Does the dilated ascending aorta in an adult with congenital heart disease require intervention?

ObjectivesThere is increasing attention to prophylactic replacement of the moderately dilated ascending aorta at aortic valve surgery. Moderate ascending aortic dilatation is common in adult patients with conotruncal anomalies. There are no data outlining actual risk of progressive ascending aortic dilatation or dissection to provide management guidelines.MethodsFrom December 1973 through January 2008, 81 consecutive adults (median age, 34 years; range, 18--59 years) with conotruncal anomalies underwent operation on the aortic root, ascending aorta, or aortic valve. Primary cardiac diagnoses included tetralogy of Fallot with or without pulmonary atresia in 60 patients, truncus arteriosus in 12, double-outlet right ventricle in 6, and other in 3. Indications for operation included aortic regurgitation in 69 patients, supracoronary ascending aneurysm in 16, aortic stenosis in 5, and other in 8. Median ascending aortic size was 45 mm (23--80 mm).ResultsOperations included isolated aortic valve repair/replacement in 63 patients, combined aortic valve replacement and reduction aortoplasty in 9, aortic root replacement in 7, and isolated ascending aortic replacement in 2. Four patients required reoperation during a median follow-up of 3.8 years (maximum 31 years). There were no ascending aortic reoperations after previous reduction aortoplasties or supracoronary ascending aortic grafts, and there were no late aortic dissections.ConclusionsModerate ascending aortic enlargement is common among patients with conotruncal anomalies coming to operation, but aortic dissection is rare, as is subsequent need for aortic reoperation. Despite current enthusiasm for prophylactic operations on the ascending aorta in patients with acquired disease, these data suggest that the moderately dilated aorta in this setting may be observed

When should a mechanical tricuspid valve replacement be considered?

BackgroundIsolated mechanical tricuspid valve replacement (mTVR) is uncommon, early mortality is reported to be high, and little is known regarding the long-term outcome. We sought to evaluate the long-term outcome of mTVR.MethodsFrom 1980 to 2007, isolated mTVR was performed in 64 patients (33 men) at our institution; the median age was 45.5 years (6-71 years). There were 2192 tricuspid valve (TV) repairs and 137 isolated bioprosthetic TV replacements during the same time interval. Valve dysfunction was caused by congenital TV abnormality in 45 patients (70%), carcinoid heart disease in 13 (20%), traumatic TV regurgitation in 3 (5%), and other reason in 3 (5%). Twenty-three patients (36%) had at least 1 previous cardiac procedure (TV repair in 8 and bioprosthetic TV replacement in 7).ResultsMechanical prostheses used included Starr-Edwards (before 1993) in 36 patients (56%) and bileaflet prostheses in 28 (44%). Concomitant procedures included atrial septal defect closure in 28 (44%), arrhythmia surgery in 11 (17%), and pulmonary valvectomy for carcinoid disease in 10 patients (16%). Early mortality occurred in 5 patients (7.8%). Early morbidity included a permanent pacemaker in 9 (14%) and reexploration for bleeding in 2 patients (3%). Mean follow-up was 6 years (maximum 22.4 years). Five- and 10-year survival was 65% and 58%, respectively. There was no valve-related mortality. Late morbidity included valve thrombosis in 5 patients (8%); 3 were managed nonoperatively and 2 underwent TV rereplacement.ConclusionsIsolated mTVR still leads to increased early mortality. A mechanical valve can be considered in select situations when anticoagulation is necessary and in the presence of good right ventricular function

Coronary artery aneurysm: case report

<p>Abstract</p> <p>Introduction</p> <p>Aneurysms of the left main coronary artery are rare with an incidence of 0.1% in large angiographic series. The majority are atherosclerotic in origin. Other causes include connective tissue disorders, trauma, vasculitis, congenital, mycotic and idiopathic. The primary complication is myocardial ischemia or infarction, with rupture being rare. Treatment options include anticoagulation, custom made covered stents, reconstruction, resection, and exclusion with bypass.</p> <p>Case Presentation</p> <p>A 66 year-old man was referred for evaluation of a 2 × 2 centimeter saccular aneurysm originating from the distal left main coronary artery. There was associated calcification and mild stenosis of the LM. The workup was prompted by a non-ST elevation myocardial infarction suffered following a laparotomy for a ruptured appendix. The past medical history was pertinent for hypertension, hyperlipidemia, and a left carotid endarterectomy.</p> <p>Cardiopulmonary bypass with hyperkalemic cardioplegic arrest was utilized. The aneurysm was exposed in the atrioventricular groove. The aneurysm was resected and oversewn. Calcification precluded patch angioplasty. The patient then underwent coronary bypass grafting with the left internal thoracic artery placed to the left anterior descending artery and a reversed greater saphenous vein graft to an obtuse marginal branch of the circumflex artery. The postoperative course was uneventful and discharge to home occurred on the fourth postoperative day. Surgical pathology confirmed an atheromatous coronary artery aneurysm.</p> <p>Conclusion</p> <p>Left main coronary artery aneurysms in adult patients are predominantly atherosclerotic in origin. The clinical presentation is that of myocardial ischemia, likely from associated embolism. Rupture is rare. Operative treatment is exclusion and revascularization.</p

Late outcome of repair of congenital coronary artery fistulas—a word of caution

ObjectivesWe reviewed our experience with repair of congenital coronary artery fistulas.MethodsFrom June 1983 to December 2009, 46 patients (median age, 59 years; range, 1-84 years) underwent surgical repair. The presenting symptoms included angina in 16 patients (35%), congestive heart failure in 11 (24%), and bacterial endocarditis in 5 (11%). Preoperatively, 9 patients (20%) had at least moderate tricuspid regurgitation. Coronary artery dominance was right in 38 patients (83%). Coronary artery aneurysms were found in 8 patients (17%). The most common pattern was right coronary artery-to-coronary sinus fistula (18 patients, 39%); 11 patients had (23%) more than 1 fistula. One patient had undergone previous coil embolization.ResultsCardiopulmonary bypass was used in 39 patients (85%), with extracardiac and intracardiac repair performed in 30 (65%) and 16 (35%), respectively. The most common associated procedures were coronary artery bypass in 13 patients (28%). Early mortality occurred in 1 patient (2%). Postoperative myocardial infarction occurred in 5 patients (11%); 4 of these patients underwent simple ligation or division of their fistulas. The mean follow-up was 6 ± 5.8 years (maximum, 22 years). Late mortality occurred in 11 patients (24%). Two patients underwent reoperation for severe tricuspid regurgitation. Survival was significantly reduced compared with the age- and gender-matched population (P = .03). Residual fistulas were detected in 3 patients (6%), with no reintervention needed.ConclusionsPerioperative myocardial infarction is an important complication of ligation of coronary artery fistulas and can contribute to reduced late survival. The tricuspid valve should be evaluated carefully at repair because of the relatively high rate of residual regurgitation in survivors

Teaching in Contemporary Forest Resources Curricula: Applications to Courses in Forest Measurements and Biometrics

Foresters face new and evolving challenges as society reconsiders the balance of its interests between wood production and the provision of ecosystem services in the management of forests. Whatever paths this process may take, sound and broad-based decisions will continue to require accurate and relevant measurements of current forest conditions and projections of future conditions under alternative management programs. Forest measurements and biometrics (FMB) will remain a key component of future forest management and a critical element in the education of future forest managers. As professors who both teach and do research in FMB, we offer teaching goals that we believe will improve FMB education in forestry schools to meet future needs. In the following sections, we outline teaching goals for university-level instruction in forest resources curricula and the roles of FMB in modern forestry. We then identify what we feel are the most critical challenges in teaching and learning FMB and discuss selected strategies to meet teaching objectives for FMB. A fourth section presents an overview of how selected strategies can be integrated into FMB classes, including examples and comments on the role that new technology might play in meeting the above-described challenges. The final section summarizes our main points and provides concluding remarks.This is the author's peer-reviewed final manuscript, as accepted by the publisher. The published article is copyrighted by the Society of American Foresters and can be found at: http://www.safnet.org/publications/jof/index.cfm.Keywords: forest inventory and monitoring, teaching applied statistics, Pacific Northwest, forest analysis, forest pedagog

Mechanics of the tricuspid valve: from clinical diagnosis/treatment, in vivo and in vitro investigations, to patient-specific biomechanical modeling

Proper tricuspid valve (TV) function is essential to unidirectional blood flow through the right side of the heart. Alterations to the tricuspid valvular components, such as the TV annulus, may lead to functional tricuspid regurgitation (FTR), where the valve is unable to prevent undesired backflow of blood from the right ventricle into the right atrium during systole. Various treatment options are currently available for FTR; however, research for the tricuspid heart valve, functional tricuspid regurgitation, and the relevant treatment methodologies are limited due to the pervasive expectation among cardiac surgeons and cardiologists that FTR will naturally regress after repair of left-sided heart valve lesions. Recent studies have focused on (i) understanding the function of the TV and the initiation or progression of FTR using both in-vivo and in-vitro methods, (ii) quantifying the biomechanical properties of the tricuspid valve apparatus as well as its surrounding heart tissue, and (iii) performing computational modeling of the TV to provide new insight into its biomechanical and physiological function. This review paper focuses on these advances and summarizes recent research relevant to the TV within the scope of FTR. Moreover, this review also provides future perspectives and extensions critical to enhancing the current understanding of the functioning and remodeling tricuspid valve in both the healthy and pathophysiological states

Experience With the Cardiac Surgery Simulation Curriculum: Results of the Resident and Faculty Survey

BACKGROUND: The Cardiac Surgery Simulation Curriculum was developed at 8 institutions from 2010 to 2013. A total of 27 residents were trained by 18 faculty members. A survey was conducted to gain insight into the initial experience. METHODS: Residents and faculty were sent a 72- and 68-question survey, respectively. In addition to demographic information, participants reported their view of the overall impact of the curriculum. Focused investigation into each of the 6 modules was obtained. Participants evaluated the value of the specific simulators used. Institutional biases regarding implementation of the curriculum were evaluated. RESULTS: Twenty (74%) residents and 14 (78%) faculty responded. The majority (70%) of residents completed this training in their first and second year of traditional-track programs. The modules were well regarded with no respondents having an unfavorable view. Both residents and faculty found low, moderate, and high fidelity simulators to be extremely useful, with particular emphasis on utility of high fidelity components. The vast majority of residents (85%) and faculty (100%) felt more comfortable in the resident skill set and performance in the operating room. Simulation of rare adverse events allowed for development of multidisciplinary teams to address them. At most institutions, the conduct of this curriculum took precedence over clinical obligations (64%). CONCLUSIONS: The Cardiac Surgery Simulation Curriculum was implemented with robust adoption among the investigating centers. Both residents and faculty viewed the modules favorably. Using this curriculum, participants indicated an improvement in resident technical skills and were enthusiastic about training in adverse events and crisis management