COVID-19-related Floating Thrombus in the Ascending Aorta - A Case Report

BACKGROUND/AIM

Multiple aortic mural thrombi at the level of the ascending aorta represent a rare condition, only isolated cases have been reported so far. The aim of the current article was to report the case of a 61-year-old patient diagnosed with this pathology.

CASE REPORT

A 61-year-old patient with history of COVID infection six months previously was initially diagnosed with acute upper right limb ischemia and submitted to Fogarty desobstruction. Furthermore, the patient was diagnosed with a free-floating mass in the ascending aorta, for which he was submitted to aortotomy and floating thrombi, measuring 5.6×1.5 cm and 3×1.5 cm, were completely removed. The postoperative outcomes were favorable; at the three month follow up the patient proved to have a perfect circulated aortic lumen and supra-aortic vessels.

CONCLUSION

immediate aortic desobstruction followed by reconstruction might be a lifesaving maneuver in ascending aortic thrombosis.

Predictors of Late Mortality in Patients With Surgically Resected Cardiac Myxomas: A Single-Center Experience

Background and objective

Myxomas are the most common cardiac tumors. This study aimed to analyze the possible risk factors associated with late mortality in this group of patients and assess long-term survival.

Methods

A retrospective study was conducted among patients who underwent myxomas resection between January 2008 and July 2019 in our service. The patients' preoperative, intraoperative, and postoperative data were analyzed. Multivariate logistic regression was performed to identify predictors of mortality at five years. The Kaplan-Meier curve and Cox proportion-adjusted survival curves were used to assess mortality at five and 10 years.

Results

A total of 108 patients with cardiac myxomas were identified. All cardiac tumors resected were confirmed as myxomas on histopathological examination. Ninety-six patients presented with left-side myxomas (94 left-atria and two left-ventricle) and 12 with right-side myxomas (11 right-atria, one right-ventricle); 78 of the tumors were capsulated, and 30 were sessile-papillary. The mean dimensions were 37 ±6.1 mm on the left side and 41 ±6.7 mm on the right side. Surgical excision was successful in all cases, with 25% requiring interatrial septum patch repair. Recurrence occurred in 2.77% of the patients. Multivariate logistic regression showed chronic kidney disease (CKD) (OR: 7.96, 95% CI: 1.469-43.125, p=0,016) to be an independent predictor for five-year mortality. The mean follow-up period was 7.13 ±2.965 years, and the Kaplan-Meier curve cumulative proportion survival of patients at five years and 10 years were 100% and 88.8%, respectively. There was no statistically significant difference in late-term survival between patients with and without CKD in the Cox proportion-adjusted survival curve (p=0.275).

Conclusions

Patients with myxomas have a good long-term prognosis following surgical resection. The multivariate logistic regression showed CKD to be an independent predictor of five-year mortality.

Endoventricular Pericardial Patch Repair of a Giant Left Posterior Ventricular Aneurysm

BACKGROUND/AIM

Left ventricular aneurysms are complications following acute myocardial infarction. Left posterior left ventricular aneurysms occurring in a submitral position constitute a minor entity, and those leaving the mitral apparatus intact are extremely rare.

CASE REPORT

Herein, we report the case of a 58-year-old patient with a past medical history of coronary artery disease and myocardial infarction with a giant left posterior left ventricular aneurysm with moderate mitral valve incompetence.

RESULTS

The patient underwent myocardial revascularization and, through a transaneurysmal approach, successful endoventricular pericardial patch wall reconstruction with no impact on mitral valve competence.

CONCLUSION

Whenever the mitral valve is not affected, a trans aneurysmal approach with endoventricular pericardial patch in association with myocardial revascularization represents a safe and reproducible approach with good functional outcomes.

