Approach to a large rare diaphragmatic hernia in a patient undergoing cardiac surgery.

Hernia of Morgagni is an unusual congenital defect of the sternal portion of the diaphragm. Its concurrence with cardiac surgical pathology is rarely described in the literature. Notwithstanding, huge hernia of Morgagni have been noted to cause serious peri-operative impediment and complications.

An Intervention to Reduce the Time Interval Between Hospital Entry and Emergency Coronary Angiography in Patients with ST-Elevation Myocardial Infarction.

Background: Outcomes of patients with acute ST-elevation myocardial infarction (STEMI) are strongly correlated to the time interval from hospital entry to primary percutaneous coronary intervention (PPCI). Current guidelines recommend a door to balloon time of < 90 minutes.

Objectives: To reduce the time from hospital admission to PPCI and to increase the proportion of patients treated within 90 minutes.

Systemic inflammatory response syndrome after transcatheter or surgical aortic valve replacement.

Objective: An inflammatory response after cardiac surgery is associated with worse clinical outcomes, but recent trials to attenuate it have been neutral. We evaluated the association between systemic inflammatory response syndrome (SIRS) and mortality after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) for aortic stenosis (AS) and evaluated whether diabetes influenced this relationship.

Methods: Patients (n=747) with severe AS treated with TAVR (n=264) or SAVR (n=483) between January 2008 and December 2013 were included and 37% had diabetes mellitus.

Potential neurotoxic effects of polymethylmethacrylate during cranioplasty.

Cranioplasty for the surgical correction of cranial defects is often performed using polymethyl methacrylate (PMMA), or bone cement. Immediately prior to PMMA application, a liquid monomer form (methylacrylate) and a benzoyl peroxide accelerator are mixed resulting in polymerization, an exothermic reaction during which monomer linking and subsequent formation of solid polymer occur. The potential side effects of residual methylacrylate monomer toxicity and thermal damage of neural tissue during PMMA hardening have been described in various in vitro, animal, and cadaveric studies; however, clinically documented in vivo neurotoxicity in humans attributed to either of the above two mechanisms during PMMA cranioplasty is lacking.

Multi-modality guided trans-apical closure of recurrent mitral para-valvular regurgitation after failed surgical management in a patient with osteogenesis imperfecta.

We report a case of a 54 year-old man with osteogenesis imperfecta who developed severe para-valvular mitral regurgitation after a second heart operation to correct the same problem. The large para-valvular leak was successfully closed with an Amplatzer Vascular Plug III delivered from the apical approach.

Alkaptonuria-associated aortic stenosis.

Alkaptonuria is an autosomal recessive disorder of tyrosine metabolism, which results in accumulation of unmetabolized homogentisic acid and its oxidized product in various tissues, including the heart. Cardiovascular involvement is a rare but serious complication of the disease. We present two patients who have undergone successful aortic valve replacement for alkaptonuria-associated aortic stenosis along with a review of the literature.

Brain and neck tumors among physicians performing interventional procedures.

Physicians performing interventional procedures are chronically exposed to ionizing radiation, which is known to pose increased cancer risks. We recently reported 9 cases of brain cancer in interventional cardiologists. Subsequently, we received 22 additional cases from around the world, comprising an expanded 31 case cohort.

Stanford type a aortic dissection in pregnancy: a diagnostic and management challenge.

Background: In women under the age of 40, over 50% of type A aortic dissections occur in the obstetric population. This is a complex situation, with potential catastrophic outcomes for mother and child. Time to diagnosis is often delayed by a low degree of suspicion, atypical presentation and difficulties investigating pregnant women.

Brain tumours among interventional cardiologists: a cause for alarm? Report of four new cases from two cities and a review of the literature.

Aims: Interventional cardiologists who work in cardiac catheterisation laboratories are exposed to low doses of ionising radiation that could pose a health hazard. DNA damage is considered to be the main initiating event by which radiation damage to cells results in development of cancer.

Methods And Results: We report on four interventional cardiologists, all with brain malignancies in the left hemisphere.

Targeted nonviral gene-based inhibition of Gα(i/o)-mediated vagal signaling in the posterior left atrium decreases vagal-induced atrial fibrillation.

Background: Pharmacologic and ablative therapies for atrial fibrillation (AF) have suboptimal efficacy. Newer gene-based approaches that target specific mechanisms underlying AF are likely to be more efficacious in treating AF. Parasympathetic signaling appears to be an important contributor to AF substrate.

Pattern of activin A and follistatin release in a sheep model of cardiopulmonary bypass.

Objective: Activin A, a member of transforming growth factor-β superfamily, has been established as a critical cytokine released early in endotoxemia and other inflammatory syndromes. The release of activin A and its binding protein, follistatin during cardiopulmonary bypass (CPB) has not been previously reported. Our study aimed to define the pattern of activin A and follistatin release in a sheep CPB model.

Medtronic Mosaic porcine bioprosthesis: assessment of 12-year performance.

Background: The Mosaic porcine bioprosthesis (Medtronic, Inc, Minneapolis, Minn) was approved in 2000 by the US Food and Drug Administration. Clinical performance was evaluated in 6 centers.

