So Many Ways…

Enlargement of left ventricular outflow tract using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy through trans-mitral approach for the hypertrophic obstructive cardiomyopathy Zhang et al (1) describe their experience in septal myectomy for hypertrophic obstructive cardiomyopathy. Of 247 consecutive cases with HOCM treated during 2016-2019 with a variety of techniques, this report is on 16 patients who underwent trans-mitral septal myectomy and enlargement of left ventricular outflow with an autologous pericardial patch in transverse configuration. The technique reportedly decreased the gradient from average 90+ to 10+ mm Hg and resolved systolic anterior leaflet motion in all with only mild residual mitral regurgitation. There were no deaths or any other major complications in this group. It is a small group of patients with excellent result but no definitive conclusion can be drawn regarding validity of the technique from this study. The controversy remains regarding the approach, trans-aortic vs. trans-mitral and whether leaflets should be left alone, plicated or lengthened as well as whether mitral valve should be repaired or replaced in addition to septal myectomy. One certainty remains, extended myectomy done either way, is the foundation of the surgical treatment of hypertrophic cardiomyopathy.

Pseudoaneurysm following a neonatal coarctation repair; a dreadful complication

Aneurysms of descending thoracic aorta following surgical repair of coarctation have been reported in literature. Almost always, they are seen in repairs involving prosthetic patch aortoplasty. We report a neonate who underwent resection and an extended end to end anastomosis repair of coarctation and subsequently developed a huge pseudoaneurysm at a 3-month follow-up. He underwent a repair of the same through a sternotomy approach under hypothermic low flow cardiopulmonary bypass. An autologous pericardial patch aortoplasty was done successfully.

A Case of Giant Right Atrium Diverticulum with Atrial Septal Defect

Right atrium diverticulum is a rare congenital malformation. We present a previously unreported case of giant right atrium diverticulum (153 × 109 mm) in a 17-year-old female patient. Echocardiographic examination also showed an atrial septal defect (11 mm). Considering the risk of right atrium rupture, we performed femoral arteriovenous cannulation first, followed by median thoracotomy. The defect was repaired with an autologous pericardial patch. The patient recovered well after the operation, and this case is referential for surgical treatment of giant right atrium diverticulum.

Aortic Arch Reconstruction in Infants Using Autologus Pericardium

Background. Aortic arch hypoplasia is a congenital anomaly of the development of the aortic arch characterized by hemodynamically significant narrowing of one or more segments of the aortic arch. This defect occurs either as an isolated condition or combined with other congenital heart defects. The materials used to enlarge aorta for successful repair and prevention of postoperative complications range from the patient’s own aortic tissue (in most cases) to other materials (autopericardium, xenopericardium, pulmonary artery tissues, synthetic patches). An autologous pericardial patch is the most common, available and cheap option. The purpose of this work is toanalyze immediate and long-term results of our experience using autologous pericardium to reconstruct the aortic arch. Materials and methods. From 2011 to 2019 at the National M.M. Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine and Ukrainian Children’s Cardiac Center 16 infants underwent aortic arch repair using autologous pericardial patch. The group included 6 (37.5%) male and 10 (62.5%) female patients. The mean age of the patients was 1.3 ± 0.9 months (from 0.06 to 4.5 months), the average body weight was 3.8 ± 1.6 kg (from 2.2 to 8.7 kg). The average body surface area was 0.24 ± 0.05 m?. Antegrade selective cerebral perfusion was performed in all the patients during the aortic arch reconstruction. Results. Hospital mortality was 6.2% (n = 1). The cause of death was not related to the reconstruction technique. The average duration of cardiopulmonary bypass was 142.5 ± 38.5 minutes, the aortic cross-clamp time was 76.9 ± 33.7 minutes, and the time of selective cerebral perfusion was 50.4 ± 25.4 minutes. Six patients (37.5%) in the early postoperative period had delayed sternal closure. According to echocardiographic data at discharge, the average pressure gradient at the site of aortic arch reconstruction was 15 ± 5.5 mm Hg, the left ventricular ejection fraction was 65.9 ± 5.9%. The mean follow-up period ranged from one month to 6.1 years (mean 2.8 ± 2.3 years). There were no deaths in the long-term period. Four (25%) patients developed aortic arch restenosis in the postoperative period. One patient presented with an aortic arch aneurysm 1 month after the initial operation. There were no cases of compression of the trachea, main bronchi, neurological complications in the follow-up period. Conclusions. The use of autologous pericardium in aortic arch reconstruction is an effective and safe procedure for infants with good immediate and long-term results. The study showed that autologous pericardium may be an acceptable alternative to reconstruct the aortic arch. A large percentage of reinterventions encourages more thorough removal of ductal tissues and determining the size of the autopericardial patch.

