Aortic Isthmus Pseudoaneurysm After Coarctation Repair as a Source of Thromboembolism

A 60 year old male, smoker with a past medical history of moderate hypertension, hypercholesterolemia, bronchial asthma and surgically corrected aortic coarctation with interposition grafting at the age of 17, was presented with four episodes of post-exercise lower limb thromboembolism within a period of two years. The electrocardiogram was normal and multiple Holter recordings showed no rhythm abnormalities. The cardiac transthoracic echocardiogram showed normal left ventricular dimensions and systolic function, normal right ventricle, bicuspid aortic valve with moderate insufficiency and mild stenosis, ascending aorta with a diameter of 46mm, and a pressure gradient across the aortic isthmus of 20mmHg. The cardiac transesophageal echocardiogram revealed no intracardiac thrombi or shunts and in addition neither dissection nor thrombus in the descending thoracic aorta was detected. Although the patient was subjected to multiple diagnostic imaging examinations, it was the Dual Source Computed Tomography with three-dimensional image reconstruction of the aorta that disclosed the detachment of the graft’s wall inner surface at the site of its proximal anastomosis with the descending thoracic aorta, just distal to the origin of the left subclavian artery, that resulted in the formation of a pseudoaneurysm which served as the source of distally embolizing thrombi. Moreover, in the distal thoracic aorta just after the graft’s distal anastomosis, a mild stenosis occurred due to intense intramural calcification. Although various therapeutic approaches were considered, the patient was finally taken to the operating theatre, where, via a left lateral thoracotomy, the preoperative findings were confirmed and the lesions successfully repaired

Asymptomatic papillary fibroelastoma of the Aortic valve in a young woman - a case report

Echocardiography represents an invaluable diagnostic tool for the detection of intracardiac masses while simultaneously provides information about their size, location, mobility and attachment site as well as the presence and extent of any consequent hemodynamic derangement

Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery

Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery