With the passing of Donald Nixon Ross, DSc, FRCS, on 7 July 2014, at the age of 91, cardiac surgery lost one of its most innovative and daring pioneers. Dr. Ross performed the United Kingdom's first heart transplant in 1968. He achieved even greater renown for developing the pulmonary autograft procedure, in
The guest editorial that follows is a transcript of the commencement address delivered in May 2014 to the graduating seniors at the University of Texas Medical School in Houston by the president of the Harris County Medical Society, Dr. Elizabeth Torres.1 I find Dr. Torres's remarks to be pithy, perspicuous, and powerful, and I agree with her sentiments completely. We at the Texas Heart Institute Journal are pleased and proud to make her thoughts available to our readers around the world. Although her message is specifically designed for newly minted doctors, it serves as a timely reminder
Initially, it was just an occasional ache in my left shoulder. I don't remember exactly when or how it started, but the ache soon became a pain. It typically appeared when I used my left hand to scratch my back or to lift a wallet from my left hip pocket. The pain was intermittent, never severe, and did not
Atrial fibrillation is associated with substantial morbidity and mortality rates. The incompletely understood pathogenesis of this cardiac dysrhythmia makes it difficult to improve approaches to primary and secondary prevention. Evidence has accumulated in regard to a relationship between inflammation and atrial fibrillation. Investigators have correlated the dysrhythmia with myocarditis, pericardiotomy, and C-reactive protein levels, suggesting that inflammation causes atrial fibrillation or participates in its onset and continuation. Conversely, other investigators suggest that atrial fibrillation induces an inflammatory response. In this review, we summarize and critically discuss the nature and clinical role of inflammation and C-reactive protein in atrial fibrillation.
The development of transcatheter aortic valve implantation (TAVI) has increased the use of balloon aortic valvuloplasty (BAV) in treating aortic stenosis. We evaluated our use of BAV in an academic tertiary referral center with a developing TAVI program. We reviewed 69 consecutive stand-alone BAV procedures that were performed in 62 patients (mean age, 77 ± 10 yr; 62% men; baseline mean New York Heart Association functional class, 3 ± 1) from January 2009 through December 2012. Enrollment for the CoreValve® clinical trial began in January 2011. We divided the study cohort into 2 distinct periods, defined as pre-TAVI (2009–2010) and TAVI (2011–2012). We reviewed clinical, hemodynamic, and follow-up data, calculating each BAV procedure as a separate case. Stand-alone BAV use increased 145% from the pre-TAVI period to the TAVI period. The mean aortic gradient reduction was 13 ± 10 mmHg. Patients were successfully bridged as intended to cardiac or noncardiac surgery in 100% of instances and to TAVI in 60%. Five patients stabilized with BAV subsequently underwent surgical aortic valve replacement with no operative deaths. The overall in-hospital mortality rate (17.4%) was highest in emergent patients (61%). The implementation of a TAVI program was associated with a significant change in BAV volumes and indications. Balloon aortic valvuloplasty can successfully bridge patients to surgery or TAVI, although least successfully in patients nearer death. As TAVI expands to more centers and higher-risk patient groups, BAV might become integral to collaborative treatment decisions by surgeons and interventional cardiologists.