Surgical management of a giant right coronary artery aneurysm with coronary arteriovenous fistula: case report

Background Coronary artery aneurysms (CAAs) are uncommon, and giant aneurysms (>2 cm) are even more unusual. Coronary atherosclerosis and Kawasaki disease are the leading causes for this pathology. The treatment for this condition is controversial because the evidence is based on case report series. Case summary We describe the case of a 77-year-old female patient who presented with heart failure symptoms. She was diagnosed with a giant saccular aneurysm arising from the right coronary artery (RCA) ostium and a fistula between the RC and the left anterior descending artery (LAD) to the coronary sinus. And an atrial septal defect (ASD) and severe tricuspid regurgitation were also found. The patient underwent surgery through a medium sternotomy, the aneurysm was opened and resected under cardiopulmonary bypass. The RCA was ligated at the distal end of the aneurysm, and a saphenous vein graft bypass was performed. A coronary arteriovenous fistula from the distal portion of RC and LAD artery to a severely enlarged coronary sinus was found and corrected with an autologous pericardial patch. Closure of the ASD was performed with a pericardial patch and a tricuspid ring annuloplasty was done. Post-operative course was uneventful. Discussion There are few cases of giant coronary aneurysms associated with fistulas reported in the literature. Despite the endovascular percutaneous techniques available to treat these patients, we believe that surgical treatment was the best option for this particular case. We consider that surgical treatment is a very good option for giant CAAs associated with AV fistulas that are not susceptible for current endovascular available devices. The literature lacks evidence regarding the best approach for these cases, and we think that invasive treatment should be tailored according to the heart’s anatomy and patient risk.

A Case Report of Infective Endocarditic Aortic Valve Abscess with Perforation in Infant

Background: Infective endocarditis (IE) is an uncommon but a potentially life-threatening infectious disease in children. The epidemiology of IE has changed in the past three to four decades and its incidence has been increasing recently. This case with atypical present including culture-negative and no-cardiovascular diseases got cardiovascular structural damage that deteriorate in short time. Case presentation: This case was an infant less than one year old without basic cardiovascular disease,and this case was admitted with Kawasaki disease early. His diagnosis was infective endocarditic aortic valve abscess with perforation. The patient received intravenous injection of cefotaxime for two days and piperacillin sulbactam and cefazolin for six days. On 9 th day, piperacillin sulbactam combining with vancomycin were used. On 10 th day, the patient was sent to cardiac surgery department to receive aortic valve repair. The operation is successful.The abscess cavity of the inferior aortic valve and the vegetations on the aortic valve were completely removed, the left coronary valve was removed, and the left coronary valve was locally widened by autologous pericardial patch. Conclusions: Infective Endocarditis in children may be difficult to diagnosis and manage.and the treatment are becoming a new challenge for conventional antibiotic therapy. Some IE require serial follow-up to determine potential need for subsequent cardiovascular surgery (CVS) intervention despite microbiologic cure with antimicrobial therapy.

Enlargement Of Left Ventricular Outflow Tract Using An Autologous Pericardial Patch For The Anterior Mitral Valve Leaflet And Septal Myectomy Through Trans-mitral Approach For The Treatment Of Hypertrophic Obstructive Cardiomyopathy

Background: Modified Morrow procedure is the gold standard of surgical intervention for hypertrophic obstructive cardiomyopathy (HOCM). However, there are certain cases without clear exposure through the traditional trans-aortic approach; we therefore described a trans-mitral approach by enlarging left ventricular outflow tract (LVOT) using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy. We aimed to retrospectively analyze this series of patients to reveal its safety and efficiency.Methods: We retrospectively analyzed 16 HOCM patients underwent enlargement of LVOT using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy through trans-mitral approach in our center from January, 2016 to December, 2019. Baseline characteristics, operative details and postoperative data were extracted from our hospital medical records. Results: Of the 16 patients, there was no operative mortality. No new onset atrial fibrillation, no new onset stroke with symptoms, no permanent pacemaker implantation and no ventricular septal defects formation were observed during operation and three months follow-up. The peak pressure gradient of LVOT decreased from 97.56±23.81 mmHg to 7.56±2.13 mmHg (P < 0.01) after operation and 10.19±2.93 mmHg (P < 0.01) three months after operation. The average aortic cross-clamp time was 54.56±6.10 mins (range, 48 to 69 minutes). The systolic anterior motion (SAM) sign disappeared uneventfully in all cases. No patients had more than moderate MR.Conclusions: Enlargement of LVOT using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy through trans-mitral approach is feasible and reliable for the treatment of certain types of HOCM cases.Trial registration: Not applicable.