Stubborn Hypoxia in Neonates with D-Transposition of the Great Arteries after Arterial Switch Operation: Central Sleep Apnea as the Cause and Potential Indicator of Brain Immaturity

D-transposition of the great arteries(d-TGA)is surgically repaired with the arterial switch operation(ASO)with excellent results,however short and long-term morbidities still develop including neurocognitive delay.Clinically significant central sleep apnea is uncommon in non-premature infants,but when present indicates immature autonomic control of respiration likely due to a neurologic disorder.We report the unanticipatedfinding of central sleep apnea in four-term neonates with d-TGA after uncomplicated ASO,with the short-term complication of delayed hospital discharge and long-term concerns regarding this early marker of brain immaturity and its hindrance to normal development.Within this report,we will review each patient’s clinical course and then examine the literature on pediatric central sleep apnea,neurodevelopmental outcomes after ASO,and the important overlap of these entities in the care of patients going forward.

Considerations for the use of porcine organ donation models in preclinical organ donor intervention research

Use of animal models in preclinical transplant research is essential to the optimization of human allografts for clinical transplantation.Animal models of organ donation and preservation help to advance and improve technical elements of solid organ recovery and facilitate research of ischemia-reperfusion injury,organ preservation strategies,and future donor-based interventions.Important considerations include cost,public opinion regarding the conduct of animal research,translational value,and relevance of the animal model for clinical practice.We present an overview of two porcine models of organ donation:donation following brain death(DBD)and donation following circulatory death(DCD).The cardiovascular anatomy and physiology of pigs closely resembles those of humans,making this species the most appropriate for pre-clinical research.Pigs are also considered a potential source of organs for human heart and kidney xenotransplantation.It is imperative to minimize animal loss during procedures that are surgically complex.We present our experience with these models and describe in detail the use cases,procedural approach,challenges,alternatives,and limitations of each model.

Evolution of heart transplant donor characteristics in the 21st century: A United States single center’s experience

Despite a record setting number of heart transplants performed annually,the national donor shortage continues to plague transplant teams across the United States.Here we describe the barriers to adaptation of numerous“non-traditional”orthotopic heart transplant donor characteristics including donors with hepatitis C virus,those meeting criteria for donation after cardiac death,donors with coronavirus disease 19 infection,donors with the human immunodeficiency virus,and grafts with left ventricular systolic dysfunction.Our center’s objective was to increase our transplant volume by expanding our donor pool from“traditional”donors to these“non-traditional”donors.We detail how medical advances such as certain laboratory studies,pharmacologic interventions,and organ care systems have allowed our center to expand the donor pool thereby increasing transplantation volume without adverse effects on outcomes.

Extracellular Vesicles from Mesenchymal Stromal Cells (imEVs) Improve Cold Preservation of Isolated Mitochondria

Mitochondrial organelle transplantation (MOT) is an innovative strategy for the treatment of mitochondrial dysfunction such as cardiac ischemic reperfusion injuries, Parkinson’s diseases, brain and spinal cord injuries, and amyotrophic lateral sclerosis (ALS). However, one of the major challenges for widespread usage is a methodology for preservation of isolated mitochondria. Extracellular vesicles (EVs) are phospholipid bilayer-enclosed vesicles released from cells. EVs carry a cargo of proteins, nucleic acids, lipids, metabolites, and even organelles such as mitochondria. Purpose: To test if EVs enhance the stability of isolated mitochondria. Methods: We mixed isolated mitochondria of fibroblasts with EVs of mesenchymal stromal cells (imEVs) (9:1 in volume) and stored the mixture at 2°C - 6°C for different time periods. We measured morphology, mitochondrial membrane potential (MMP) and mitochondrial ATP content at 0, 2, 5 days. Key findings: After 2 days of storage, the mito-chondria without imEVs lost approximate 70% MMP (RFU: 1822 ± 68), compared to the fresh mitochondria (RFU: 5458 ± 52) (p 0.05). In agreement with MMP, mitochondria without imEVs lost significant mitochondrial ATP content (p 0.05), after 2 days of cold storage, compared to fresh mitochondria. Microscopy showed that imEVs promoted aggregation of isolated mitochondria. Summary: The preliminary data showed that imEVs enhanced the stability of isolated mitochondria in cold storage.