There have been attempts to find new approaches to the treatment of multivessel coronary artery disease without increasing adverse events. Deployment of drug-eluting stents (DES) for complex lesions and bare-metal stents (BMS) for simpler lesions, although already in wide use, has not been well supported by clinical study. A cohort of 1,658 patients who underwent multivessel percutaneous coronary intervention from March 2003 through June 2011 was studied for 1 year. These patients were divided into 3 groups: BMS only (599 patients); DES only (481 patients); and hybrid stenting (578 patients). Baseline characteristics were similar except for hyperlipidemia and moderate-to-severe mitral regurgitation, which were more frequent in the DES and hybrid groups, respectively. Lesion characteristics were more complex in the DES group, compared with the other groups: more B2/C type lesions, longer stents, and smaller reference-vessel diameters (P <0.001). The rates of major adverse cardiac events (MACE) at 1 year were similar between the groups (BMS=5.2%, hybrid=3.9%, and DES=3.4%; P=0.248). Subgroup analysis yielded no differences in death, nonfatal myocardial infarction, target-vessel revascularization, or target-lesion revascularization. On multivariable analysis, the strongest predictors of 1-year MACE were percutaneous intervention complicated by dissection, renal failure, left ventricular ejection fraction below 0.40, mean lesion length, reference vessel diameter, and percutaneous intervention on the left circumflex coronary artery. The latter two had inverse relationships with MACE. In conclusion, implanting the DES for more complex lesions and the BMS for simpler lesions seems more sensible than the exclusive use of the DES or the BMS.
The internal thoracic artery (ITA) is typically harvested from the chest wall by means of conventional electrocautery. We investigated the effects of electrocautery on endothelial-cell and vessel-wall morphology at the ultrastructural level during ITA harvesting. Internal thoracic artery specimens from 20 patients who underwent elective coronary artery bypass grafting were investigated in 2 groups. The ITA grafts were sharply dissected with use of a scalpel and clips in the control group (n=10) and were harvested by means of electrocautery in the study group (n=10). Each sample was evaluated for intimal, elastic-tissue, muscular-layer, and adventitial changes. Free flow was measured intraoperatively. Light microscopic examinations were performed after hematoxylin-eosin and Masson's trichrome staining. Transmission electron microscopy was used to evaluate ultrastructural changes in the endothelial cells and vessel walls of each ITA. In the sharp-dissection group, the endothelial surfaces were lined with normal amounts of original endothelium, endothelial cells were distinctly attached to the basal lamina, cytoplasmic organelles were evident, and intercellular junctional complexes were intact. Conversely, in the electrocautery group, the morphologic integrity of endothelial cells was distorted, with some cell separations and splits, contracted cells, numerous large cytoplasmic vacuoles, and no visible cytoplasmic organelles. The subendothelial layer exhibited disintegration. Free ITA flow was higher in the sharp-dissection group (P=0.04). The integrity of endothelial cells can be better preserved when the ITA is mobilized by means of sharp dissection, rather than solely by electrocautery; we recommend a combined approach.
The epidemiologic profile of infective endocarditis has changed substantially over the past few years, especially in industrialized countries. Our study evaluates the clinical and pathologic characteristics of infective endocarditis patients treated by cardiac surgery in China during a 12-year period. We retrospectively evaluated 220 surgically treated infective endocarditis patients and analyzed their changes from the beginning of 1998 through 2009. The mean age of the patients increased from 36.9 to 42.7 years during those 12 years (P=0.036). The chief predisposing disease was congenital heart disease (32.8%), rather than rheumatic heart disease (13.2%); this rate did not change significantly during the 12 years. The prevalent congenital lesion was bicuspid aortic valve, the rate of which (55.6%) increased significantly over the 3 time intervals studied (P=0.016). The frequency of infective endocarditis after non-dental surgical and nonsurgical intervention was significantly greater (23.3%) during 1998 through 2001, compared with the 2 intervals that followed (9%; P=0.019). Streptococcus viridans was the most frequent causative agent overall (25.6%). Forty-seven of the 220 patients (21.4%) carried the clinical diagnosis of some other form of heart disease before surgery, but at surgery they were found to have infective endocarditis as the fundamental disease process. Of 47 patients, 33 (70.2%) had either very small or no vegetations but had focal necrosis and inflammation of valve tissue that supported the diagnosis of infective endocarditis.
