This review article is written so as to present the pathophysiology, the symptomatology and the ways of diagnosis and treatment of a rather rare aortic disease called Intra-Mural Haematoma (IMH). Intramural haematoma is a quite uncommon but potentially lethal aortic disease that can strike as a primary occurrence in hypertensive and atherosclerotic patients to whom there is spontaneous bleeding from vasa vasorum into the aortic wall (media) or less frequently, as the evolution of a penetrating atherosclerotic ulcer (PAU). IMH displays a typical of dissection progress, and could be considered as a precursor of classic aortic dissection. IMH enfeebles the aortic wall and may progress to either outward rupture of the aorta or inward disruption of the intima layer, which ultimately results in aortic dissection. Chest and back acute penetrating pain is the most commonly noticed symptom at patients with IMH. Apart from a transesophageal echocardiography (TEE), a tomographic imaging such as a chest computed tomography (CT), a magnetic resonance (MRI) and most lately a multy detector computed tomography (MDCT) can ensure a quick and accurate diagnosis of IMH. Similar to type A and B aortic dissection, surgery is indicated at patients with type-A IMH, as well as at patients with a persistent and/or recurrent pain. For any other patient (with type-B IMH without an incessant pain and/or without complications), medical treatment is suggested, as applied in the case of aortic dissection. The outcome of IMH in ascending aorta (type A) appears favourable after immediate (emergent or urgent) surgical intervention, but according to international bibliography patients with IMH of the descending aorta (type B) show similar mortality rates to those being subjected to conservative medical or surgical treatment. Endovascular surgery and stent-graft placement is currently indicated in type B IMH.
Abstract During open heart surgery the influence of a series of factors such as cardiopulmonary bypass (CPB), hypothermia, operation and anaesthesia, as well as medication and transfusion can cause a diffuse trauma in the lungs. This injury leads mostly to a postoperative interstitial pulmonary oedema and abnormal gas exchange. Substantial improvements in all of the above mentioned factors may lead to a better lung function postoperatively. By avoiding CPB, reducing its time, or by minimizing the extracorporeal surface area with the use of miniaturized circuits of CPB, beneficial effects on lung function are reported. In addition, replacement of circuit surface with biocompatible surfaces like heparin-coated, and material-independent sources of blood activation, a better postoperative lung function is observed. Meticulous myocardial protection by using hypothermia and cardioplegia methods during ischemia and reperfusion remain one of the cornerstones of postoperative lung function. The partial restoration of pulmonary artery perfusion during CPB possibly contributes to prevent pulmonary ischemia and lung dysfunction. Using medication such as corticosteroids and aprotinin, which protect the lungs during CPB, and leukocyte depletion filters for operations expected to exceed 90 minutes in CPB-time appear to be protective against the toxic impact of CPB in the lungs. The newer methods of ultrafiltration used to scavenge pro-inflammatory factors seem to be protective for the lung function. In a similar way, reducing the use of cardiotomy suction device, as well as the contact-time between free blood and pericardium, it is expected that the postoperative lung function will be improved.
We would like to present an interesting case operated on in our department and discuss the international bibliography about this issue. We also present some interesting images of this case. Our material is composed from a 68-year-old woman treated by the authors. She presented with a small murmur in the auscultation while she was asymptomatic and then she diagnosed with a tumor on of the left coronary cusp of the aortic valve with the characteristics of papillary fibroelastoma. On the basis of the potential embolic risk either of the mass itself or of associated thrombus and the possibility of further enlargement, the patient although asymptomatic at the time of diagnosis was referred for elective surgical excision of the mass. She underwent on median sternotomy and through extracorporeal circulation the mass has been excised with the preservation of the well-functioning valve. Through this case, we would like to discuss the bibliography for the decision making in these cases. Hence, the aim of our study is that we have to keep in mind that this kind of friable mass may be the cause of embolism, stroke or coronary artery occlusion and must be excided in a conservative setting, sparing the aortic valve.