Methods: From 1994 to 2000, 797 patients (mean age 69 years) had aortic valve replacement (AVR) and 232 (mean 67 years) had mitral valve replacement (MVR).

Epicardial high-intensity focused ultrasound cardiac ablation for surgical treatment of atrial fibrillation.

Background: The available alternatives to an effective but technically complex Cox maze procedure for surgical treatment of atrial fibrillation include ablation using radiofrequency, microwave, laser, cryotherapy or ultrasound energy sources. The purpose of this study was to evaluate the safety and efficacy profile of high-intensity focused ultrasound cardiac ablation for the surgical treatment of atrial fibrillation.

Methods: 14 patients underwent epicardial high-intensity focused ultrasound treatment for atrial fibrillation using the Epicor cardiac ablation system between August 2006 and August 2007.

Managing deep sternal wound infections with vacuum-assisted closure.

Deep sternal wound infection is an uncommon but serious complication of cardiac surgery. Currently, there is no consensus on the optimal management. Vacuum-assisted closure (VAC) has been increasingly used to facilitate wound healing.

Giant coronary artery aneurysms in Kawasaki disease--the need for coronary artery bypass.

The incidence of coronary artery involvement has fallen markedly following early gammaglobulin infusions in Kawasaki disease. Nevertheless such involvement may still occur and if giant coronary aneurysms develop they are more likely to lead to myocardial ischaemia. Two subjects are described who developed giant aneurysms, one of whom was subjected to successful coronary artery bypass following the detection of myocardial ischaemia on a nuclear perfusion scan 5 years following his acute episode.

Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin.

To examine the impact of contrast enhanced multidetector computed tomography (MDCT) on clinical decision-making in patients who present to the emergency department (ED) with chest pain of possible ischemic origin, we studied 58 consecutive patients (age 56 +/- 10 years, 36% female) with chest pain, intermediate risk, and no ischemic electrocardiographic changes or increased biomarker measurements. After standard ED patient assessment including cardiology consultation, a diagnosis of acute coronary syndrome was made in 41 patients (71%), hospitalization was recommended in 47 (81%), and 32 (55%) were scheduled for an early invasive strategy. Patients underwent 64-slice contrast agent-enhanced MDCT with image reconstruction in multiple formats using retrospective electrocardiographic gating, which revealed normal (no or trivial atheroma) coronary vasculature in 15 patients, nonobstructive atheroma in 20 patients, and obstructive coronary disease (> or =1 luminal narrowing of > or =50%) in 23 patients.

Urgent transcatheter closure of patent foramen ovale followed by elective right-sided valve surgery for decompensated carcinoid heart disease.

The presence of a patent foramen ovale (PFO) is associated with morbidity and mortality in patients with carcinoid heart disease (CHD). We report a 66-year-old male patient with tricuspid and pulmonary valve regurgitation secondary to CHD, who developed severe hypoxia due to a right-to-left shunt through a PFO. A 35 mm Amplatzer septal occluder was deployed to reduce the right-to-left shunt as an urgent procedure.

Prevalence and extent of obstructive coronary artery disease in patients with zero or low calcium score undergoing 64-slice cardiac multidetector computed tomography for evaluation of a chest pain syndrome.

We examined the extent of coronary artery disease (CAD) on 64-slice contrast-enhanced multidetector computed tomography in patients who underwent investigation of a chest pain syndrome who had a zero or low coronary calcium score (CS). In 668 consecutive patients with chest pain syndromes (39% with acute presentation, 61% with long-term presentation) who underwent cardiac multidetector computed tomography, we assessed prevalence and severity of coronary stenoses (>or=1 coronary artery stenosis with >or=50% luminal narrowing) in 231 patients (54 +/- 12 years of age, 45% women) with a 0 (n = 125) or low (n = 106) coronary CS. Obstructive (>or=50% lesion) CAD was present in 27 of 231 patients, in 9 of 125 patients (7%) with a 0 CS, in 18 of 106 (17%) with a low CS (1 to 100), and in 14 of 90 patients (16%) with an acute presentation and 13 of 141 patients (9%) with a long-term presentation (p = NS).

Thrombolysis followed by early revascularization: an effective reperfusion strategy in real world patients with ST-elevation myocardial infarction.

Background: Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes.

Methods: A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center.

Predictors of surgery after percutaneous mitral valvuloplasty.

Background: Percutaneous mitral valvuloplasty (PMV) is a minimally invasive treatment option for selected patients with mitral stenosis (MS). In general, the procedure is well-tolerated with a high success rate. However, relatively little is known about the predictors of surgical intervention after PMV.

Experience with unipolar radiofrequency ablation for atrial fibrillation.

Background: The cut and sew Cox maze procedure for atrial fibrillation (AF), although effective, is not widely used because of technical complexity, prolonged duration and significant risk of postoperative bleeding. This study reviews our experience with the unipolar radiofrequency ablation (RFA) procedure, which was used to create a modified maze to treat AF.

Methods: A retrospective review of 31 patients undergoing consecutive cardiac surgery who had concomitant RFA for AF over a 16-month period was carried out.