Transapical Left Ventricular Approach for Cardiac Papillary Fibroelastomas: A Case Report

BACKGROUND/AIM

Cardiac papillary fibroelastomas (CPF) are benign tumors, frequently asymptomatic, characterized by a mobile pedunculated mass that arises from the endocardium. When CPF is located in the left ventricle, it may protrude into the left ventricular outflow tract and affect hemodynamics. They are highly thrombogenic, and can also cause some life-threatening events such as cerebral and peripheral embolization.

CASE REPORT

We herein report a case of a 74-year-old female admitted to our center with palpitations and dyspnea on exertion. Her past medical history revealed that she had had a transient ischemic attack 7 months before presentation. Echocardiography and cardiac magnetic resonance imaging revealed an intracardiac mass anchored in the anteroapical interventricular septum without interference with aortic or mitral valve functionality. Surgical resection of the left ventricular mass was performed through the left apical ventriculotomy approach. Histopathological examination of the tumor was suggestive of papillary fibroelastoma. The postoperative course was uneventful. The patient was discharged home on the eighth postoperative day, with no recurrence at 6 months.

CONCLUSION

Although left ventricular papillary fibroelastomas are benign tumors, they carry a high risk for embolic complications and therefore surgery should be proposed, the transapical approach being a safe and effective method.

Successfully superior mesenteric artery stenting in operated type A aortic dissection complicated with delayed mesenteric malperfusion

Here, we describe a case of a 61-year-old male patient with acute type A aortic dissection involving the ascending aorta, aortic arch, descending aorta, and the abdominal aorta down to the iliac bifurcation with evidence of left common iliac artery occlusion. Computed tomography angiography revealed progressive dissection into the superior mesenteric artery and left renal artery with no clinical signs of mesenteric ischemia. Emergent ascending aortic reconstruction of the dissected aorta relieves the leg ischemia. On a postoperative day 9, the evolution was complicated by massive right hemothorax. Although the patient was hemodynamically stable after obtaining hemostasis, the patient developed paralytic ileus with a high elevated lactate level. Visceral malperfusion was not detected by exploratory laparotomy. Emergency abdominal aortic angiography revealed superior mesenteric artery intermittent occlusion, successfully treated by stenting implantation.

Catheter-related giant right atrial thrombosis mimicking a myxoma: A case report

Despite the development of imagistic methods, the differential diagnosis of a right atrial mass may be difficult to be established, the most common pathologies which should be taken in consideration being represented by thrombus, tumors, prominent crista terminalis, or vegetation of infectious endocarditis. In this study, we present the case of a 63-year-old man with chronic kidney disease, in hemodialysis (HD) with a silicone central venous catheter (CVC) with the incidental transthoracic echocardiography (transthoracic echocardiogram, TTE) finding of a tumoral mass of 35x26 mm in the right atrium (RA), not related with the catheter, which was diagnosed as right atrial myxoma and underwent surgical excision. After reviewing the histopathology probe, the diagnosis of right atrial thrombus was confirmed. In conclusion, differentiating intracardiac right atrial masses (RAMs) could may prove challenging. In our patient, clinical presentation and the preoperative investigations could not differentiate the right atrial thrombus from a myxoma, and only the postoperative histopathology diagnosis was able to guide correct diagnosis.

Abdominal paraaortic paraganglioma: Management of intraoperative hemodynamic emergencies during elective resection procedures (A case presentation)

Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.

Iatrogenic Iliac Arteriovenous Fistula Management after Lumbar Discectomy Surgeries: A Case Report and Review of the Literature

Iatrogenic iliac arteriovenous fistula (IAVF) is an extremely rare complication after lumbar discectomy surgery (LDS), with potentially life-threatening consequences. An IAVF results from the close anatomic relation between the iliac vessels and the last lumbar vertebrae and the corresponding discs. We report the case of a 45-year-old woman who developed a large right IAVF 3 years after L4-L5-S1 laminectomy. The arteriovenous fistula (AVF) was successfully treated with an endovascular technique using a WALLSTENT self- expanding stent. The postoperative period was uneventful, and the patient was discharged from the hospital in good general condition on the third postoperative day.

