Patent foramen ovale-management challenges: a case series

Background: Patent foramen ovale (PFO) is an anatomical interatrial communication with potential for right-to-left shunt. It is detected in 10-15% of the population by transthoracic echocardiography (TTE) and up to 27% by autopsy. Most patients with isolated PFO are asymptomatic. Patients may have a history of stroke or transient ischemic event of undefined etiology.1,2 The recurrence rate of stroke or TIA has been reported to be as high as 3.4-3.9% per year. In patients with atrial septal aneurysm and PFO, the risk of first recurrent stroke within 2 years has been reported to be as high as 9%, whereas the rate of subsequent stroke or TIA recurrence within 2 years increases to 22%. No consensus exists on treatment of PFO in patients with transient ischemic attack (TIA) or stroke. Traditional treatment has been antiplatelet therapy alone in low-risk patients or combined with warfarin in high-risk individuals to prevent cryptogenic stroke.3,4 Case report: We represent three cases of PFO diagnosed in our hospital within past 14 months. Case 1: 34-year-old man hospitalized at the Neurology Department due to transient loss of consciousness. Echocardiography showed interatrial septal aneurysm, and two septal defects – subaortal, 11mm in diameter with left-to-right shunt and second one, 3mm in diameter. There was also visible smaller thrombotic mass in left auricle. Patient underwent surgical closure. Case 2: 39-year-old woman presented at the routine echocardiographic examination after she was discharged from Neurology department where she was treated for stroke. Her brain MRI showed multiple ischemic infarctions with no focal deficit on neurological examination. TTE showed small PFO, 3mm in diameter with right-to-left shunt (Figure 1, Figure 2). Patient received percutaneous surgical closure. Case 3: 63-year-old man presented to the internist after loss of consciousness. ECG showed atrial fibrillation and TTE was subsequently performed. It showed atrial septal aneurysm, a septal defect, 14mm in diameter with left-to-right shunt (Figure 3, Figure 4). The patient is on the waiting list for surgical treatment. Conclusion: Surgical closure PFO has resulted in elimination of residual shunt across the PFO. Advantages include the following: permanent closure of the defect, prevents future paradoxical emboli, no long-term anticoagulation and its risks

Pseudoaneurysm of the ascending aorta and superior vena cava syndrome after aortic valve replacement

Introduction: Ascending aortic pseudoaneurysm is a rare, sometimes fatal complication after aortic surgical procedures. Contrast computed tomographic scan is the investigation of choice. Transesophageal echocardiography is helpful before, during and after treatment of pseudoaneurysm. Surgical treatment of pseudoaneurysm is often considered like treatment of choice but is associated with high morbidity and mortality. Sometimes transcatheter closure may be an effective treatment in selected patients.1,2 We describe the successful management of a pseudoaneurysm of the ascending aorta which was united with fistula between superior vena cava and aortic pseudoaneurysm. Case report: 71-year-old male came to hospital with superior vena cava syndrome which manifested in facial swelling, neck distension, and enlarged veins of the upper chest, which developed two days before admission. One year ago, he had aortic valve replacement with biological valve, mitral valve repair, plastic of tricuspidal valve and implantation of the pacemaker. Chest computed tomography showed pseudoaneurysm dimension 85x57x65 mm on right lateral contour of the ascending aorta. The neck of pseudoaneurysm was 17 mm in diameter. In the area of dorsal contour of pseudoaneurysm sachets was communication with a vena cava superior in the sense of fistula. A transesophageal echocardiography exam shows pulsatile flow between aorta and pseudoaneurysm. After a heart time discussion, the percutaneous approach was undertaken. In the Hybrid operating room under transesophageal echocardiography and fluoroscopic guidance the Amplatzer duct occluder device was placed in the neck of pseudoaneurysm, but day after procedure control transesophageal echocardiography showed flow right next to device between pseudoaneurysm and aorta. The high velocity blood flow move Amplatzer device. Next day patients has open chest surgery with pseudoaneurysmectomy, reconstruction of ascending aorta and reparation defect of the superior vena cava. Several days after surgery the facial and neck swelling was disappeared, and patient felt better

