Angiosarcoma of the Left Atrium: A Case Report

Background Primary cardiac tumors are rare, andmany diagnosed tumors are benign with an incidence of 0.001% to 0.03%. The primary angiosarcoma is one of the malignant entities. Discussion We discuss a case report of a 76-year-old male who underwent a preoperative diagnosis for an upcoming shoulder operation when his cardiologist diagnosed a large cardiac tumor. The patient was referred to our department where he received further diagnostics. The transesophageal echocardiography and the cardiac-magnetic resonance imaging showed a massive tumor with a dimension of 8.6 x 5.6 cm with no signs of malignity. Method The operation was performed by standard median sternotomy. The tumor was adherent to the septum and the left atrium, and we were able to remove the specimen in toto. Pathological examinations showed an angiosarcoma with neovascularization and core expression of ERG+ and cytoplasmic expression of CD31+/CD34+, due to the size of the mass. The resection of primary cardiac tumors is mostly the therapy of choice, but in this case concerning an angiosarcoma the prognosis is poor, considering that the angiosarcoma responds very badly to chemotherapy and radiotherapy

Constrictive pericarditis with a life-threatening giant pericardial cyst and pectus excavatum as unusual cause for malign cardiac arrhythmias

Pericardial cysts are rare, abnormal, benign and usually congenital anomalies with an estimated incidence of 1:100.000 and are caused by an incomplete coalescence of foetal lacunae of pericardium development. The size of pericardial cysts varies from 1 to 5 cm and generally do not cause any symptoms. Pectus excavatum is one of the most frequent chest wall abnormalities with a caved-in appearance of the chest and mostly of unknown pathogenesis. We present a rare case of constrictive pericarditis with a huge pericardial cyst (11.6 x 8.7 x 7.1 cm) and pectus excavatum which led to compression of the heart and life-threatening cardiac arrhythmias

Direct oral anticoagulation in atrial fibrillation and heart valve surgery - a meta-analysis and systematic review

Aims: Oral anticoagulation with direct oral anticoagulants (DOAC) could provide an alternative to vitamin K antagonists (VKA) for patients with atrial fibrillation (AF) undergoing bioprosthetic heart valve replacement or valve repair. Methods and results: The aim of this meta-analysis was to review the safety and efficacy of DOAC in patients with surgical implanted bioprosthetic heart valves or valve repairs and AF including data from six clinical trials with a total of 1,857 patients. The efficacy and safety data of DOAC and VKA were pooled to perform random-effects meta-analyses using the Mantel-Haenszel method with pooled risk ratios (RR) and 95% confidence interval (CI). A trial sequential analysis (TSA) was performed to assess statistical robustness. Death caused by cardiovascular cause or thromboembolic events were comparable (RR 0.67, 95% CI: 0.42-1.08; p= 0.101 as DOAC significantly reduced the risk for major bleeding (RR 0.55, 95% CI: 0.35-0.88; p = 0.01) and thromboembolic stroke or systemic embolism rates (RR 0.54, 95% CI: 0.32-0.90; p= 0.021. Rates for intracranial bleeding and hemorrhagic stroke (RR 0.27, 95% CI: 0.07-0.99; p= 0.051 show a trend toward fewer events in the DOAC group. Outcomes for major or minor bleeding events and all-cause mortality were comparable for DOAC and VKA. Conclusion: Cumulative data analysis reveals that DOAC may provide an effective and safe alternative to VKA in patients with AF after surgically implanted bioprosthetic heart valves or repair with AF. Within a relatively heterogeneous study population, this meta-analysis shows a risk reduction of major bleedings and thromboembolic stroke or systemic embolisms for DOAC

Factor Xa Inhibitors for Patients after Mechanical Heart Valve Replacement?