Brachial Mycotic Pseudoaneurysms Due to Prosthetic Valve Infective Endocarditis: A Case Report and Review of the Literature

Brachial mycotic pseudoaneurysms (BMPA) are a rare complication of infective endocarditis (IE), but potentially could be a limb-threatening condition. We present the case of a 38-year-old male referred to our department, complaining of the sudden onset of a painful pulsatile mass 5 x 10 cm in the right antecubital fossa that slowly progressed over time. Two years before this, he underwent aortic and mitral valve replacement with mechanical prosthetic valves and tricuspid annuloplasty for IE with methicillin-susceptible Staphylococcus aureus after a six-week course of intravenous antibiotherapy with oxacillin. Clinical examination of the right upper limb revealed a pulsatile and compressible mass with a normal temperature and without other clinical signs of inflammation. Pulse of the axillary artery, brachial and radial arteries were palpable. He was diagnosed by Doppler ultrasonography and digital subtraction angiography with BMPA. Furthermore, transesophageal echocardiography (TEE) revealed normal function of the aortic and mitral prosthetic valve with no signs of prosthetic valve endocarditis and no feature of congestive heart failure. Considering these clinical findings, surgical treatment was planned. He underwent re-section of the brachial pseudoaneurysm and arterial reconstruction. One year after the pseudoaneurysm resection, evolution was excellent. This manuscript presents this rare, uncommon complication after IE and also reviews the available surgical management strategies for this pathology.

Successful concomitant open surgical repair of aortic arch pseudoaneurysm and percutaneous myocardial revascularization in a high risk patient: A case report

INTRODUCTION

We present a case of open surgical repair of an aortic arch pseudoaneurysm (AAP) without the use of hypothermic circulatory arrest in a patient with low ejection fraction and associated coronary artery disease (CAD) and discuss some issues regarding the management of this case.

PRESENTATION OF THE CASE

A 69-year-old male with multiple pathologies and history of angina pectoris was transferred to our center from a local hospital with an initial diagnosis of non-ST-segment elevation myocardial infarction. Coronary angiography revealed stenotic lesions affecting all three coronary arteries. Multislice 3D contrast-enhanced computed tomography (CT-scan) revealed a 36 × 27 mm AAP. Endovascular stent-grafting was deemed to be unsuitable due to hostile landing zone. Therefore, the heart team decided for simultaneou treatment of the AAP and percutaneous therapy of CAD. The AAP was excised, and repair was performed with a Dacron patch on beating heart. After the surgical procedure, PCI with drug-eluting stents (DES) was performed on the right coronary artery (RCA) and the left circumflex artery (LCx) in the operating room. The patient's postprocedural course was uneventful and after thirteen days, he was discharged in good shape. 3D CT-scan performed after three month showed no residual AAP.

DISCUSSION

We established this approach as being the most suitable for our case based on favorable circumstances such as: stable CAD, beating heart procedure with low impact on myocardial ischemia, the impossibility of successful placement of an endovascular stent-graft, the presence of a pseudoaneurysm neck with minimum calcification.

CONCLUSION

We consider the best approach for individual cases is tailoring the treatment plan and the procedure to the patient's specific anatomy and pathology.

Unusual Location of a Posterior Lipoma Originating From the Left Atrial Roof: Case Report and Review of the Literature

Lipomas are the most common type of soft tissue tumors. They mainly are located in subcutaneous tissue in the body, including the heart. The cardiac location of lipomas is rare, mostly asymptomatic, and can cause life-threatening complications by rapid growth. The clinical symptoms, when present, occur in evolution with the growth in size, depending upon the location and degree of invasion in the endocardium. We present the case of a 63-year-old male patient with a large intrapericardial lipoma with an unusual location, originating from the left atrial roof. The initial symptoms of the patient were shortness of breath, dizziness, and mild dyspnea. Transthoracic echocardiography (TTE) was the first line diagnosis method, followed by computed tomography (CT); both showed a large posterior intrapericardial mass. Resection of a 12/8/5 cm lipomatous tumor mass was performed via median sternotomy, under cardiopulmonary bypass (CPB) on the beating heart. Histopathologic examination revealed the presence of diffuse proliferation of large- and medium-sized mature adipocytes consistent with the diagnosis of pericardial lipoma. The patient was discharged at home on the seventh postoperative day, with a marked improvement of his clinical state and effort tolerance. He did not present evidence of recurrence at his 1-year follow up.