The Warden procedure for the correction of a right-sided partial anomalous pulmonary venous connection to the high superior vena cava is well established. It has the advantages of avoiding sinoatrial node dysfunction and pulmonary and systemic venous obstruction. In the case related here, a 3-year-old girl presented with a superior vena cava type of sinus venosus atrial septal defect and an anomalously draining right upper pulmonary vein, with bilateral superior venae cavae. Our approach to the Warden procedure was through a right posterolateral thoracotomy, which provided additional advantages.
Uterine leiomyomatosis is a common disease in women; however, intravenous leiomyomatosis with intracaval and intracardiac tumor extension is rare. We sought to analyze the clinical and echocardiographic features of intracardiac leiomyomatosis. From January 2003 through July 2012, 7 women (age range, 24–59 yr) underwent surgical resection of histopathologically diagnosed intracardiac leiomyomas at our hospital. Most of the patients had histories of hysterectomy or uterine leiomyoma. We retrospectively analyzed their preoperative echocardiograms. We found that the tumors had no stalks, did not adhere to the wall of the right side of the heart, were highly mobile, and moved back and forth in the right atrium near the tricuspid orifice. All tumors originated from the inferior vena cava and had borders well demarcated from that structure's wall. Most of the masses extended into the inferior vena cava and right atrium through the right internal and common iliac veins. Computed tomograms revealed pelvic tumors and contiguous filling defects in 6 patients. When echocardiograms reveal a right-sided cardiac mass that originates from the inferior vena cava, particularly in women who have a history of hysterectomy or uterine leiomyoma, intracardiac leiomyomatosis should be suspected. If the mass has no stalk and freely moves within the inferior vena cava and right-sided cardiac chambers without attachment to the endothelial surface or endocardium, intracardiac leiomyomatosis should be diagnosed. We discuss our findings and briefly review the relevant medical literature.
The following single-case reports on pulmonary artery sarcoma (PAS)1,2—2 of them in number—emphasize its rarity and underscore its characteristic propensity to masquerade as pulmonary thromboembolism (PTE). Correct diagnosis and complete resection are the key to survival. In both patients, the clinical diagnosis was PTE—acute in one,1 subacute-to-chronic in the other.2 Nevertheless, in each case, pulmonary embolectomy uncovered PAS, not PTE. One of the patients died on the 10th postoperative day.2 The other patient was alive and well with no evident disease 36 months after surgical resection, chemotherapy, and radiation therapy.
We describe the case of a 38-year-old man with a history of metastatic testicular cancer who had undergone multiple thoracic surgical procedures, including tricuspid valve replacement with a bioprosthetic valve as a result of tricuspid involvement of his malignancy. He presented at our outpatient cardiology clinic with worsening fatigue, shortness of breath, and peripheral edema, investigation of which revealed severe tricuspid bioprosthesis stenosis with central regurgitation. Because of the patient's medical history, he was considered to be a high-risk surgical candidate. Therefore, transcatheter tricuspid valve-in-valve implantation of a 26-mm Edwards Sapien® valve was attempted through a transjugular approach. The procedure restored tricuspid valvar competence and substantially improved the patient's symptoms. We discuss the technical aspects of this case and briefly review the usefulness of the valve-in-valve technique in the tricuspid position.
Bioprosthetic heart valves can degenerate and fail over time. Repeat surgery as a means of replacement increases morbidity and mortality rates, and some patients are not candidates for reoperation. A newer treatment, percutaneous transcatheter valve-in-valve implantation, might delay or substitute for invasive procedures. We present the case of a 51-year-old woman, a poor candidate for surgery who had prosthetic tricuspid valve degeneration and stenosis. We successfully performed valve-in-valve placement of a Melody® valve, using a procedure originally intended to treat pulmonary valve conduit obstruction or regurgitation. To our knowledge, this is among the first case reports to describe the use of the Melody pulmonary valve in transcatheter valve-in-valve replacement for prosthetic tricuspid stenosis that was otherwise not correctable. Additional data and longer follow-up periods are necessary to gain an understanding of ideal indications and selection of patients for the percutaneous transcatheter treatment of tricuspid valve stenosis.
