Bentall–De Bono procedure for aortic regurgitation and intraoperative rupture of moderately dilated ascending aorta: A case report

<p>We herein present a clinical case of root and ascending aortic replacement in a patient with borderline enlargement of the ascending aorta and aortic valve insufficiency. A 65-year-old man was admitted to our clinic with signs of heart failure. Subsequent echocardiography and contrast-enhanced computed tomography revealed hemodynamically significant aortic insufficiency, as well as expansion of the ascending aorta. Diameter at the levels of the sinuses of Valsalva, sinotubular junction and tubular portion of the ascending aorta were 48, 47 and 44 mm, respectively. Based on the aforementioned data, indications for isolated aortic valve replacement were determined. Although the main portion of the surgery was unremarkable, at its final stage, a rupture of a section of the ascending aorta occurred. The results of intraoperative express histological examination of the enlarged aorta revealed connective tissue dysplasia and cystic median necrosis. Replacement of the ascending aorta was performed using the modified Bentall–De Bono technique. This case demonstrated that a borderline aortic dilatation of 40–50 mm at the ascending aorta was associated with pathological changes in its wall, which can cause fatal complications (rupture and dissection) and may require a more aggressive approach during surgical correction. Intraoperative express histological examination of the wall of the ascending aorta in ambiguous situations can help determine the scope of the intervention.</p><p>Received 16 March 2021. Revised 14 September 2021. Accepted 15 September 2021.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> The authors declare no conflict of interest.</p><p><strong>Contribution of the authors<br /> </strong>Literature review: S.Yu. Boldyrev, M.A. Marukyan<br /> Drafting the article: S.Yu. Boldyrev, M.A. Marukyan, V.N. Suslova<br /> Critical revision of the article: S.Yu. Boldyrev, V.A. Porkhanov<br /> Surgical treatment: S.Yu. Boldyrev, M.A. Marukyan<br /> Final approval of the version to be published: S.Yu. Boldyrev, M.A. Marukyan, V.N. Suslova, K.O. Barbukhatti, V.A. Porkhanov</p>

Subcapsular hepatic hematoma as a complicating cardiac surgery

An 80-year-old woman was hospitalized for aortic valve insufficiency, paroxysmal atrial fibrillation, and ascending aortic aneurysm. She underwent aortic valve replacement, pulmonary vein isolation, left atrium appendectomy, and ascending aorta replacement. She developed a subcapsular hepatic hematoma during the surgery. The patient was managed conservatively and discharged successfully.

Cardiac involvement in Multisystem Inflammatory Syndrome in Children cases

Multisystem Inflammatory Syndrome in Children is a rare form of COVID-19 that affects various organ systems and carries the risk of morbidity and mortality. Cardiac involvement is commonly observed in Multisystem Inflammatory Syndrome in Children cases; hence, this study was conducted to evaluate the cardiac findings of the Multisystem Inflammatory Syndrome in Children cases that were diagnosed and followed up in our hospital. Materials and methods: The medical histories, laboratory results, cardiac findings, and treatments of the cases that were diagnosed with Multisystem Inflammatory Syndrome in Children between December 2020 and August 2021 were evaluated retrospectively. Results: Our study group consisted of 14 males and 12 females whose median age was 3.67 years. Of the 26 patients, 24 had echocardiographic findings and 12 cases had cardiac pathologies that were mostly mild. Among these, mitral valve insufficiency, coronary artery pathology, and pericardial effusion were the most common. Perivascular brightness, aortic and tricuspid insufficiency, systolic dysfunction, and tricuspid thrombosis were less common. The cardiac pathologies of all patients resolved in less than a month following treatment. Conclusion: Although the cardiac pathologies of Multisystem Inflammatory Syndrome in Children cases disappear fairly rapidly, the long-term cardiac effects of this disease are not known clearly. To improve our current understanding of Multisystem Inflammatory Syndrome in Children, more multi-centred studies with long-term follow-up periods should be conducted, and treatment protocols for cases of different severities should be developed to maximise the treatments’ efficacy.

610 Fontan associated kidney and liver disease: can we predict organ involvement with echocardiographic assessment of systolic function and atrioventricular valve insufficiency?

