Kommerell's diverticulum of retroesophageal aberrant brachiocephalic artery with right aortic arch in an adult

A retroesophageal aberrant brachiocephalic artery is a very rare congenital aortic arch anomaly. We herein presented a 29-year-old man with right aortic arch, retroesophageal aberrant left brachiocephalic artery, left ligamentum arteriosus, and absent left internal carotid artery. Graft replacement of the descending aorta and anatomical reconstruction of left brachiocephalic artery was successfully performed using a midline sternotomy approach without blood transfusion. We discuss the surgical management for Kommerell's diverticulum.

Complications of epi- and endocardial pacing in children

Aim To analyze complications of cardiac pacing in children depending on the implantation method. Actuality Recently epicardial lead implantation becomes more and more popular either due to more serious complications of transvenous pacing or due to possibility of choice of hemodynamically optimal pacing zone. Methods and materials 242 patients with pacemakers are under our supervision. Epicardial pacemakers were implanted to 145 patients, endocardial – to 97 patients. In “old era” in most children the primary epicardial implantations were performed at RV free wall. In 27 children, having primary implantation at our Institute lately, the epicardial lead was placed at LV apex, or endocardial – at RV apex. Results The comparative analysis of complications of epi- and endocardial implantation showed the following results: 22% of complications at epicardial stimulation, and at transvenous stimulation – 45%. The most often complications at epicardial stimulation (53%) were connected with hemodynamic disorders – dyssinchronous cardiomyopathy. Hemodynamic complications, connected with dyssinchrony of endocardial RV pacing, were disclosed in 16%. The most often complication of endocardial stimulation was TV insufficiency (32%). Venous vessel thrombosis was diagnosed in 9%. Epicardial and transvenous lead failure was discovered in similar percentage ratio (28%). Infectious complications of transvenous pacing, especially, bacterial endocarditis, took place in 6,8%. Thus, progressive bacterial endocarditis and TV insufficiency (3d deg.) appeared in one patient in 10 years after the primary implantation. Afterwards, elimination of endocardial system by open surgery, TV plasty followed by epicardial pacing implantation are required. Infection of pacing site was disclosed in both types of implantation (1%). Perforation of atrial endocardial lead was found in two cases (4%). A case of mechanical complication (cardiac strangulation) was diagnosed in a child (3%) in four years after the primary implantation of epicardial pacing system. Pericarditis was recorded immediately after the epicardil pacemaker implantation in 9% of cases. Our center performs epicardial lead implantation with the help of midline sternotomy that provides clear approach to right atrium. However, the difficulties of lead fixation at LV apex appear here. It concerns, especially, the patients after CHD correction as the repeated sternotomy in them presents high risk of RV insufficiency. Nevertheless, the given approach is still the best possible with epicardial pacing if there is a “preclude”, sufficient experience of CHD correction. Conclusion The possibility of choice of optimal epicardial pacing site exceeds risks of leads and midline sternotomy. Any primary pacemaker implantation in children of any age with ventricular lead should be epicardial. FUNDunding Acknowledgement Type of funding sources: None.

Solving the impossible. Penetrating cardiac injuries, a case series of diagnostic workup and management

For a long time, any heart-based injury was an off-limits area for surgeons; a patient with a traumatic cardiac injury was doomed to die. Little more than one hundred years have passed since the first surgical correction of a penetrating cardiac injury and there is still a high rate of mortality, despite the medical advances. We present the case of 6 patients with penetrating cardiac injuries that were repaired at a third level hospital of Mexico, alongside relevant findings on the literature about the topic. From 2019 to 2020, an incidence of 6 patients with penetrating cardiac injuries was present; all men aged 30 years or older. The etiology of 4 (67%) patients was stab wounds and 2 (33%) gunshot wounds. Left anterolateral thoracotomy was used on 5 (83%) patients and midline sternotomy on 1 (17%) patient. 2 (33%) injuries on the left ventricle presented along with coronary arteries injuries. Left ventricle and right atrium injuries presented each 50% of mortality. The mortality was of 33%, 1 patient died due to intraoperative complications and another one due to massive cerebral infarction and polyuric syndrome because of diabetes insipidus. There is a long path ahead of the surgical field on this topic and further to be analyzed. An excellent tool for cardiac tamponade diagnosis due to penetrating cardiac injuries is cardiac ultrasound, therefore it should be used on every hemodynamic unstable patient in the context of PCI. Definitively, time is of the essence, and the survival of patients depends on immediate transport to a hospital and an opportune surgical intervention.

Minimally Invasive and Robotic Mitral Valve Surgery: Methods and Outcomes in a 20-Year Review

In the mid- to late-1990s the cardiac surgery community began to apply limited incisions in mitral valve surgery. Ministernotomies and right-sided minithoracotomies were placed instead of the classic midline sternotomy. Adjunct technology such as videoscopy, advanced peripheral cannulation techniques, procedure specific long shafted surgical instruments, as well as surgical robots became available, and the procedures were refined in a stepwise fashion. In 2021, minimally invasive mitral valve repair is routine at many centers around the globe. We reviewed a total of 50 consecutive patient series published on the topic between 1999 and 2019. Three main versions of minimally invasive mitral valve surgery were applied in 20,539 patients. The surgical methods, their specific results, and the cumulative outcome of less invasive mitral valve surgery published over more than 20 years are reported and an integrated view on what less invasive mitral valve surgery can offer is presented.