Patients with a mechanical heart valve need a lifelong anticoagulation due to the increased risk of valve thrombosis and thrombo-embolism. Currently, vitamin K antagonists (VKA) are the only approved class of oral anticoagulants, but relevant interactions and side effects lead to a large number of patients not achieving the optimal therapeutic target international normalized ration (INR). Therefore, steady measurements of the INR are imperative to ensure potent anticoagulation within a distinctive range. Direct oral anticoagulants (DOACs) with newer agents could serve as a possible alternative to VKAs in this patient cohort. DOACs are approved for several indications, e.g., atrial fibrillation (AF). They only have a minor interaction potential, which is why monitoring is not needed. Thereby, DOACs improve the livability of patients in need of chronical anticoagulation compared with VKAs. In contrast to dual platelet inhibition using aspirin in combination with an ADP receptor antagonist and the direct thrombin inhibitor dabigatran, the oral factor Xa inhibitors apixaban and rivaroxaban show promising results according to current evidence. In small-scale studies, factor Xa inhibitors were able to prevent thrombosis and thrombo-embolic events in patients with mechanical heart valves. Finally, DOACs seem to represent a feasible treatment option in patients with mechanical heart valves, but further studies are needed to evaluate clinical safety. In addition to the ongoing PROACT Xa trial with apixaban in patients after aortic On-X valve implantation, studies in an all-comer collective with rivaroxaban could be promising

Multiple Grafting with Single Left Internal Mammary Artery as T-Graft with Itself

Background Revascularization strategies might be limited in patients with lack of sufficient bypass graft material and increased risk of wound healing disturbances. In this regard, we present first results of patients treated with left internal mammary artery (LIMA) as T-graft with itself due to left-sided double-vessel disease, elevated risk of wound healing infection, and lack of graft material. Methods Eighteen patients were retrospectively analyzed in this study. All patients received LIMA grafting, and additional T-graft with itself during off-pump coronary artery bypass surgery. The investigation was focused on intraoperative and postoperative outcomes. Results LIMA-LIMA T-graft was performed in a total of 18 patients. Mean Fowler score accounted for 18.22.9. Severe vein varicosis was present in 9 patients, and 38.9% of patients had lacking venous graft material due to prior vein stripping. A total of 2.5 +/- 0.5 distal anastomoses were performed. Mean flow of LIMA-left anterior descending anastomosis was 41.72 +/- 12.11mL/min with a mean pulsatility index (PI) of 1.01 +/- 0.21. Mean flow of subsequent T-graft accounted for 26.31 +/- 4.22mL/min with a mean PI of 1.59 +/- 0.47. Median hospital stay was 7(6.75;8) days. No incidence of postoperative wound healing disorders was observed and all patients were discharged off hospital. Conclusions LIMA as T-graft with itself to treat left-sided double-vessel disease is feasible and safe in patients with missing bypass graft material and increased risk of deep sternal wound infection. Further prospective studies are necessary to confirm our results

Major Bleeding after Surgical Revascularization with Dual Antiplatelet Therapy

Objective Patients with acute coronary syndrome are treated with dual antiplatelet therapy containing acetylsalicylic acid (ASA) and P2Y12 antagonists. In case of urgent coronary artery bypass grafting this might be associated with increasing risks of bleeding complications. Methods Data from 1200 consecutive urgent operations between 2010 and 2018 were obtained from our institutional patient database. For this study off-pump surgery was excluded. The primary composite end point major bleeding consisted of at least one end point: transfusion >= 5 packed red blood cells within 24hours, rethoracotomy due to bleeding, chest tube output >2000mL within 24hours. Demographic data, peri-, and postoperative variables and outcomes were compared between patients treated with mono antiplatelet therapy, ASA+clopidogrel (ASA-C) +ticagrelor (ASA-T) or +prasugrel (ASA-P)<72hours before surgery. Furthermore, we compared patients with dual antiplatelet therapy with ASA monotherapy. Results From 1,086 patients, 475 (44%) received dual antiplatelet therapy. Three-hundred seventy-two received ASA-C (77.7%), 72 ASA-T (15%), and 31 ASA-P (6.5%). Major bleeding (44 vs. 23%, p <0.0001) was more frequently in patients receiving dual therapy with higher rates of massive drainage loss within 24hours (23 vs. 11%, p <0.0001) of mass transfusion (34 vs. 16%, p <0.0001) and rethoracotomy (10 vs. 5%, p =0.002) when compared with ASA. In this analysis, ASA-T and ASA-P were not associated with higher bleeding complications compared with ASA-C. Conclusion Dual antiplatelet therapy is associated with higher rates of major bleeding. Further studies should examine the difference in the prevalence of major bleeding complications in the different dual antiplatelet therapy regimes in patients requiring urgent surgery

Ten-Year Long-Term Analysis of Mechanical and Biological Aortic Valve Replacement