Trans-Frame Aortic Regurgitation of New-Generation Aortic Bioprosthesis

A widely used aortic valve bioprosthesis is susceptible to regurgitation between the sewing ring and the frame of the valve due to its relatively thin fabric coverage. In some cases this leak has been shown to resolve with administration of protamine, however, tension on this area from annular sutures placed in an asymmetric bicuspid valve annulus may exacerbate the defect.

Carotid-subclavian bypass and endovascular aortic repair of Kommerell’s diverticulum with aberrant left subclavian artery:A case report

BACKGROUND Kommerell’s diverticulum(KD)with aberrant left subclavian artery is a rare congenital deformity and also has very little research literature about it(35%of case study).There are three types of aortic arch diverticulum.Even literature concerning the treatment options are limited.CASE SUMMARY We present a case report of a 50-year-old male with KD in the right aortic arch with aberrant left subclavian artery.We conducted a total endovascular repair procedure,which is innovative and will spread more light in the medical world.Our patient has no past medical history and is a non-smoker and non-alcoholic.Patient presented with shortness of breath,chest pain and dizziness for six months.Blood tests were done and computerized tomography(CT)angiogram of the chest confirmed the diagnosis,illustrating showed a 3.9 cm KD.On Day 1,the CT angiogram showed mild dilatation of the thoracic aorta,adjacent esophagus,trachea was compressed and displaced.Surgery was planned as the treatment modality.Carotid-Subclavian artery bypass and endovascular aortic repair was conducted.We used prolene 5-0 C1 sutures to precisely anastomose a 6-mm Dacron graft to the left subclavian artery.Haemostasis was secured and wounds were closed.Protamine was administered and patient was shifted to intensive care unit.Post-operative,patient responded favorably and was discharged.Regular follow-up is done.CONCLUSION The procedure we performed is novel.This will help the cardio-thoracic surgeons a better insight about the full procedures we conducted,thereby bringing more light and better treatment options in managing KD with aberrant subclavian artery.

Surgical removal of a large mobile left ventricular thrombus via left atriotomy

Left ventricular(LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus(3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.

Giant hibernoma of the thoracic pleura and chest wall

Hibernoma is a rare tumor containing prominent brown adipocytes that resemble normal brown fat.Brown fat(versus white fat) is predominantly found in hibernating mammals and infants.Brown fat adipocytes contain a higher number of small lipid droplets and a much denser concentration of mitochondria.The tumor can occur in a variety of locations however the extremities,followed by the head and neck,have been the most common sights.All variants of hibernoma described have followed a benign course with the majority presenting as a small,lobulated,nontender lesions.We present a case of a giant hibernoma arising from the pleura which invaded the intra and extra-thoracic chest.

Risk scoring model for prediction of non-home discharge after transcatheter aortic valve replacement

Background Patients undergoing transcatheter aortic valve replacement(TAVR) are likely to be discharged to a location other than home. We aimed to determine the association between preoperative risk factors and non-home discharge after TAVR. Methods Patients discharged alive after TAVR at three centers were identified from a prospectively maintained database randomly divided into 80% derivation and 20% validation cohorts. Logistic regression models were fit to identify preoperative factors associated with non-home discharge in the derivation cohort. Multivariable models were developed and a nomogram based risk-scoring system was developed for use in preoperative counseling. Results Between June 2012 and December 2018, a total of 1,163 patients had TAVR at three centers. Thirty-seven patients who died before discharge were excluded. Of the remaining 1,126 patients(97%) who were discharged alive, the incidence of non-home discharge was 25.6%(n = 289). The patient population was randomly divided into the 80%(n = 900) derivation cohort and 20%(n = 226) validation cohort. Mean ± SD age of the study population was 83 ± 8 years. In multivariable analysis, factors that were significantly associated with non-home discharge were extreme age, female sex, higher STS scores, use of general anesthesia, elective procedures, chronic liver disease, non-transfemoral approach and postoperative complications. The unbiased estimate of the C-index was 0.81 and the model had excellent calibration. Conclusions One out of every four patients undergoing TAVR is discharged to a location other than home. Identification of preoperative factors associated with non-home discharge can assist patient counseling and postoperative disposition planning.

Resolution of hemolysis from pump thrombus during left ventricular assist device exchange

A 50-year-old male who underwent a Heart Mate Ⅱ left ventricular assist device placement for ischemic cardiomyopathy presented with discolored urine and hemolysis 3 mo after the operation. His hemolysis was thought to be due to thrombosis within the pump. Imaging studies were not able to visualize a left ventricular thrombus. Medical management with anticoagulation failed and he underwent surgery for a pump exchange. Intraoperatively, a firm thrombus was found within the pump of the Heart Mate Ⅱ, and the color of the urine changed dramatically from cola-colored to yellow which enabled us to confirm the diagnosis.

Growth of the Pulmonary Valve Annulus after the Modified Blalock-Taussig Shunt in Patients with Tetralogy of Fallot

Background:The surgical outcomes of tetralogy of Fallot(TOF)have evolved dramatically and have resulted in lower mortality rate.Currently,the many cardiac centers have a trend to early single-stage complete repair more than a staged repair.However,the patients who have an early primary repair were required transannular patch augmentation of a pulmonary valve frequently.This effect has been developed a chronic pulmonary insufficiency may lead to right ventricular dilation,dysfunction.In this era,the aim of treatment of TOF is attempted to preserve pulmonary valve annulus for prevent right ventricular dysfunction in the future.The systemic to pulmonary artery shunt is a palliative procedure or known as staged repair for symptomatic patients with TOF.The modified Blalock-Taussig shunt(mBTS)is the most useful systemic to pulmonary shunt and perform as an initial procedure before complete repair.The mBTS can provide increase pulmonary blood flow as well as improve oxygenation and also promote pulmonary artery(PA)growth.However,the effect of this procedure to promote growth of a pulmonary valve annulus is still debate.Objectives:To compare a growth of pulmonary valve annulus between after staged repair and primary repair in patients with TOF(without pulmonary atresia).Methods:A retrospective case-control study,review of patients with TOF underwent total repair at our hospitals from January 2005 and December 2017 was performed,a total number of 112 patients underwent TOF repair.Twenty-nine patients(26%)underwent a staged repair(mBTS group)and 83(74%)underwent total repair only or primary repair(PR group).We evaluated diameter of pulmonary valve annulus by using echocardiography at the time of first diagnosis and before complete repair on both groups.Results:The age of diagnosis of mBTS group were younger than PR group(p=0.011).Therefore,pulmonary valve annuls were smaller in mBTS group.(Z-score,−2.93±1.42 vs.−1.89±0.97;p=0.001).However,the growth potential of pulmonary valve annulus was increase more than PR group significantly(Z-score,−1.46±1.02 vs.−2.11±1.19;p=0.009)Even though a patent ductus arteriosus was found commonly in PR group(p=0.018).Conclusions:Our results suggest the systemic to pulmonary shunt or mBTS can promote growth of pulmonary valve annulus in patients with TOF.

The ASD that Wouldn’t Go Away:An Unusual Case of ASD Device Failure in a Patient with Marfan Syndrome

Marfan syndrome patients have connective tissue abnormalities that predispose them to intracardiac defects and postoperative complications.We present a case of late onset ASD device failure secondary to device movement within the atrial septum in a girl with Marfan syndrome.This case study suggests that further studies are necessary to determine the optimal device and approach for ASD repair in this patient cohort.

A Rare Case of Late LAD Reimplantation after Arterial Switch Operation

Arterial switch operation(ASO)is a complex neonatal operation in which transfer of the coronary arteries origins is the key to success.Coronary events after a successful ASO are not uncommon.We describe a rare case of a child who underwent an ASO in the neonatal period with one coronary(LAD)described as atretic left in place.At age seven,he developed myocardial ischemia due to retrograde flow with a steal phenomenon from the LAD into the pulmonary artery.The patient underwent a late LAD reimplantation.This case underscores that even very small ostia should be translocated at the time of ASO.

Neuromodulation in treatment of hypertension by acupuncture: A neurophysiological prospective

Hypertension is a major public health problem affecting over one billion individuals worldwide. This disease is the result of complex interactions between genetic and life-style factors and the central nervous system. Sympathetic hyperactivity has been postulated to be present in most forms of hypertension. Pharmaceutical therapy for hypertension has not been perfected, often requires a multidrug regimen, and is associated with adverse side effects. Acupuncture, a form of somatic afferent nerve stimulation has been used to treat a host of cardiovascular diseases such as hypertension. It has long been established that the two major contributors to systemic hypertension are the intrarenal reninangiotensin system and chronic activation of the sympathetic nervous system. A number of important studies on the baroreflex response and its response to acupuncture are discussed. The inhibitory effects of acupuncture on the rostral ventrolateral medulla (rVLM) reduces sympathetic nerve activity and blood pressure suggesting overactivity of the angiotensin system in this nucleus may play a role in the maintenance of hypertension. Our experimental studies have shown that electroacupuncture stimulation activates neurons in the arcuate nucleus, ventro-lateral gray, and nucleus raphe to inhibit the neural activity in the rVLM in a model of visceral reflex stimulation-induced hypertension. The significant role of spinal cord opioids and nociceptin are also reviewed. Although clinical studies of acupuncture to date have met some success, they are rarely scientifically robust and do not feature randomization and long-term follow up. Based on a great deal of basic scientific evidence, large trials are desperately needed to study the effects of acupuncture on the hyperensive man.

Primary pneumothorax:Should surgery be offered after the first episode?

Surgery is the recommended and most effective means of preventing the recurrence of primary spontaneous pneumothorax(PSP). However, the conventional belief amongst most clinicians is that surgery should not be routinely offered to patients with an uncomplicated first episode of PSP. The view that surgery should be reserved for recurrent episodes of ipsilateral PSP is based on an apprehension regarding traumatic thoracicsurgery combined with a perception that recurrences after a single episode of PSP are unlikely. Modern advances in minimally invasive thoracic surgery have now dramatically reduced the morbidity of PSP surgery. Such surgery is now safe, effective and causes minimal indisposition for patients. On the other hand, modern clinical data suggests that recurrence rate of PSP is perhaps much higher than previously assumed, with more than half of patients experiencing a second episode within several years of the first. With such new appreciations of the current situation, it is appropriate to now consider offering surgery to patients even after the first episode of PSP.

Epidemiology and Pathophysiology of Acquired Heart Failures Amenable to Surgical Interventions in the Sub-Saharan Africa

Heart failure (HF) is an important cause of morbidity and mortality in sub-Saharan Africa and indeed worldwide. The management of this condition has largely been thought to be within the domain of the Physician with the Surgeon having little or no role to play. The commonest cause of HF that may require surgical intervention is rheumatic valvular heart disease especially in the young age group while ischaemic heart disease still remains at the low rung of the ladder and interestingly, hypertrophic cardiomyopathy is becoming common. Most of the literatures reviewed failed to identify pericardial diseases, though it ranked topmost in the face of tuberculosis and HIV infections in the sub-region, and the other non-cardiac structures as important causes of HF which is amenable to surgical intervention. Equally, what have not been clearly identified are the surgical aspects;indeed its sub-classifications into heart and non-heart causes have hitherto not been documented. Even though these lists from this review are not exhaustive of the numerous unidentified causes of surgical HF, this would act as stimulus for further and extensive documentation of guideline for the recognition of these sub-classifications of HF amenable to surgery.

Surgical Management of Coronary Arteriovenous Fistula in Patients Presenting with Acute Coronary Syndrome—A Local University Hospital 6 Years Experience

Background: Anomalies of the coronary arteries are uncommon, usually discovered incidentally during diagnostic cardiac catheterization or cardiac computed tomography (CCT). Coronary artery fistula (CAF) is one of the varieties of coronary termination anomalies. Some of CAF patients have symptoms of myocardial ischemia. Methods: In King Abdulaziz university hospital (KAUH) over six years period, five patients presented with acute coronary syndrome (ACS) and were diagnosed to have CAF by cardiac catheterization during the diagnostic workup of ischemic heart disease (IHD), four males and one female, mean age 57.4 ± 6.6 years;four patients had CAF with associated coronary atherosclerotic disease (CAD);one patient had large complex CAF with no significant CAD;all patients with CAD underwent closure/excision of the CAF with surgical revascularization;the patient with no CAD preferred surgical excision over endovascular intervention. Results: All patients had surgery with uneventful postoperative course and they were doing well with 3 to 7 years outpatient follow up. Conclusion: Surgical management is safe in patients with coronary artery anomalies presenting with ACS.

