Journal of Cardiothoracic Surgery最新文献

Background: Single umbilical artery aneurysms (SUAA) are extremely rare vascular malformations. Most of the times aneurisms are located in the cors insertion on the placenta, and are associated with increased perinatal morbidity, including fetal growth restriction and increased fetal mortality.

Case presentation: This report describes a case of a single SUAA diagnosed by prenatal ultrasound at 22 weeks and 1 day of gestation. The characteristic ultrasound findings included cystic dilatation at the placental end of the umbilical cord, accompanied by disrupted blood flow on color Doppler imaging, indicative of abnormal umbilical artery expansion. At 37 weeks and 2 days of gestation, the presence of venous-like changes in the Doppler spectrum, accelerated peak systolic velocity (PSV) of the middle cerebral artery (MCA), and decreased pulsatility index (PI) raised concern for fetal intrauterine distress. An emergency cesarean section was performed. The neonate exhibited mild asphyxia at birth and was admitted to the neonatal intensive care unit (NICU). After 19 days of monitoring and treatment, the infant was discharged in stable condition.

Conclusion: SUAA is a rare but potentially fatal pregnancy complication, associated with increased fetal mortality and adverse perinatal outcomes. Early detection through ultrasound of cystic dilatation and disturbed blood flow patterns is crucial for optimizing perinatal management. Continuous monitoring of fetal growth, particularly the detection of fetal growth restriction (FGR) and abnormal fetal heart rate patterns, plays a vital role in reducing the risk of intrauterine distress and fetal demise. In cases of SUAA, elective cesarean delivery has been shown to effectively mitigate the risk of intrauterine hypoxia and fetal distress, thereby improving neonatal survival rates and long-term prognosis.

Background: Ventilator-associated pneumonia (VAP) is a major contributor to morbidity and mortality in critically ill patients receiving mechanical ventilation. Microaspiration of subglottic secretions has a pivotal role in VAP pathogenesis, yet the optimal positive end-expiratory pressure (PEEP) for preventing microaspiration has not been extablished.

Methods: This prospective, single-center study determined the impact of different PEEP levels on microaspiration in 90 mechanically ventilated patients. Participants were stratified into three groups based on PEEP levels (0-3 cmH₂O, 4-6 cmH₂O, and 7-10 cmH₂O). Primary outcomes included biomarkers, such as pepsin concentration in airway secretions, and the incidence of microaspiration. Secondary outcomes assessed subglottic secretion volume, mechanical ventilation duration, and ICU length of stay.

Results: Higher PEEP levels (4-6 cmH₂O and 7-10 cmH₂O) were associated with significantly lower microaspiration rates and pepsin concentrations in airway secretions compared to the lowest PEEP group (0-3 cmH₂O; P < 0.05). Patients in the higher PEEP groups exhibited reduced total subglottic secretion volumes over 7 d and a shorter duration of mechanical ventilation. Group C (7-10 cmH₂O) demonstrated the most pronounced benefits with respect to microaspiration. No significant differences were observed in the duration of ICU stay among the groups.

Conclusion: Elevated PEEP levels, especially within the 7-10 cmH₂O range, effectively reduce microaspiration, minimize subglottic secretion leakage, and shorten the duration of mechanical ventilation. These findings highlight the clinical importance of higher PEEP settings in reducing VAP risk and improving patient outcomes.

Objectives: This multicentric study evaluated short- and mid-term clinical outcomes, with specific focus on the need for repeat revascularization, in patients undergoing coronary artery bypass grafting (CABG) with VEST supported saphenous vein graft (SVG).

Methods: A total of 397 patients underwent CABG in a three-center setting, with or without concomitant procedures, with at least one SVG supported with an external stent. Open vein harvesting was performed in 80.3% of patients. The majority (73.3%) of patients underwent on-pump CABG, 6.8% of patients had concomitant valve surgery, and the average number of grafts per patient was three. Patients were followed for major adverse cardiac and cerebral events (MACCE) for a median duration of 24 (1-101) months.

Results: Overall, 469 of 654 SVG (71.7%) received external stents. Freedom from MACCE at 1, 3, and 5 years was 95.1% (SE 0.011), 85.4% (SE 0.021), and 82.4% (SE 0.030) respectively. Revascularization rates in territories which were grafted with a stented SV was low in general (1.28%) and statistically significantly lower than in territories grafted with a non-stented SVG (4.32%, p = 0.015). Arterially grafted territories confirmed low revascularization rates as well (0.9%).

Conclusions: VEST-enhanced CABG is feasible and associated with low MACCE in real world routine practice which includes on and off pump CABG, sequential grafting, and concomitant surgery. Short- to mid-term clinical follow up suggests that VEST enhanced CABG is associated with very low target vessel revascularization rates, with most re-revascularization happening at non-grafted or non-VEST-enhanced grafted territories.

Background: Pulmonary sequestration (PS) is a rare congenital pulmonary dysplasia. Due to atypical clinical symptoms, PS is frequently challenging to differentiate from other common respiratory diseases.

Case presentation: A 16-year-old male presented with acute fever and expectoration as chief complaints. The patient had undergone tooth extraction more than one month prior. A chest computed tomography (CT) scan revealed a large cavity lesion with an air-fluid level in the left lower lobe, leading to an initial diagnosis of a lung abscess potentially caused by odontogenic flora. Elevated levels of carbohydrate antigen 19 - 9 (CA19-9) were detected in both serum and abscess drainage fluid. Due to an inadequate response to broad-spectrum antimicrobial therapy and percutaneous drainage of the lung abscess, the patient was referred for surgical intervention. Intraoperative findings revealed an anomalous arterial supply to the left lower lobe, confirming the diagnosis of intralobar pulmonary sequestration. Left lower lobectomy was successfully performed.