Multiorgan thrombosis as a complication of COVID-19 pneumonia

A 47-year-old man, positive for SARS-CoV-2, was diagnosed with acute coronary syndrome (ACS) complicated by myocarditis on a background of COVID-19 pneumonia. He was medically treated for ACS; however, 3 days into his admission, the patient developed neurological complications confirmed on MRI of the brain. MRI showed established infarcts involving a large part of the left temporal lobe and right occipital lobe, with minor foci of micro-haemorrhagic transformation in the left temporal lobe. A left ventricular mural thrombus was then confirmed on echocardiogram, and this was attributed as the cause of his neurological infarct. Further infarctions in the kidneys and spleen, and thrombi in the superior mesenteric and left femoral artery were also identified on imaging of the abdomen. The left ventricular mural thrombus was removed surgically via a midline sternotomy incision under general anaesthesia. Surgery was successful and the patient was discharged to a rehabilitation centre.

Aortic Coarctation of the newborn and infant: predictors of morbidity and mortality

Funding Acknowledgements Type of funding sources: None. Introduction Aortic coarctation represents 8% of all congenital heart disease. Whether isolated or associated with an intra or extra cardiac anomaly, newborns or infants coarctation could lead to early heart failure. this specific form can be associated with peri-operative difficulties and subsequent complications especially recoarctation and late hypertension. Objective : our objective is to determine the predictive factors of morbi-motality in this disease. Methods It’s a monocentric and restrospcetive study of 34 newborns and infants operated on for aortic coarctation between January 2010 and december 2019. Clinical, paraclinical and therapeutic data have been collected. Results Our study include 23 newborns and 11 infants, with sex ratio of 2,4. The diagnosis was retained at an average age of 2 months and 2/3 of which before the age of 1 month. The main clinical signs were an abnormality of the femoral pulses in 92% of cases (abolished in 15 babies), tachycardia with polypnea in 68% of cases and hypertension in 48% of patients. Other signs are less common, such as hepatomegaly (44%), left side-sternal murmur (38%) and hypotrophy (20.6%). The mean gradient in blood pressure between the upper and lower limbs was 22 mm Hg [17-38mmHg]. Eight patients required mechanical ventilation. Biological examinations showed metabolic acidosis in 8 patients hepatic failure and renal failure in five patients each one. On the chest x-ray, 60% had cardiomegaly and 42% had pulmonary edema. The trans-thoracic echocardiography detect coarctation in all cases which was preductal in 70.6% of cases. The averge of trans-isthmic gradient was 37mmHg. The main associated cardiac abnormalities were: IVC in 7 patients and aortic bicuspid in 6. However, persistent ductus arteriosus was in 27 cases (79.4%). Cardiac catheterization was used in 5 babies aged between 4 and 9 months with a mean trans-isthmic hemodynamic gradient of 65 mmHg [45-100] and MRI and Ct scann was done in 3 patients each one. The average weight at the time of the operation was 4.780 kg [2.4-9.8]. 3 newborns were operated between the 9th and 20th days of life. The first approach was a posterolateral thoracotomy in the left 4th intercostal space in 33 patients and a vertical midline sternotomy in a single infant with a total abnormal pulmonary venous return. The modified Crafoord technique (extended-anastomosis) was performed in the majority of cases (97.05%) and 4 patients with unrestricted IVC required also pulmonary artery banding. The overall mortality rate was 29.4%. Prematurity, a birth weight <2.5 kg, an operative age <120 days and complex heart disease were significantly associated with mortality (P< 0.05). Conclusion Coarctation of the aorta in newborns and infants is a surgical emergency in some cases, with still high mortality despite the surgical and anesthetic progress.

Right axillary minithoracotomy: An alternative access to close an ASD

A vertical right axillary thoracotomy is a favorable alternative to a median sternotomy for surgical correction of common congenital heart defects in patients of all ages. The right-sided heart structures can be approached through a 4- to 5-cm vertical incision in the midaxillary line. In contrast to a midline sternotomy, osseous thoracic structures can be preserved through a muscle-sparing approach simply by retracting the ribs. Consequently, recovery is usually faster, and the resulting scar is completely hidden under the resting arm. In addition, there is no need for special equipment. The entire operation can be performed with established techniques. Operative outcome and long-term results have been shown by several research groups to be comparable to those obtained with a median sternotomy. This tutorial demonstrates the stepwise performance of an axillary thoracotomy and the extracorporeal circulation setup by the example of the closure of an atrial septal defect.

Surgical Repair of a Transannular Rupture During Transfemoral Transcatheter Aortic Valve Replacement

Annular rupture is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR). Mortality rates are high if immediate intervention, most often necessitating surgical repair, is not performed. Herein, we describe an 87-year-old man who, after deployment of TAVR, experienced acute decompensation and required urgent conversion to a midline sternotomy to repair an aortic annular rupture. This case demonstrates an example of a rare but severe complication of TAVR. This report provides an in-depth description of the surgical approach to repair an aortic annular rupture and demonstrates the utility of performing minimally invasive procedures inside a hybrid operating room.

Right Anterior Mini-Thoracotomy for Discrete Fibromembranous Subaortic Stenosis

Discrete fibromembranous subaortic stenosis is a common type of subaortic stenosis causing clinically significant left ventricular outflow obstruction. Surgery for discrete subaortic stenosis is most often performed through a typical midline sternotomy. Herein, we present our experience with an adult patient who underwent a right mini-thoracotomy for subaortic membrane resection with central cannulation under direct operative vision.