Primary sarcomas that arise from major blood vessels are exceedingly rare, and some of the published cases have been autopsy reports. Most patients are adults. We report a case of pulmonary artery sarcoma in a 77-year-old man who presented with acute onset of dyspnea. Magnetic resonance imaging of the chest revealed a large mass within the pulmonary trunk and its main branches. Because massive pulmonary embolism was suspected, both anticoagulant and thrombolytic therapies were initiated. The patient responded poorly to these therapies, which then necessitated resection of both the mass and the pulmonary valve. A bioprosthetic porcine valve replaced the native valve, and we reconstructed the right ventricular outflow tract with a Dacron patch. Histopathologic examination revealed a high-grade sarcoma with focal myogenic and chondrogenic differentiation. The patient tolerated the procedure well and was discharged from the hospital on postoperative day 7. He was subsequently treated with chemotherapy and radiation and continued to show no evidence of disease. The diagnosis of pulmonary artery sarcoma should be suspected in patients who present with manifestations of pulmonary embolism, especially when there is no evidence of deep venous thrombosis and poor response to anticoagulant therapy. Multimodal therapy can provide prolonged survival.
We describe the case of a 60-year-old woman who presented with pulmonary artery sarcoma, a very rare tumor of the cardiovascular system. Her tumor was initially misdiagnosed as chronic pulmonary thromboembolism, and she underwent pulmonary endarterectomy. Early diagnosis of primary pulmonary artery sarcoma is crucial. That alternative should always be considered before settling on a diagnosis of pulmonary embolism. Suspicion should be aroused by the failure of anticoagulant treatment to alleviate pulmonary perfusion abnormalities and systemic symptoms. Surgical resection of the tumor—preferably by pulmonary endarterectomy, followed by reconstruction as needed—is currently the most promising treatment for pulmonary artery sarcoma.
We report a case of fulminant myocarditis after a primary cytomegalovirus infection, in a previously healthy 72-year-old woman. The infection underwent clinical and immunologic resolution consequent to treatment with oral valganciclovir. In an immunocompetent host, the primary cytomegalovirus infection is usually asymptomatic or manifests itself as a heterophile-negative mononucleosis-like syndrome. Cytomegalovirus myocarditis is uncommon in immunocompetent patients. After presenting our case, we review the literature on cytomegalovirus myocarditis in immunocompetent individuals.
Cardiac rhabdomyoma, the primary cardiac tumor most often diagnosed in children, is frequently present in patients with tuberous sclerosis. Most pediatric patients with rhabdomyoma are asymptomatic; however, various electrocardiographic abnormalities can be detected, such as Wolff-Parkinson-White syndrome, ectopic atrial tachycardia, and atrioventricular node dysfunction. We describe the case of a 10-month-old infant girl who had tuberous sclerosis and multiple cardiac rhabdomyomas. Her electrocardiographic presentation was notable for dome-shaped T waves and no ST segment in some leads. To our knowledge, this electrocardiographic finding has not been described in patients with tuberous sclerosis and cardiac masses.
Carcinoid tumors are rare neuroendocrine malignancies that typically originate from the gastrointestinal tract. Patients who are diagnosed with carcinoid heart disease generally have poor prognoses because of advanced metastases during staging and few therapeutic options. We present the case of a 61-year-old woman with right-sided heart failure, secondary to carcinoid heart disease caused by a primary ovarian carcinoid tumor. After undergoing surgical resection of the left ovary and fallopian tube, the patient experienced complete resolution of her heart failure symptoms. In addition to the patient's case, we discuss the diagnosis, nature, and treatment of this rare condition.