Impact of Ventricular Assist Device Implantation on Clinical and Economic Outcomes of Heart Transplantation in the United States from 2003-2007

The use of ventricular assist devices (VADs) as a bridge to transplantation (BTT) has evolved considerably as clinical experience has grown and newer generation devices have become available. This study investigated the impact of VAD implantation on the clinical and economic outcomes of patients undergoing heart transplantation in the United States(US) from 2003-2007. A retrospective study was carried out using the Nationwide Inpatient Sample, to track the characteristics and outcomes of an estimated 7859 patients undergoing heart transplantation in the United States from 2003-2007. Patients were divided based on whether they were bridged to transplant with a VAD and whether they were outpatient (VAD Outpt) or inpatient (VAD Inpt). Multivariate analysis was performed to identify risk factors for inhospital mortality following heart transplantation. Hospital costs were also measured. A VAD was used as a BTT in 20.8% of patients undergoing heart transplantation during the study period. Early in the series the frequency of VAD Outpts and Inpts was similar but in later years patients were more commonly bridged as outpatients. Hospital mortality for the entire population was 6.2%. Multivariate analysis identified several risk factors for mortality, including advanced age, history of congenital heart disease, and VAD Inpt status. VAD Inpt status was the strongest predictor of mortality. The hospital cost of patients bridged as inpatients was more than double the cost of outpatients. Median hospital cost declined by 11% over the study period, from $115,868 to $103,578. Much of this cost reduction was related to the shift in VAD status from Inpt to Outpt. Heart transplant recipients are increasingly bridged to transplantation with VADs as outpatients. Those bridged as inpatients have substantially higher hospital mortality and cost. These findings have important clinical implications and should inform policy development, resource utilization and donor allocation.

Factors Predictive of Right Internal Jugular Vein Cross-Sectional Area Change in Response to Trendelenburg Positioning

Background/Purpose: The right internal jugular vein (RIJV) is the most commonly accessed central venous site in the cardiac operating room. The Trendelenburg position is frequently used to increase the cross-sectional area (CSA) of the RIJV to facilitate its cannulation. However, the extent of change of RIJV CSA in response to Trendelenburg positioning in anesthetized patients and its predictive factors remain unknown. Methods: Thirty-seven patients presented for the cardiac surgery, and 20 ASA I and II surgical patients without a history of cardiac disease (control) were studied. After induction of anesthesia, RIJV CSA was measured both at supine level position and in 10-degree Trendelenburg using vascular ultrasonography. Central venous pressure was measured in cardiac surgery patients only, since the patients in control group did not require invasive lines placement. Results and Conclusions: Body-surface area, central venous pressure, type of surgery and ejection fraction did not show any correlation with the degree of RIJV CSA change. RIJV dilation in response to Trendelenburg was significantly less pronounced, and more variable, in female patients.

Comparison of Patient Survival after Resection for Pulmonary Carcinoid Tumors Compared to Other Neuroendocrine Tumors: A United States Population Study

Background: We hypothesized: 1) resected pulmonary typical carcinoid (TC) will show a favorable clinical pattern compared to other bronchopulmonary neuroendocrine tumors (BPNETs);and 2) Atypical carcinoid (AC) and large-cell neuroendocrine carcinoma (LCNEC) patients will have similar outcomes. Methods: The Surveillance Epidemiology and End Result database was queried to compare demographics and tumor specific variables in patients undergoing resection for TC, AC, LCNEC and small cell lung cancer (SCLC) from 2001 to 2006. Results: Similar to LCNEC, AC patients had greater incidence of histologic positive lymph nodes compared to TC (P < 0.001). Survival analysis showed a mean survival of 40.0 ± 1.9 months for SCLC, 46.2 ± 2.2 months for LCNEC, 58.3 ± 2.3 months for AC, and 70.2 ± 0.2 months for TC tumors. TC patients demonstrated favorable survival, and SCLC patients poorer survival, compared to AC and LNEC patients (P < 0.01). Conclusion: AC tumors are a BPNET histology that exhibits clinical behavior distinct from TC. AC tumors should be staged, and treated with stage appropriate therapeutic strategies similar to other non-small cell lung cancers.