Transseptal Approach for Mitral Valve Replacement in Dextrocardia with Situs Inversus Totalis: A Case Report and Review of the Literature

We consider mitral valve disease requiring surgery in a patient with dextrocardia and situs inversus totalis to be an exceptional finding. The transseptal approach for mitral valve surgery in dextrocardia represents a technical challenge owing to its anatomic particulars. We present the case of a 56-year-old female patient who had been diagnosed with situs inversus totalis in childhood and with chronic atrial fibrillation in adulthood and was under oral anticoagulant treatment. She was referred to our hospital for increasing dyspnea and palpitation. Transthoracic echocardiography detected severe mitral regurgitation associated with moderate tricuspid regurgitation, with normal left and right ventricular function. Contrast chest computed tomography (CT) and preoperative abdominal CT showed both dextrocardia and situs inversus totalis, with normal continuity of the inferior vena cava. Biatrial cannulation was performed with the surgeon standing on the right side of the patient, and mitral valve replacement using a transseptal approach was performed with the surgeon standing on the left side of the patient. In this case report, we emphasize the rarity of mitral valve disease in a patient with dextrocardia and the inherent potential difficulty that can appear in this particular anatomic condition.

Case Report: Aberrant Left Vertebral Artery Management in Traumatic Transection of the Aortic Isthmus

Association of elective debranching and endovascular thoracic aortic repair (TEVAR) with aberrant left vertebral artery (AVA) revascularization and supra-aortic left carotid-subclavian bypass in post-traumatic pseudoaneurysm of the distal aortic arch are extremely rare procedures that can minimize unnecessary neurologic complications. The patient was a 42-year-old man, stable, with a post-traumatic transection of the aortic isthmus, with origin of the AVA between the left common carotid artery (LCCA) and left subclavian artery (LSA). Preoperative planning and proper sizing of the stent-grafts were evaluated by means of computed tomography angiography (CT scan) images. The patient underwent a hybrid procedure that included TEVAR with landing zone 2, covering the origin of both the AVA and LSA and concomitant supra-aortic reimplantation of the AVA in the LCCA and left carotid-subclavian bypass combined with both ligation of the AVA and LSA proximally. Postoperative arteriography images confirmed the exclusion of the aneurysm and the patency of all arch vessels, including the AVA. No endoleak was reported.

Giant Aortic Syphilitic Aneurysm of The Ascending Aorta with Erosion in the Chest Wall: Case Report

Since the discovery of penicillin, the incidence of tertiary syphilis dramatically has decreased. However, cases of cardiovascular complications of syphilis still are present. Ascending aortic aneurysms are some of the most devastating complications. Nonetheless, syphilitic aortitis (SA) can appear and should be suspected in patients with syphilis and aortic aneurysm. We report a case of a 57-year-old patient with a large ascending aortic aneurysm with cartilage and rib erosion. The purpose of this article is to discuss the particular surgical aspects of this unusual case.