Essential thrombocythemia is a rare type of myeloproliferative disorder. Cerebral, myocardial, and peripheral thrombosis are all frequent complications of the disease. A 71-year-old man presented with severe coronary artery disease, associated with cerebral vascular ischemic changes and erythromelalgia. His platelet count was 1,486 ×103/μL. The patient underwent successful myocardial revascularization by means of an off-pump technique after his platelet count had been reduced by hydroxycarbamide administration. We conclude that the use of off-pump cardiopulmonary bypass in high-risk patients with essential thrombocythemia is safe. Reducing platelet count via the administration of hydroxycarbamide and the careful balancing of antiplatelets and anticoagulants is crucial in determining the outcome of surgery.
Primary malignant cardiac lymphomas associated with grafts are extremely rare: to our knowledge, only 6 cases of prosthesis-associated B-cell lymphoma have been reported. Ours is the first report of recurrent diffuse large B-cell lymphoma associated with aortic valve allografts. We treated a 60-year-old man who presented in early 2007 with aortic valve endocarditis. He underwent aortic valve replacement with an allograft; the resected native valve showed active endocarditis without tumor. In January 2011, the patient underwent repeat aortic valve replacement because of symptomatic aortic regurgitation. The explanted valve specimen displayed diffuse large B-cell lymphoma. In September 2011, the patient presented with fever and a mass around the aortic valve. He died in January 2012. On autopsy, the explanted replacement valve displayed recurrent diffuse large B-cell lymphoma. The recurrent lymphoma on a new graft leads us to believe that this tumor is more aggressive than had been thought. We propose early systemic chemotherapy, in addition to tumor resection, for the possibility of a better prognosis. We discuss our patient's case and review the relevant medical literature.
The presence, severity, and extent of ischemia predict the outcome of coronary artery disease. Indeed the extent of myocardial ischemia and viability determines the value of revascularization in coronary stenosis after acute myocardial infarction. In multivessel coronary artery disease, noninvasive methods for the evaluation of ischemia are often inadequate to guide percutaneous coronary intervention. It is a common misperception that revascularization might not benefit a myocardial segment in the chronic total occlusion distribution when that segment is supplied by well-developed collateral vessels, because severe ischemia is unlikely to be present under these circumstances. An 82-year-old man presented with acute coronary syndrome, tandem stenoses in a “donor” artery, and a chronic total occlusion of the right coronary artery. We present a rationale for using fractional flow reserve to determine the existence of ischemia and to aid in deciding the best approach to the treatment of that ischemia.
A 65-year-old man was evaluated for chronic chest pain that had been present for 8 years after placement of a dual-chamber implantable cardioverter-defibrillator to treat inducible ventricular tachycardia. Previous coronary angiography had revealed nonobstructive coronary artery disease and a left ventricular ejection fraction of 0.45 to 0.50, consistent with mild idiopathic nonischemic cardiomyopathy. Evaluation with chest radiography and transthoracic echocardiography showed the implantable cardioverter-defibrillator lead to be embedded within the right ventricle at the moderator band, which had mild calcification. Treatment included extraction of the dual-coil lead and placement of a new single-coil right ventricular lead at the mid septum. The patient had complete relief of symptoms after the procedure. This case shows that chest pain can be associated with the placement of a right ventricular implantable cardioverter-defibrillator lead in the moderator band and that symptomatic relief can occur after percutaneous lead extraction and the implantation of a new right ventricular lead to the mid septal region.
Primary malignant cardiac tumors are rare. Among these tumors, cardiac plasmacytoma is extremely rare and is the subject of few case reports. We present the case of a 73-year-old man who had isolated cardiac plasmacytoma 26 years after successful treatment of an axillary plasmacytoma. Multiple imaging methods—including echocardiography, cardiac magnetic resonance, and positron-emission tomography/computed tomography—were valuable and complementary to each other in this patient's diagnosis and optimal management. His case illustrates the use of these techniques in the successful diagnosis and treatment of a rare clinical entity, cardiac plasmacytoma.