Aims Fontan operation represents the surgical palliative option for congenital heart disease with single ventricle physiology. With the improvement of surgical and percutaneous technique, we are facing a growing population of patients with an unique pathophysiology and potential complications. Methods and results Patients that underwent Fontan palliation in our centre between 1993 and 2016 were included in this prospective study. We excluded patients with major congenital renal anomalies, those that underwent cardiac transplantation, and redo-Fontan patients. All the subjects underwent clinical evaluation, laboratory exams with complete renal and hepatic function, transient hepatic elastography, and complete cardiac evaluation. We used Schwartz equation for estimating glomerular filtration rate in patients younger than 18 years, and CDK-EPI equation for adult patients. We enrolled 35 patients, 46% female (N = 16), and 54% male (N = 19). Medium age was 17 years old, median age 15 years old (range: 10–31 years old). Medium time from Fontan completion was 160 months (range: 57–340 months). Regarding to cardiac anatomy, 10 patients had functional single left ventricle (FSLV, 28.5%) and 21 a functional single right ventricle (FSRV, 60%); 4 patients had undetermined single ventricle (11.5%). Total cavo-pulmonary connection (TCPC) with intracardiac lateral tunnel was performed in 7 patients (20%, N = 7), whereas 28 patients had TCPC with external conduit (80%). Data from echocardiographic evaluation showed a medium EF established with Simpson’s method of 60% in patients with FSLV; patients with a FSRV or undetermined single ventricle had a medium FAC of 41.1%, with 15.1% having a reduced FAC &lt; 35%. No FSLV patients had an EF &lt; 50%. When using creatinine-based formula, data about renal function in our population showed a stage 2 chronic kidney disease (eGFR: 60–89 ml/min 1.73 mq) in 11% of total population (N = 4), that became 26% when using cystatin C-based equation (N = 9), with one patient showing a moderate reduced loss of kidney function (eGFR: 40–59 ml/min 1.73 mq). Urinalysis showed 29% (N = 10) of patients having microalbuminuria (microalbumin/creatinine ratio between 30 and 300 mg/g). Statistical analysis demonstrated a negative correlation between systolic function (TAPSE for FSRV) and cystatin C blood levels (Pearson’s R −0.428, P = 0.053), and between systolic function (FAC and Simpson) and microalbuminuria (Pearson’s R −0.414 with P = 0.049 and Pearson’s R −0.754 with P = 0.019, respectively). Transient elastography reported 10 patients (29.4%) with abnormal hepatic stiffness for Fontan patients. That condition appeared to be more frequent in patients with higher grade of AV valve insufficiency (P &lt; 0.05). Conclusions Our population showed an higher prevalence of FSRV Fontan patients, with an expected lower systolic function compared with FSLV. 2D evaluation of systolic function showed a linear inverse correlation with renal function, suggesting that Fontan patients need a closer renal monitoring. Hepatic stiffness, which is a warning sign of potential hepatic cirrhosis need to be monitored in all Fontan patients, especially those with a worse AV valve insufficiency.

Experience in the use of steroid hormones in the complex treatment of rheumatism and some other diseases in children

Of 33 patients with active rheumatism in 1958-60. 20 received cortisone and 13 received ACTH. Myocarditis was observed in 5 people, endomyocarditis with mitral valve insufficiency - in 1, endomyocarditis with combined defects - in 23, pancarditis with combined defects - in 4. Articular manifestations (polyarthritis, polyarthralgia) were noted in 16 children. Only 5 children fell ill with rheumatism for the first time.

Murmur on top of the head: bioprosthetic mitral valve insufficiency

In 1961, K Merendino ‘in pure curiosity’, while tracking the murmur of mitral regurgitation, placed his stethoscope ‘on the vertex of the head’, and ultimately led to a medical curiosity and exam finding that not only bears his name, but awes medical learners at all stages of their careers. Merendino and colleagues collected seven such cases of the ‘Murmur on Top of the Head’ building on the work of others who provided a detailed description of mitral regurgitation and noted murmur radiation to the neck and cervical/lumbosacral spine. The majority of patients suffered from rheumatic heart disease or subacute bacterial endocarditis in native heart valves. Here, we report on a case of the ‘Murmur on Top of the Head’ and provide the reader/listener with a direct recording of the ‘Merendino murmur’ (as well as its spinal correlate) in an elderly woman with a bioprosthetic mitral valve.

