Concomitant giant coronary artery and coronary sinus aneurysms

Peak early diastolic velocity rather than pressure half-time is the best index of mechanical prosthetic mitral valve function

Objective Prosthetic mitral valve dysfunction remains a devastating complication in heart surgery. This study aims to assess the risk factors and the technical approaches to reach the best way to deal with and improve the outcome in these patients. Patients and methods Between January 2002 and March 2005, 60 patients underwent emergency reoperation for prosthetic mitral valve dysfunction, where 36 (60%) patients were in New York Heart Association class III, and 24 (40%) patients were in New York Heart Association class IV. There were 33 (55%) male and 27 (45%) female patients. The mean age at operation was 32.4 ± 6.3 years. Nine (15%) patients presented with fever. Hemodynamic status was unstable in 18 (30%) patients. Surgery has been carried out through repeat sternotomy or right anterolateral thoracotomy. Results The 30-day mortality rate was 12 (20%) patients. Analysis of preoperative, intraoperative, and postoperative factors revealed that significant predictors of early mortality were the surgical approach, time until surgical intervention, and depression of left ventricular function. The cause of prosthetic mitral valve malfunction was valve thrombosis in 39 (65%) patients, pannus formation in nine (15%) patients, paravalvular leakage in three (5%) patients, and prosthetic valve endocarditis (PVE) in nine (15%) patients. Right anterolateral thoracotomy (24.3 ± 8.5 min) proved to be faster than median sternotomy (63.1 ± 63 min) from skin incision to on bypass with a significant reduction of intraoperative complications and postoperative wound infections. Conclusion Hospital mortality can be reduced in patients with prosthetic mitral valve dysfunction if the surgery is carried out before cardiac dysfunction develops, with excellent results. Right anterolateral thoracotomy is feasible and safe for selected patients and should be considered whenever repeat median sternotomy could prove to be hazardous especially in the prominent right ventricle and pulmonary hypertension.

Resection of Giant Coronary Artery Aneurysms in a Takayasu's Arteritis Patient

<p>Coronary artery aneurysm (CAA) is a rare entity, defined as localized dilation that exceeds the normal vessel diameter by a factor of 1.5. A giant CAA is described as a very large dilation, when diameter exceeds 20 mm. CAA has a preva-lence of 0.02% [Markis 1976]. Different factors may lead to CAA formation, including Kawasaki disease, atherosclerosis, congenital malformations, autoimmune and infectious disor-ders, and percutaneous interventions [Hartnell 1985]. Man-agement of these patients remains controversial due to a lack of data from large series studies.</p><p>We reported a case of a young female patient, who pre-sented with an acute inferior infarction and was diagnosed with a giant right coronary artery (RCA) aneurysm. She underwent aneurysmectomy and revascularization on a beat-ing heart through a right lateral thoracotomy. Due to the minimally invasive nature of this procedure, the patient was able to recover quickly without substantial cosmetic changes.</p>

BackgroundGiant coronary artery aneurysms are rare conditions with potentially devastating consequences. We report a case of the largest documented giant right coronary artery (RCA) aneurysm to date.Case presentationA 57-year-old male patient visited our outpatient clinic for abdominal pain and exertional dyspnea. Computed tomography identified a 10.2 × 9.8 cm RCA aneurysm with RCA pressure waves were similar to aortic pressures. After discussion by the cardiac team, elective resection with ligation of the proximal and distal ends of the RCA was performed due to the presence of adequate collaterals.ConclusionWe highlight the challenges related to the management of patients presenting with giant coronary artery aneurysms. Optimal management strategies and outcomes for such rare cardiovascular conditions implies the need for standardised management guidelines.