Background For patients undergoing aortic valve replacement (AVR), structural valve deterioration (SVD) of a bioprosthesis (BP) is substantially accelerated in younger patients and valve-in-valve implantation is not always a considerable option. The risk-benefit assessment between SVD versus the risk of bleeding and thromboembolic events in patients with a mechanical prosthesis (MP) resulted in an age limit shift irrespective of inconsistent results reported in literature. Method This retrospective single-center study compared 10-year long-term outcomes in patients undergoing isolated AVR with MP or BP. The risk-adjusted comparison of patients undergoing isolated AVR ( n = 121) was performed after 1:1 propensity score matching (PSM) for age, sex, endocarditis, and chronic renal impairment (caliper of 0.2) leading to 29 pairs. Short- and long-term outcomes with respect to reoperation, major bleeding, stroke, all-cause and cardiovascular mortality, and overall survival at 10 years were analyzed. Results After PSM, groups were comparable with respect to preoperative characteristics, including patients with a mean age of 65 +/- 3 years (MP) and 66 +/- 4 years (BP) and an incidence rate of 6.9% for infective endocarditis in both cohorts. Short-term outcomes (transient neurologic disorder = 0.0 vs. 6.9%; stroke = 0.0%; in-hospital mortality = 3.4%) and in-hospital stays were comparable between MP and BP. Conclusion After isolated AVR with MP and BP, 10-year long-term outcomes were comparable in the reported single-center cohort. MP can still be implanted safely without a disadvantage as regards long-term survival

Impact of Chronic Kidney Disease and Dialysis on Outcome after Surgery for Infective Endocarditis

Infective endocarditis (IE) carries a heavy burden of morbidity and mortality in chronic kidney disease (CKD) and hemodialysis (HD) patients. We investigated the risk factors, pathognomonic profile and outcomes of surgically treated IE in CKD and HD patients. We preoperatively identified patients with CKD under hemodialysis (HD group) and compared them with patients without hemodialysis (Non-HD group). Furthermore, we divided the cohort into four groups according to the underlying stage of CKD, with a subsequent outcome analysis. Between 2009 and 2018, 534 Non-HD and 58 HD patients underwent surgery for IE at our institution. The median age was 65.1 [50.6–73.6] and 63.2 [53.4–72.8] years in the Non-HD and HD groups, respectively (p = 0.861). The median EuroSCORE II was 8.0 [5.0–10.0] vs. 9.5 [7.0–12.0] in the Non-HD vs. HD groups (p = 0.004). Patients without CKD had a mortality rate of 5.6% at 30 days and 15.5% at 1 year. Mortality rates proportionally rose with the severity of CKD. Among HD patients, 30-day and 1-year mortality rates were 38.1% and 75.6%, respectively (p Staphylococcus aureus IE was significantly more frequent in the HD group (p = 0.006). In conclusion, outcomes after surgery for IE correlated with the severity of the underlying CKD, with HD patients exhibiting the most unfavorable results. Pre-existing CKD and staphylococcus aureus infection were independent risk factors for 1-year mortality

Is It Reasonable to Perform Isolated SAVR by Residents in the TAVI Era?

Background The role of conventional surgical aortic valve replacement (SAVR) is increasingly questioned since the indication for transcatheter aortic valve implantations (TAVIs) is currently extended. While the number of patients referred to SAVR decreases, it is unclear if SAVR should be performed by junior resident surgeons in the course of a heart surgeons training. Methods Patients with isolated aortic valve replacement (AVR) were analyzed with respect to the surgeon's qualification. AVR performed by resident surgeons was compared with AVR by senior surgeons. The collective was analyzed with respect to clinical short-term outcomes comparing full sternotomy (FS) with minimally invasive surgery and ministernotomy (MS) with right anterior thoracotomy (RAT) after a 1:1 propensity score matching. Results The 30-day all-cause mortality was 2.3 and 3.4% for resident versus senior AVR groups, cerebrovascular event rates were 1.1 versus 2.6%, and no cases of significant paravalvular leak were detected. Clinical short-term outcomes between FS and minimally invasive access, as well after MS and RAT were comparable. Conclusion Our current data show feasibility and safety of conventional SAVR procedure performed by resident surgeons in the era of TAVI. Minimally invasive surgery should be trained and performed in higher volumes early in the educational process as it is a safe treatment option