Performing axillary artery cannulation, during cardiopulmonary bypass in patients with an atherosclerotic ascending aorta or acute dissection of the ascending aorta and arch, is of growing interest. Our aim is to present our experience, to describe the surgical technique, and to demonstrate the sufficient cerebral and total body perfusion through axillary artery cannulation.Twenty-two patients (17 male, five female) underwent surgical treatment with the axillary technique. The log euro SCORE ranged from 6.77% to 70% (mean 28.28). Nine of these patients underwent elective procedure. Eight underwent aortic surgery for pathologies of the aorta and in one patient we performed combined aortic valve replacement and coronary artery bypass grafting. Thirteen patients underwent emergency operation because of acute dissection of the aorta. Twelve of these patients had a type A dissection (according to Stanford classification) and one patient had a type B aortic dissection.The majority of complications were associated with ruptured dissection of the thoracoabdominal aorta and acute dissection of ascending aorta. Despite preoperative disease states that placed our patients at high risk of stroke and visceral end-organ injury, no clinically demonstrable permanent postoperative deficits were observed. Our patients had no neurological dysfunction, stroke, or other complications.Antegrade cerebral perfusion is of paramount importance in cases of aortic atherosclerosis or aortic dissection. The axillary artery provides an excellent site for safe antegrade perfusion, which may play a role in preventing stroke.
Abstract Background Left ventricular diastolic dysfunction (DD) is defined as the inability of the ventricle to fill to a normal end-diastolic volume, both during exercise as well as at rest, while left atrial pressure does not exceed 12 mm Hg. We examined the concept of left ventricular diastolic dysfunction in a cardiac surgery setting. Materials and methods Literature review was carried out in order to identify the overall experience of an important and highly underestimated issue: the unexpected adverse outcome due to ventricular stiffness, following cardiac surgery. Results Although diverse group of patients for cardiac surgery could potentially affected from diastolic dysfunction, there are only few studies looking in to the impact of DD on the postoperative outcome; Trans-thoracic echo-cardiography (TTE) is the main stay for the diagnosis of DD. Intraoperative trans-oesophageal (TOE) adds to the management. Subgroups of DD can be defined with prognostic significance. Conclusion DD with elevated left ventricular end-diastolic pressure can predispose to increased perioperative mortality and morbidity. Furthermore, DD is often associated with systolic dysfunction, left ventricular hypertrophy or indeed pulmonary hypertension. When the diagnosis of DD is made, peri-operative attention to this group of patients becomes mandatory.
Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pulmonary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infection, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the following perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achievement. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopulmonary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagulation management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary.
Adult cardiac surgery is associated with significant perioperative morbidity and mortality rates, mainly in elderly patients with co-morbidities. A series of postoperative complications may arise and delay the recovery of patients undergoing cardiac surgery. Such complications also increase the burden of resource use and may affect late survival rates. Neurological complications appear mainly as stroke of varying degrees, with impairment of mobility and ability of the patient. We describe a rare case of progressive paraparesis after on-pump coronary artery bypass grafting, and review its aetiology, diagnosis and management.
Primary cardiac tumors are uncommon but not extremely rare. Cardiac tumors, mostly intracavitary, include benign and malignant tumors that arise from the endocardium, heart valves or myocardium. This retrospective study summarizes the experience of the Cardiac Surgery Departments of three tertiary Hospitals in this field, and particularly in cardiac myxomas, over the last 29 years. Herein, we present the results of cardiac tumors excision in relation to postoperative morbidity and mortality.Between 1985 and 2014, 117 patients, aged from 16 to 82 years, underwent resection of a cardiac tumor.Ninety one of the tumors (77.78%) were myxomas, 15 of them (12.82%) were other primary cardiac tumors, 7 of them (5.98%) were infra-diaphragmatic tumors and the remaining 4 tumors (3.42%) were benign intracavitary masses (thrombi). Patients operated on for a cardiac tumor had a 30-day mortality rate of 3.29%. Atrial fibrillation appeared in 21 out of 91 patients (23.07%) operated on for cardiac myxoma, while neurological complications were observed in 3 patients (3.29%). Re-exploration for bleeding was performed in 5 out of 91 cases (5.49%) and recurrence occurred in 4.39% of myxomas.Despite being rare, primary cardiac tumors require open heart intervention soon after their diagnosis in order to prevent complications and achieve low mortality rates.