Patient: Male, 64-year-oldFinal Diagnosis: Huge coronary aneurysmSymptoms: Chest discomfort • dyspneaMedication: Losar 25 mg twice daily • Amlodipine 5 mg twice daily • Aspirin 80 mg daily • Atorovastatin 20 mg daily • Pantaprazole 20 mg dailyClinical Procedure: Coronary artery bypass graft surgerySpecialty: Cardiac Surgery • CardiologyObjective:Rare diseaseBackground:Giant coronary artery aneurysm (GCAA) is a rare disease, with an incidence of 0.02% in the general population. GCAA is defined as when the diameter of the coronary artery is more than 4 times the adjacent part or more than 8 mm. There are several causes of GCAA, with atherosclerosis being the most common. Patients with giant coronary artery aneurysms can be asymptomatic or develop chest pain, dyspnea, and palpitations. Complications of GCCA include myocardial infarction, thrombosis, and sudden death, so early treatment is necessary to prevent mortality. There is no standard surgical approach for a giant coronary artery aneurysm.Case Report:A 64-year-old man with hypertension, opium addiction, morbid obesity (body weight 151 kg and BMI 46), and benign prostate hyperplasia presented with a giant coronary aneurysm in coronary angiography. The patient underwent cardiac surgery, and a 42-mm coronary aneurysm was detected. The aneurysm had many orifices that opened to the left main coronary artery, left circumflex artery, LAD, the diagonal branch of the LAD, and the septal branch of the LAD. Aneurysmectomy and coronary artery bypass graft were successfully performed.Conclusions:Giant coronary artery aneurysms are rare. Patients with giant coronary artery aneurysms may experience sudden death due to myocardial infarction and other cardiovascular complications due to ischemia. Because it is rare, there is no standard surgical approach for a giant coronary artery aneurysm. Further studies need to focus on standardized surgical management of patients with giant coronary artery aneurysms.

Background: Prosthetic Mitral valve dysfunction is a serious complication associated with a high mortality rate particularly in obstructive cases. The number of cases undergoing redo mitral valve surgery is increasing. This study aims to identify the risk factors of mortality and morbidity in patients who underwent redo mitral valve surgery for prosthetic mitral valve dysfunction.
 
 Methods: This study was conducted on 80 patients who underwent re-operation for management of prosthetic mitral valve dysfunction from December 2014 to February 2018. Patients’ age ranged between 21 and 58 years with a mean of 36.8±9.60 years, and 53 patients (66.3%) were males. The causes of mitral valve malfunction were thrombus in 67 patients (83.7%) and pannus in 13 patients (16.3%).
 Results: 53 patients (66.25%) had urgent surgical intervention. Thrombectomy or pannus resection was done in 75 patients (93.75%) and valve replacement in 5 patients (6.25%). Re-exploration was required in 11 patients (13.75%) and was significantly associated with diabetes (p= 0.004), preoperative liver dysfunction (p= 0.04), elevated INR (p= 0.006), trial of thrombolysis (p<0.001) and prolonged ischemic time (p= 0.01). Postoperative renal failure occurred in 11 patients (13.75%) and was associated with diabetes (p< 0.001), preoperative renal dysfunction (p< 0.001), prolonged cardiopulmonary bypass and ischemic times (p< 0.001). 17 patients (21%) required prolonged mechanical ventilation and it was significantly associated with chronic obstructive lung disease (p< 0.001), pulmonary edema (p <0.001), low systolic blood pressure (p <0.001), low ejection fraction (p<0.001) and thrombectomy (p<0.001). Operative mortality occurred in 13 patients (16%) and was significantly associated with preoperative stroke, renal dysfunction, low blood pressure and acute pulmonary edema (p <0.001).
 Conclusion: Reoperation for prosthetic mitral valve dysfunction is associated with high morbidity and mortality. Outcomes can be predicted based on preoperative clinical status and operative times. Thrombectomy and pannus resection with the repair of the paravalvular leak is a simple and easy technique for management of those patients with a reduction of cardiopulmonary bypass and cross-clamp times.

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound: A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the

The giant coronary artery aneurysm is a very rare finding (0.02% of the general population), in which the right coronary artery is most often affected by aneurysms. Herein, we present a rare case of a giant left coronary artery aneurysm involving multiple major coronary arteries and compressing the cardiac cavity. The giant coronary artery aneurysm was opened and explored under cardiopulmonary bypass, and many mixed thrombi and calcified tissue were exposed. The patient was discharged uneventfully 7 days after surgery. The best management strategy at present is based on case reports, small case series, and personal experience. Treatment must be individualized according to the aetiology, location, symptoms, size, disease progression, the existence of infection, and the degree of any coexisting atherosclerosis. Surgery is a good alternative, particularly if a giant coronary artery aneurysm has a high risk of rupture and compressing the cardiac cavity. Even today, the treatment strategy is still open to debate and a clear evidence-based management strategy has not been established.