Conclusion: Lung abscess may not represent a straightforward diagnosis. This case report highlights the necessity of including pulmonary sequestration in the differential diagnosis of lung abscess, particularly when clinicians encounter adolescent patients with significantly elevated CA19-9 levels. Chest computed tomography angiography is recommended as a diagnostic tool to reduce the risk of misdiagnosis and potentially life-threatening intraoperative hemorrhage.

Background: We investigated the international mini-mitral registry (MMIR) for differences in minimally-invasive access for surgery on the mitral and tricuspid valve. We compared direct vision with partially or fully endoscopic approaches.

Methods: From 2015 to 2021, 7,513 consecutive patients underwent mini-MVR ± TVR in 17 international Heart-Valve-Centers. Data were collected according to MVARC definitions and 6463 patients undergoing first time mitral with or without tricuspid valve surgery were analyzed. Uni- and multivariable regression analyzes were performed to compare the different approaches.

Results: Patients were 65 years (57% male) and oldest in the direct-vision group (n = 1594). Endoscopes (video-assisted: n = 2850, fully-endoscopic: n = 1963) were used in slightly more selected patients (less obesity, diabetes, dialysis, CAD, pulmonary hypertension, reduced LVEF and urgent status compared to direct vision). Robot was used in 56 cases (most selected, no mortality, not further analyzed). Fully-endoscopically, most cases were repairs, concomitant tricuspid surgery was lowest (13% vs. 20%) and both cardiopulmonary bypass and cross-clamp times were longest (90 min, IQR 71-113 min). Cross-clamp times were shortest in the direct vision group (-20 min). Technical success was high (above 96%), in-hospital mortality and stroke rates low and not significantly different between groups. Low output was highest with direct vision and acute kidney injury highest fully-endoscopically. However, this difference was not significant.

Conclusions: In this large registry, the type of minimally-invasive approach did not significantly affect outcome. It appears that fully endoscopic and robotic cases are used more selectively. Mastering both techniques may optimize patient care.

IgG4-related disease (IgG4-RD) is a systemic immune-mediated disorder that causes tissue inflammation and fibrosis in affected organs. A 68-year-old woman underwent aortic valve replacement due to severe aortic regurgitation. Aortic valve leaflets showed abnormal thickening, and fibrosclerosis of the subvalvular structure was observed. Histopathology revealed fibromyxoid degeneration with multifocal dense infiltration of IgG4-positive plasma cells and immunostaining confirmed IgG4-positive plasma cells, therefore the patient was clinically diagnosed with IgG4-RD. After discharge, she underwent implantable cardioverter defibrillator implantation and radiofrequency catheter ablation for refractory ventricular tachycardia. If a patient with underlying IgG4-RD develops a valvular disease or arrythmia, it is necessary to consider the possibility that IgG4-RD is the cause and pre/postoperative systemic inflammation control and thorough evaluation must be performed.

Background: Left ventricular pseudoaneurysm (LVP) is a rare complication, typically following a prior myocardial infarction. Clinical manifestations are diverse and non-specific, posing significant challenges for early diagnosis. Given the high risk of complete rupture, LVP is typically associated with poor prognosis, necessitating urgent surgery for survival. In the current LVP case, the patient presented with isolated chest pain, and further evaluation revealed non-obstructive coronary artery disease. To our knowledge, such cases are rare, and guidelines for LVP management-especially for chronic presentations-remain scarce.

Case presentation: A man in his 50s, complaining of recurrent chest pain over 8 months, was found to have a giant abnormal mass with rim calcification close to the posterior ventricle wall on chest computed tomography. Both contrast-enhanced echocardiography and cardiac magnetic resonance confirmed the diagnosis of a giant extensively calcified LVP in the inferolateral ventricle wall, as well as left ventricle enlargement and compromised systolic function. Coronary angiography revealed non-obstructed arteries. To prevent complete rupture, avoid systemic embolism, and improve cardiac function, the patient underwent successful surgical repair following a multidisciplinary team discussion and has achieved good subsequent recovery.

Conclusion: Our experience with successful surgical intervention in managing this unusual case of a chronic giant LVP provides compelling evidence that surgical repair should be considered a first-line treatment option for such patients.

Background: Papillary fibroelastoma (PTF) of the left ventricle is rare, and surgical approach should be well considered preoperatively. We report two surgical cases of left ventricular PFE by two different approaches.

Case presentation: First patient was a 74-year-old female who presented with palpitation. An echocardiogram revealed a pedunculated mass lesion in the apex of the left ventricle Rivaroxaban was prescribed for one month because cardiac tumor with mobile thrombus was suspected, and surgical resection was indicated because the morphology of the mass did not change on the follow-up echocardiogram. Second patient was an asymptomatic 82-year-old female with history of atrial fibrillation. A screening echocardiogram incidentally revealed a pedunculated mass lesion of the septum of the left ventricular outflow tract. Surgical resection was indicated due to the mobility of the mass. In both patients, surgery was performed via median sternotomy. In first patient, ventricular tumor was approached via left atriotomy and Cooley retractor was deeply placed onto the anterior mitral leaflet to expose the tumor on the apex. In second patient, the tumor was approached via aortotomy and rolled sterile tape measure was inserted into the aortic annulus, which maintained the aortic cusps wide open to expose the interventricular septum. Both tumors were diagnosed as PFE by histopathology.

Conclusions: An attempt to create a patient-tailored surgical approach is required for the surgical resection of left ventricular papillary fibroelastoma depending on the tumor location.