Prosthetic heart valve thrombosis

Prosthetic heart valve thrombosis is one of the most dreaded complications of mechanical heart valves. Suboptimal anticoagulation is the major risk for developing prosthetic heart valve thrombosis. Prosthetic heart valve thrombosis usually presents with dyspnea or embolic events1. We present patient with prosthetic heart valve thrombosis without any symptoms, diagnosed via transthoracic echocardiography twenty days after mitral valve replacement during regular echocardiograph follow-up. In the medical history we obtained the information that the patient didn’t take anticoagulation drugs for five days after hospital discharge. Transthoracic echocardiography control revealed reduced leaflet mobility and high transvalvular gradients: MV maxPG 22mmHg, MV meanPG 12mmHg (Figure 1). Transesophageal echocardiography showed the presence of thrombus on prosthetic valve measuring 11x7 mm. Patient was readmitted to the hospital and treated with thrombolytic drug alteplase. According to the American College of Cardiology/American Heart Association Guidelines fibrinolysis can be considered in a thrombosed left-sided prosthetic heart valve, which is of recent onset (<14 days) with class I-II symptoms and a small thrombus on transesophageal echocardiography. Control echocardiography after treatment (Figure 2) showed MV meanPG 3.9mmHg and normal mobility of mitral valve. Successful thrombolytic therapy was followed by warfarin and intravenous unfractionated heparin until the INR is 3-4. Current American College of Cardiology/American Heart Association Guidelines assign Class I recommendation to transthoracic echocardiography or transesophageal echocardiography imaging in patient with prosthetic valve only in the presence of clinical symptoms or sings of valve dysfunction. Pathological studies and observational registries indicate that the risk of valve thrombosis highest in the first 3 month after surgical implantation of prosthetic valve, suggesting that anticoagulant thromboprophylaxis in this time frame may be beneficial.2 Early follow up after surgical implantation is important because early detection and treatment of thrombus formation may lead to shortterm reduction in the risk of TE events and long-term prevention of prosthetic valve degeneration

Subvalvular aortic stenosis (subaortic stenosis): a case series

Introduction: Subvalvular aortic stenosis, which may have a dynamic component, may be due to a fibrous membrane, muscular obstruction, or a combination of the 21,2. About 50% of patients with a subaortic membrane also have leakage of the aortic valve. Left ventricular outflow tract (LVOT) obstructive lesions account for approximately 6 percent of cases of congenital heart disease in children; the incidence was estimated to be 6 in 10,000 live births3,4. Subvalvar aortic stenosis (AS) is the second most common form of AS. Among children with congenital AS, subvalvar AS accounts for 10 to 14 percent of cases4. Subvalvar AS is more common in males, who account for 67 to 75 percent of cases4. Patients with severe or untreated subaortic stenosis may be at risk for sudden cardiac death. An echocardiogram will show the level and severity of the obstruction. It will also show if the left ventricle is thickened or enlarged. The progression is often very slow. This is especially true in people whose obstructions are not detected until they are adults. Surgery may be necessary to stop the progression of subaortic stenosis. Case 1: 25-year-old female patient was admitted on our department, resuscitated and afterward intubated due to ventricular fibrillation. Her condition was additionally complicated by allergy reaction and signs of acute respiratory distress syndrome. In the age of 6 verified CHA. TTE show hypertrophic obstructive cardiomyopathy (HOCM) with PGmean 76mmHg and PGmax 142mmHg in LVOT. Two months later she underwent surgical operation of septal myectomy. 10 years later she is healthy and gave two births. Case 2. 36-years-old female patient, growth with developmental difficulties, adipose with amaurose. Within the preoperative preparation for cholecystectomy operation was diagnosed for HOCM (Figure 1, Figure 2), subvalvular subaortic membrane (Figure 3), with high gradients of subaortic stenosis, PG mean 54mmHg in the LVOT and mild aortic valve regurgitation (Figures 4-6). After cholecystectomy operation, she was scheduled for surgical correction of HOCM. Conclusion: Although the development of left ventricular hypertrophy or aortic regurgitation is a clear indication for operation, the timing of intervention in the otherwise asymptomatic patient remains a point of controversy