Giant Aneurysm of the Left Atrial Branch of the Left Circumflex Artery With Fistula

Kawasaki disease (KD) is an acute systemic inflammatory illness that occurs predominately in children <5 years of age. The reported incidence varies widely depending on the ethnicity of the population and the method of case ascertainment. Recent reports would suggest the annual incidence is ≈20 to 25 per 100 000 children <5 years of age in North America, with the highest reported incidence of 188 being in Japan, where the disease was first described in 1967.1 The illness is self-limited and of unknown cause, but is complicated by a systemic vasculitis with a predilection for small- to medium-sized arteries, particularly the coronary arteries. The majority of patients will have either transient coronary artery dilation or no coronary artery luminal changes as noted on echocardiography. Long-term prognosis for these patients is considered to be excellent. Coronary artery aneurysms occur in 25% of patients, but the prevalence is reduced to ≈4% for patients treated with intravenous immunoglobulin infusion within 10 days of illness onset. Aneurysms are associated with an intense inflammatory cell infiltrate, destruction of the internal elastic lamina, and smooth muscle cell death. Coronary artery involvement is usually maximal within 6 to 8 weeks after the acute episode. Regression of aneurysms can occur primarily through myointimal proliferation, although the arterial structure and function remains abnormal,2 and there is an important ongoing risk of stenoses and occlusions.3 Long-term cardiology assessment and management is required, and some of these patients may require revascularization procedures or, rarely, cardiac transplantation. KD has become the most prevalent acquired cardiac disease in children in developed countries. Article see p 60 Although coronary artery complications are the predominant cause of morbidity and mortality, other cardiovascular abnormalities can occur. Valvulitis is a less prevalent complication, and there have been case reports of important long-term aortic and …

We report a case of sudden death due to rupture of a giant right coronary artery aneurysm, likely a sequela of remote Kawasaki disease, in a young woman with Down syndrome. The decedent was a 28 year old female with trisomy 21 who was found deceased in the backyard pool. An autopsy disclosed an enlarged heart with 400 ml of clotted blood in the pericardial sac and undiagnosed giant coronary artery aneurysms involving the left anterior descending, left circumflex, and right coronary artery, with rupture of the latter artery. The histologic findings were consistent with remote Kawasaki disease. Giant coronary artery aneurysms are a rare complication of Kawasaki disease, infectious vasculitis, and atherosclerosis, among other causes. While Kawasaki disease is typically considered a disease of children, late-onset complications should be considered in the differential diagnosis of young adults with myocardial infarction, coronary aneurysm, or sudden death.

A 53 year old woman was evaluated for recurrent native and prosthetic mitral valve thromboembolism in the setting of antiphospholipid antibody syndrome. In 1989, at age 30 years, she suffered a thromboembolic stroke and was diagnosed with antiphospholipid antibody syndrome for which long-term warfarin therapy was prescribed. She was subsequently assigned a goal international normalized ratio (INR) of 2.5–3.5. In 2008, at age 49 years, she was diagnosed with mitral valve stenosis and underwent mitral valve replacement (29 mm Carbomedics prosthesis). Pathology was consistent with nonbacterial thrombotic endocarditis involving a fibrotic and focally calcified mitral valve. After valve replacement, the target INR range was increased to 3.0–4.0. Nine months later, she developed thrombosis of the prosthetic mitral valve and required redo valve replacement surgery (27 mm St. Jude Biocor). Postoperatively, she developed heparin induced thrombocytopenia (HIT) for which she received argatroban while transitioning to warfarin. Her target INR range was subsequently increased to 3.5–4.5. In 2012, she developed recurrent prosthetic mitral valve thrombosis despite being mostly therapeutic(INR 3.5–4.5) and at times supra-therapeutic with INR monitoring. Transesophageal echocardiogram confirmed an 8 mm thick layer of organized thrombus encasing each of the prosthetic mitral valve leaflets with severe valvular stenosis. Laboratory testing upon admission revealed a prothrombin time (PT) of 101.7s (INR 11.1). Simultaneously measured chromogenic factor X activity was 20 % (therapeutic range 20–35 %) and factor II activity was 14 % (normal reference range 75–145 %), confirming adequate anticoagulation at that time. A third mitral valve replacement procedure was pursued (27 mm Hancock II bioprosthesis) and she was yet again restarted on warfarin postoperatively. Initial special coagulation testing done at our institution in 1989 established the presence of a lupus anticoagulant (LAC). This diagnosis was subsequently confirmed on four occasions (1995–2012). Prior to 2004, the LAC assays were performed using the dilute Russel viper venom time (DRVVT) assay kit from American Diagnostica (Stamford, CT). After 2004, the DRVVT assay was performed using the kit from Precision Biologics (Dartmouth, NS, Canada) following the manufacturer’s instructions. She had a persistently high titer of anticardiolipin antibodies (IgG and IgM) as well. Her baseline prothrombin PT (11.3s) and INR (1.1), were normal and remained so until 2012, when measured during brief interruptions of warfarin anticoagulation (six occasions; 1995–2011). Prior to 2009, the PT assay was performed with Innovin (Siemens, New York, NY formerly Dade Behring, Deerfield, IL). Beginning in 2009, the PT was performed with Recombiplastin 2G (Instrumentation Laboratories, Bedford, MA). The temporal trends in INR and chromogenic factor X activity are shown in Fig. 1. Since INR differences are much larger at low factor activities than at high activities, we compared the log INR with the factor activities. Log INR did not correlate well with chromogenic factor X activity (Fig. 2a, r = 0.32) and factor II (Fig. 2b, S. S. Ketha (&) R. D. McBane W. E. Wysokinski Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Gonda 4-130 (VM), 200 First St. SW, Rochester, MN 55905, USA e-mail: Ketha.Siva@mayo.edu

