt. It also showed dilated left atrium and left ventricle with severe pulmonary congestion. Echocardiogram showed PDA with dilated left ventricle and LVEF 60%. Anatomically this PDA was not suitable for device closure.

Surgical Procedure

Through posterolateral thoracotomy, PDA was dissected and doubly ligated under hypotensive anesthesia. Additionally, she had a medium size vascular clip placed at the aortic side of the PDA. She had an uneventful recovery and was discharged on seventh post-operative day.

Discussion

Patent ductus arteriosus in the adult is an extremely rare phenomenon. This condition should have been diagnosed much earlier. Aneurysm, endocarditis and calcification are few of the serious sequelae as the age advances. There are various methods to treat this condition. Open surgical division or ligation has traditionally been an extremely successful and safe method of PDA closure. Comparative results are now achievable using transcatheter devices in majority of the cases.

Multiple coronary endarterectomy in diffuse complex coronary artery disease

A 53-year-old male, known patient of hypertension, hyperlipidemia and type I diabetes mellitus, presented to the hospital with acute-onset chest pain. After initial evaluation, he was diagnosed to have non-ST elevation myocardial infarction. Coronary angiogram showed severe triple vessel disease with chronic total occlusion of left anterior descending artery and significant diffuse lesions in the left circumflex artery and right coronary . He was referred for coronary artery bypass grafting.

Surgical Procedure

After initial evaluation, the patient underwent coronary artery bypass grafting on cardiopulmonary bypass. Diffuse disease of the left anterior descending artery (LAD) with lumen of less than 1mm necessitated long closed manual endarterectomy of proximal, mid and distal LAD. Left internal mammary artery was anastomosed to the distal LAD. Diffuse calcific disease with very narrow lumen of obtuse marginal branch of left circumflex was found. This required another closed manual endarterectomy of the same vessel followed by vein graft to it. Additional three vein grafts were placed to the posterior descending artery, posterolateral branch and diagonal branch after endarterectomy of those vessels. Electively this patient was put on intra-aortic balloon pump for 24 hours. Patient had an uneventful post-operative recovery with no ischemic events or hemodynamic instability. Post-operatively patient was discharged on the 6th post-operative day on antiplatelet and anti-coagulants in addition to routine postoperative medications.

Discussion

Diffuse coronary artery disease (CAD) as such cannot be tackled with percutaneous coronary intervention and is more likely to be referred for CABG. However, up to 25% of patients with diffuse CAD cannot be safely and successfully treated by standard CABG. Therefore, several techniques including coronary endarterectomy, which involves the removal of the atherosclerotic core from the coronary artery lumen through an arteriotomy, have evolved over the years. Despite initial adverse results (high operative mortality and perioperative myocardial infarction), several recent publications have shown that it can be safely performed with improvement in surgical technique and immediate post-operative anti-thrombotic measures. Coronary endarterectomy can assure complete revascularization preventing residual ischemia. We have described a patient in whom we did multiple endarterectomies successfully.

Right atrial mass in a post-COVID-19 patient

A 38-year-old lady presented to the hospital with shortness of breath and right sided chest pain. Symptoms were gradually progressive over few weeks. Her past history was significant with history of COVID-19 eight weeks prior. There were no remarkable clinical findings on examination.

Echocardiogram showed a right atrial mass of size 2.5 cm x 0.5 cm which was abutting the tricuspid valve. Patient had no other significant findings except moderate pulmonary artery hypertension on the echocardiography. She had no evidence of deep vein thrombosis in her lower limbs or pelvic veins and chest CT scan showed minimal post-COVID residual fibrotic bands. Her hematology work-up didn’t show any thrombotic predisposition.

She was started on anticoagulation with heparin initially and then warfarin. After four weeks of anticoagulation, there was no decrease in mass size and no significant improvement in her symptoms. It was decided to proceed with surgical excision in view of the above, suspicion of myxoma or organized thrombus and its risk of embolization.

Surgical Procedure

She underwent right atrial mass excision under cardiopulmonary bypass. Intraoperative transesophageal echocardiography confirmed the preoperative echocardiographic findings. Special attention had to be paid to careful cannulation of IVC without dislodging the mass as its attachment was close to the IVC-RA junction. The mass measured 2.0 x 2.0 cm. Part of the interatrial septum, that was excised with the mass, was repaired with pericardial patch.

Discussion

Multiple cases of right atrial mass following COVID-19 have been reported. An increased incidence of thrombotic events has been reported in patients with COVID-19 infection and pulmonary thromboembolism is one of the most important causes of clinical deterioration. We found a large thrombus in the right atrium after pneumonia caused by COVID-19, in a symptomatic patient in sinus rhythm with normal biventricular function. Prior reports have suggested improvement or prevention of deterioration in such patients with anticoagulation alone. We decided to proceed with surgical excision as the patient did not improve with four weeks of anti-coagulation.

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.