MODERN PRINCIPLES OF DIAGNOSIS AND SURGICAL TREATMENT OF ISCHEMIC MITRAL INSUFFICIENCY

The purpose of the study is to evaluate and analyze the results of surgical treatment of patients with ischemic mitral insufficiency. Material and methods. The results of the examination and surgical treatment of 35 patients with ischemic mitral insufficiency are analyzed. In the operative period, in order to identify the degree of mitral insufficiency and the valvular apparatus, an echocardiography was performed, where the diameter of the fibrous ring, the interpapillary distance, the annulopapillary distance, the area of the cusp tension, and the depth of the coaptation of the valves were determined. Results. A preoperative examination proved the presence of mitral valve insufficiency with regurgitation of varying degrees. 15 patients underwent myocardial revascularization, 20 patients underwent myocardial revascularization + various options for correction of ischemic mitral insufficiency. After the operation, a significant improvement in the spatial-geometric correlation of the LV and mitral valve by reducing the tension forces acting on the valves and in the group of patients undergoing myocardial revascularization + various options for the correction of ischemic mitral insufficiency as the elimination of regurgitation. Conclusion. In patients with ischemic heart disease after echocardiographic studies, having determined the degree of mitral insufficiency with its moderate and severe degree, it is necessary to have a surgical correction of the mitral valve in its apparatus; the use of myocardial revascularization + various options for the correction of ischemic mitral insufficiency gives more tantalizing results than isolated myocardial revascularization.

Neonatal Marfan syndrome with missense variant of c.3706T>C undergoing bilateral atrioventricular valve replacement

Neonatal Marfan syndrome is a rare condition with poor prognosis because of severe mitral and/or tricuspid valve insufficiency. Mitral valve replacement is sometimes required in early infancy, while tricuspid valve replacement is rarely done. We report the first infant neonatal Marfan syndrome case with a missense variant of c.3706T>C in the fibrillin-1 gene that was successfully managed by mitral and tricuspid valve replacement. Early multiple-valve replacement may sometimes be required during infant age in this genetic syndrome.

Combining Aesthetic Septorhinoplasty With Bioabsorbable Implants for Nasal Valve Insufficiency

This case report demonstrates the usage of a bioabsorbable nasal implant (BNI) in conjunction with an aesthetic septorhinoplasty. The authors uniquely chose to use this allograft due to inadequate autologous tissue secondary to previously performed temporomandibular joint arthroplasties. In addition to evaluating our case of a 22-year-old woman who received a BNI with an aesthetic septorhinoplasty, the authors performed a comprehensive literature review on the topic. Spanning 3 databases (Scopus, PubMed, and Cochrane), this review revealed 4 primary studies, totaling 349 patients. Each utilized nasal obstruction symptom evaluation (NOSE) scores to subjectively measure symptomatic improvement. We chose to use the NOSE questionnaire on our patient both preoperatively and postoperatively, in order to help demonstrate subjective improvement. The patient’s functional and aesthetic concerns were addressed in the operating room at Parkland Memorial Hospital under general anesthesia. Notably, the patient had previously had conchal cartilage harvested bilaterally, had insufficient septal cartilage for adequate grafting, and did not desire to undergo costal cartilage harvest. Therefore, all parties agreed to use a BNI to complete the functional component of the patient’s septorhinoplasty. This day-surgery first focused on the aesthetic septorhinoplasty followed by the placement of the BNI bilaterally. Following an uneventful postoperative course, our patient endorsed not only an aesthetic improvement but also an 88% functional improvement based on her NOSE score within 4 months of surgery. The authors were able to successfully integrate functional as well as aesthetic septorhinoplasty techniques under the constraints of having both limited autologous tissue and limited accepted options from the patient. For the patient and provider team, this newer allograft was confirmed to be effective and efficient. With the correct patient selection, this is an excellent adjunct procedure that can be quickly and safely performed either in conjunction with surgical rhinoplasty or as a standalone procedure by facial surgeons.