Background: Long-term outcomes and life expectancy for children with a previous history of Kawasaki disease (KD), particularly those with coronary artery aneurysms (CAA), remain to be determined. Methods: An inception cohort of all patients with KD assessed at The Hospital for Sick Children in Toronto between 1978 and 2013 was assembled. Patient outcomes were obtained throughout their pediatric and adult clinical follow-up as long as available. Prevalence of outcomes over time was modelled with Kaplan-Meier survival curves. Life tables from Statistics Canada were used to obtain age/gender specific cumulative mortality for the general population. Results: The cohort included 2,623 KD patients, of whom 410 (16%) had coronary artery involvement (215 dilatation, 57 non-giant CAA and 138 giant CAA). Average follow-up for patients with coronary artery involvement was 6.7 years (13.3 years for giant CAA); 57 and 34 patients had at least 15 and 25 years of follow-up, respectively. No patients with coronary artery dilatation or non-giant CAA had revascularization or a myocardial infarct. Freedom from revascularization (14 events) for patients with giant CAA was 90±6%, 87±7% and 80±13% at 10, 20 and 40 years of follow-up. Freedom from myocardial infarct (11 events) was 94±4%, 92±5% and 89±7% at 5, 20 and 40 years. For patients without coronary artery involvement, 3 (0.1%) deaths were recorded, one secondary to complications of macrophage activation syndrome during the acute phase of KD and 2 from cancer. No deaths were noted for patients with coronary artery dilatation or non-giant CAA, although clinical follow-up was more limited. For patients with giant CAA, 3 deaths (2.2%) were noted, 2 related to CAA complications and 1 from non-medical cause. Cumulative mortality for patients with giant CAA was 1.5% at 10 years of age (expected mortality 0.7%, HR: 2.2 (0.3-11.5), p=0.08) and 3.1% at 40 years of age (expected 2.3%, HR: 1.3 (0.4-4.0), p=0.37). Conclusions: Despite risks of myocardial infarction and revascularization, patients with giant CAA had life-expectancy similar to that of the general population up to the fourth decade of life. Additional follow-up will be necessary to determine if these trends continue into later decades.

Giant coronary artery aneurysms, defined as diameters larger than 20 mm, are exceedingly rare and constitute a life-threatening occurrence. This case involves a patient with a giant right coronary artery (RCA) aneurysm and multivessel coronary artery disease, successfully managed by surgical intervention through quintuple coronary artery bypass grafting (CABG). A 65-year-old male with a history of hypertension presented with acute-onset chest pain. The initial workup revealed an inferolateral ST-segment elevation myocardial infarction (STEMI). The patient underwent emergency coronary angiography revealing a high-grade stenosis in the proximal and mid left anterior descending coronary artery, along with a remarkably tortuous and enlarged mid to distal RCA aneurysm measuring (21mm wide x 20mm long) and featuring significant post aneurysmal stenosis. Attempts at percutaneous angioplasty were unsuccessful due to extensive thrombosis in the RCA. The patient continued to experience active chest pain, necessitating the placement of an intra-aortic balloon pump in the right common femoral artery, the insertion of a temporary pacemaker wire to address bradycardia, and the initiation of pressor support for hypotension. Additionally, intravenous heparin and antiplatelet therapy were administered. Finally, the patient underwent a quintuple CABG to address the multivessel disease. Coronary artery aneurysm is an uncommon yet potentially perilous condition. The selection of appropriate management and intervention is crucial for averting fatal consequences associated with coronary artery aneurysms.