Mitral Valve Replacement with Thymectomy in a Patient with Ocular Myasthenia Gravis: Case Report

Patients diagnosed with ocular myasthenia gravis (MG) and mitral valve disease represent a significant perioperative management problem, especially for the anaesthesiologist, due to complex inter-actions between the disease, drugs to treat the disease, and anaesthetic agents, such as neuromuscu-lar blocking agents (NMBAs). This paper describes the successful management of a 31-year-old female with mitral valve stenosis and ocular MG who was diagnosed with MG 4 years prior to the indication for cardiac surgery. Preoperatively, the patient was under treatment with Pyridostigmine and Prednisone. Mitral valve replacement and full thymectomy were performed, under general anaesthesia, using Fentanyl, Sevoflurane and low doses of non-depolarising NMBAs. The postoperative course was uneventful, the patient was extubated at 6 hours postoperatively, in-tensive care unit stay was 48 hours, and the patient was discharged after 6 days without any compli-cations. After 3 months, at the follow-up examination, the patient's ocular symptoms (eyelid ptosis) disappeared.

Successful Management of Unremitting Spasm after Myocardial Revascularization Exclusively with Bilateral Internal Thoracic Arteries in Y-graft Configuration: A Case Report

Coronary artery spasm (CAS) after coronary artery bypass grafting (CABG) is rare, and in time may be fatal for the patient if undiagnosed. The purpose of the present study is to report the case of a patient who survived after experiencing a persistent spasm of all native coronary arteries following successful arterial myocardial revascularization. Furthermore, we aimed to discuss the therapeutic strategies which may prevent the occurrence of a coronary artery spasm in settings of myocardial revascularization, in the context of reviewed specific literature evidences.

Descending Thoracic Aortic Aneurysm Rupture Treated with Thoracic Endovascular Aortic Repair in a Patient with Peripheral Artery Disease

Descending thoracic aortic aneurysm rupture is a life-threatening disease associated with high rates of morbidity and mortality. Treatment in these cases is a surgical emergency. Less invasive therapies for the treatment of this pathology have been developed over time. For descending thoracic aneurysm rupture, endovascular stent grafting is less invasive, life-saving, and a unique alternative to open repair. However, this approach is subject to anatomical and logistic limitations. The purpose of the present study is to report a case of an emergency endovascular repair for a ruptured thoracic aortic aneurysm in a patient with peripheral arterial disease, and to discuss some important issues related to this approach. Severe calcifications were discovered in this patient on both iliac arteries, and the remaining circulated lumen was less than 2 to 3 mm. Unfortunately, only catheter insertion into the left iliac artery for angiography was able to determine the development of a dissection in the arterial wall. We decided to dilate both iliac arteries with partial stabilization of the dissection on the right iliac artery which allowed us to successfully continue the endovascular procedure. After 24 hours, the patient experienced right limb ischemia, and revascularization of the affected limb was achieved by performing a right axillofemoral bypass.

ARCH Replacement in Acute Aortic Dissection Type a in Normothermia

The purpose of this case presentation is to present a simplified surgical technique when in a patient with acute aortic dissection type A (AAD), aortic arch, and ascending aorta is completely replaced without circulatory arrest. A 67-year old male was presented in our institution with severe chest and back pain at 12 h after the onset of the symptoms. Imaging studies by 3D contrast-enhanced thoracic computed tomography (CT-scan) and transesophageal echocardiography (TEE) revealed ascending aortic dissection towards the aortic arch, which was extending in the proximal descending aorta. We practiced emergency median sternotomy and established cardiopulmonary bypass (CBP) between the right atrium and the right femoral artery with successive cross-clamping of the ascending and descending aorta below the origin of the left subclavian artery (LSA). In normothermic condition without circulatory arrest and with antegrade cerebral perfusion, we replaced the ascending aorta and aortic arch with a four branched Dacron graft. Patient evolution was uneventful, and he was discharged, after fourteen days from the hospital. At a one-year follow-up, 3D CT-scan showed no residual dissection with a well-circulated lumen of the supra-aortic arteries. Using the described surgical approach, CPB was not interrupted, the brain was protected, and hypothermia was no used. This approach made these surgical procedures shorter, and known complications of hypothermia and circulatory arrest are avoided.Acute aortic dissection aortic type A, total arch replacement, normothermia