A 46-year-old man emergently presented after developing chest pain while running for a taxi. He reported no associated shortness of breath, palpitations, or dizziness. His vital signs were stable, and the results of respiratory and cardiovascular examination were normal. An electrocardiogram showed ST-segment elevation in leads V2 through V6 (Fig. 1). An urgent coronary angiogram revealed narrowing at the origin of the left main coronary artery (LMCA) that did not resolve after intracoronary nitroglycerin was administered (Fig. 2). However, there was no evident atherosclerotic disease.
A 70-year-old man with a history of orthotopic heart transplantation developed severe coronary allograft vasculopathy and presented with cardiogenic shock. He was resuscitated, and both inotropic and vasopressor support were initiated. Subsequently, an intraaortic balloon pump (IABP) was inserted for further hemodynamic support. After 4 weeks, the IABP was moved from the common femoral artery to the left axillary artery, to motivate the patient to exercise and enable him to sit up in bed. The procedure was performed in the hybrid suite under fluoroscopic guidance. The left axillary artery was surgically exposed, and a 6-mm Vascutek® Gelweave™
A 73-year-old woman with a history of hypertension and dyslipidemia was admitted with acute coronary syndrome. A coronary angiogram revealed a severe stenosis in the proximal left anterior descending coronary artery (LAD) and a moderate stenosis in the mid-LAD (Fig. 1A). A 0.014-in, non-stiff, floppy Intuition® guidewire (Medtronic, Inc.; Minneapolis, Minn) was advanced across the lesion; however, it could not be advanced to the distal LAD because of marked tortuosity. Next, a hydrophilic-coated PT2™ Moderate Support Guide Wire (Boston Scientific Corporation; Natick, Mass) was advanced into the coronary artery. Contrast injection revealed multiple filling
A 65-year-old previously asymptomatic woman with a history of tobacco use presented after experiencing an hour of chest pain and syncope. A 12-lead electrocardiogram revealed an inferior ST-elevation myocardial infarction. Coronary angiography revealed an acute thrombotic occlusion of the right coronary artery (Fig. 1); however, there was difficulty in maneuvering diagnostic catheters to the coronary ostia. Subsequent aortography revealed a double aortic arch (Fig. 2). After revascularization, 64-slice computed tomography (CT) of the aorta (Fig. 3) showed a dominant right aortic arch (Fig. 4A) to the right of the trachea, with separate
To the Editor: We read with interest the article in the Texas Heart Institute Journal by Vukovic and colleagues,1 and we have a few comments that we think are of note. Cor triatriatum dexter (CTD) and prominent eustachian valve are thought to result from the incomplete and abnormal regression of the embryonic right valve of the sinus venosus, caused by abnormal fetal circulation. Whereas the left leaflet of the sinus venosus is incorporated into the interatrial septum and forms part of the septum secundum, the right leaflet is reabsorbed, forming the eustachian and thebesian valves. A
To the Editor: I read with interest the article in the Texas Heart Institute Journal by Franco and colleagues1 about isolated right ventricular myocardial infarction (RVMI). First, I want to thank the authors for reminding us that isolated RVMI can easily be misdiagnosed as acute anterior myocardial infarction (MI) and should be considered in the differential diagnosis. In clinical practice, isolated RVMI is rare in comparison with anterior MI.2 There are important differences in the approach to treating these types of MI, particularly in regard to vasodilator medication. Therefore, the differential diagnosis is important,
To the Editor: I appreciated the article by Roy and colleagues1 in the Texas Heart Institute Journal. To the authors' knowledge, theirs were the first reported cases in which apical-variant hypertrophic cardiomyopathy was masked by apical ballooning from stress-induced cardiomyopathy. The authors added information about 5 reported cases of patients with hypertrophic cardiomyopathy (HCM) who had experienced an episode of takotsubo cardiomyopathy, all of whom had the obstructive HCM “with asymmetric septal hypertrophy, not apical-variant HCM.” What was actually observed is a recently detected phenomenon of apparent left ventricular (LV) apical hypertrophy,2,3