Clinical characteristics of poor-grade aneurysmal subarachnoid hemorrhage treatment

Background: The initial clinical status after aneurysm rupture, whether primary or secondary, determines the final outcome. The most common cause of patient deterioration is a high Hunt and Hess (HH) score, which correlates closely with a high mortality rate. Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is determined as an HH score 4 or 5. The aim of this study was to evaluate the clinical characteristics of poor graded aneurysmal SAH at our institution. Patients and Methods  During the 5-year period, 415 patients with intracranial aneurysm were admitted to our institution. Patients with poor-grade aneurysmal SAH accounted 31.08% ( n  = 132) of the total number of ruptured aneurysms. Interventional treatment was predominantly in the form of surgery, whereas conservative treatment included medication and external ventricular drainage. Final outcome was assessed with a modified Rankin score (mRs). Statistical analysis was performed using SPSS version 23.0 with a significance level set to 5% (α = 0.05). Results  The majority of patients (57.6%) were in the age range from 51 to 69 years. Twenty-five patients (18.9%) had an HH score of 4, whereas 107 patients (81.1%) had an HH score of 5. Depending on the location, the majority of patients ( n  = 43) had an aneurysm on the medial cerebral artery (MCA). The final aneurysm occlusion was performed in 71 patients, of whom 94.36% were treated surgically. A positive outcome (mRs 0-4) was found in 49.25% of patients who underwent primarily surgical, treatment with a mortality of 42.3%. Although the outcome was better in patients with an HH score 4, both groups benefited from surgical treatment. Conclusion  Poor-grade aneurismal SAH is a condition of the middle and older age, with most patients with an HH 5 score and deep comatose state. There was better outcome in patients with an HH score of 4 compared to an HH score of 5 and both groups benefited from surgical treatment, which resulted in a positive outcome in almost 50% of surgically treated patients

Minimally invasive mini-thoracotomy access as a surgical method in state-of-the-art treatment of single-vessel coronary heart disease

Aim To compare outcomes of two different surgical techniques of coronary artery bypass grafting (CABG) for treating isolated left anterior descending (LAD) coronary artery disease by full median sternotomy technique vs. minimally invasive approach via left anterior mini-thoracotomy. Methods This retrospective, observational study, which included 61 elective patients, was conducted at the Clinic for Cardiovascular Surgery of the Clinical Centre of the University of Sarajevo in the period from June 2019 to January 2022. Patients were divided in two groups according to the operative technique used, the sternotomy CABG group of 30 patients where the access considered full median sternotomy, and the minimally invasive CABG group where left anterior mini-thoracotomy was performed. The groups were compared by previously defined primary and secondary clinical postoperative outcomes. Results Out of 61 patients, the majority was males, 50 (82%). The analysis of the outcomes of the minimally invasive CABG surgery showed significantly shorter operative times (p=0.001), less postoperative drainage (p=0.001) and transfusion requirements, shorter mechanical ventilation duration (p=0.0001), low major adverse cardiac and cerebrovascular events rates, as well as shorter Intensive Care Unit stay days with mean of 3.3±1.442 days (p=0.025), but no total hospital stay days with mean of 6.7±1.832 days (p=0.075) compared to sternotomy CABG group. Conclusion Minimally invasive approach for CABG surgery in treating isolated single vessel LAD disease, together with the fasttrack protocol, offers a reasonable alternative to full median sternotomy, leading to faster patients’ overall recovery and improving the quality of life