Successful Surgical Repair Research Articles

Ruptured Sinus of Valsalva Aneurysm Causing Aorto-Atrial Fistula and Acute Heart Failure: A Rare Encounter.

A ruptured sinus of Valsalva aneurysm as a cause of aorto–atrial fistula is very rare. We present the case of a 53-year-old female who presented with symptoms of acute heart failure and suspicion of an aorto–atrial fistula found on a transthoracic echocardiogram, which was confirmed on transesophageal echocardiography. A coronary angiogram showed normal coronary arteries but confirmed the right aorto–atrial fistula on aortogram. She underwent successful surgical repair of the fistula. Her postoperative echocardiogram showed a normal right atrium and right ventricle with no shunt. A ruptured sinus of Valsalva aneurysm is a devastating event and presents as acute heart failure. Prompt diagnosis and surgical repair is necessary to prevent mortality.LEARNING POINTSA ruptured sinus of Valsalva aneurysm causing an aorto–atrial fistula can present as acute heart failure.A transthoracic echocardiogram can identify the presence and location of a sinus of Valsalva aneurysm, while a transesophageal echocardiogram can recognize fistulous tract formation. Cardiac magnetic resonance imaging and computed tomography can confirm or better categorize echocardiographic findings.The management of an aorto–atrial fistula is surgical intervention, involving a patch repair.

A Multidisciplinary Approach to Manage of a Recurrent Congenial Diaphragmatic Hernia; A Case Report

: Recurrent congenial diaphragmatic hernia (CDH) causes challenging conditions. In spite of several advantageous of laparoscopic surgery, this method is associated with the higher risk of recurrence. We described a three- month infant with a recurrent CDH following a successful laparoscopic repair. First, he did not have any specific symptoms and was at a high risk of misdiagnosis. He underwent an emergency surgery with proper surgical and anesthesia management. In order to achieve desired goals in CDH recurrence cases, an early diagnosis, urgent intervention, and a constant communication between the surgeon and the anesthesiologist are crucial. The parents should also be informed about the potential risks of recurrence after even a successful surgical repair.

Adult-Type Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Syndrome

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare cardiac malformation accounting for 0.25% of congenital heart diseases with reported incidence of 1 in 300,000 live births. It frequently occurs as an isolated defect and is associated with early infant mortality and sudden death in adults. Surgical repair is the treatment of choice and should be done soon after diagnosis. We report the case of a 38-year-old female, presenting as cardiac arrest and being finally diagnosed as adult ALCAPA. Successful surgical repair was performed using the trap door technique. The patient had an uneventful recovery.

P720 Antenatal and postnatal echocardiographic diagnosis of Truncus Arteriosus III (TAIII) complicated by spontaneous PDA (patent ductus arteriosus) closure and LPA (left pulmonary artery) disconnection

Abstract Introduction TA III is a rare form of truncus arteriosus when the branch pulmonary arteries originate independently from the common arterial trunk or aortic arch, with origin of one pulmonary artery from the underside of the aortic arch from a ductus arteriosus. Accurate diagnosis and timing of surgery is essential for survival of neonates affected. Purpose Illustration of various imaging modalities utilized to diagnose and manage this lesion and the importance of spontaneous PDA closure. Results TAIII diagnosed at 24 weeks gestation by fetal echocardiography images 1,2,3. Baby was spontaneously delivered at term with 3 Kg weight and 8,9 Apgar score. Diagnosis was confirmed by transthoracic echocardiography images 4,5 , however on 7th day of life routine echocardiogram was performed to assess PDA , markedly decreased flow noted in LPA/left pulmonary veins and no PDA could be seen at that time images 5,6. Spontaneous ductal closure was confirmed by tomography image 7 then cardiac intervention performed to establish LPA patency image 8,9. Successful total repair was done within the neonatal period with excellent results at follow up ( image 10 at 3 years old). Conculsions 1- TAIII can can be diagnosed and assessed by echocardiography. 2- PDA patency to maintain LPA continuity is essential in TAIII management. 3- Successful total surgical repair with good outcomes can be achieved for neonates with this rare complex cyanotic CHD. Abstract P720 Figure. Images

Use of Selective Pulmonary Vasodilators to Treat Pulmonary Arterial Hypertension Prior to Successful Surgical Closure of Atrial-Level Shunts

Background: Significant pulmonary hypertension [PH] is often considered a contraindication for closure of atrial septal defects [ASD]. Treatment of pulmonary arterial hypertension [PAH] with selective pulmonary vasodilators can allow for surgical repair of ASD otherwise considered prohibitive. We describe our experience in the assessment and treatment of adults with ASD and PAH with pulmonary vasodilator therapy who underwent successful surgical repair.

Surgical Management of Herniated Intrathoracic Gastric Perforation in Traumatic Diaphragmatic Rupture: An Unusual Two Rare Cases

Gastric perforation into the thoracic cavity through a diaphragmatic rupture is rare but, when it occurs, patients present in severe distress, with mortality approaching 50%. We present our experience of two rare and unusual cases of traumatic diaphragmatic rupture from penetrating chest injury associated with herniated intrathoracic gastric perforation over a five-year period from January 2015 to December 2020 at the cardiovascular and thoracic surgery department of the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Both patients underwent successful surgical repair through standard posterolateral thoracotomy with one having earlier negative exploratory laparotomy. The essence of the paper is to share and discuss the clinical presentation, diagnostic challenges, surgical management and the postoperative care of this very rare complication of traumatic diaphragmatic rupture.

Successful open surgical repair of an infrarenal, abdominal aortic aneurysm (AAA) in a young Malawian female: A case report

A 39-year-old woman presented to Queen Elizabeth Central Hospital in Blantyre, Malawi with a 3-week history of worsening peri-umbilical abdominal pain radiating to the lower back associated with anorexia, nausea and vomiting. There was no history of trauma, diarrhoea, obstipation, fevers, or urinary symptoms. She reported history of ‘spinal surgery’ performed 6 years prior due to a herniated intervertebral lumbar disk.

The MRL/MpJ Mouse Strain Is Not Protected From Muscle Atrophy and Weakness After Rotator Cuff Tear.

Chronic rotator cuff tears are a common source of shoulder pain and disability. Patients with rotator cuff tears often have substantial weakness, fibrosis, and fat accumulation, which limit successful surgical repair and postoperative rehabilitation. The Murphy Roths Large (MRL) strain of mice have demonstrated superior healing and protection against pathological changes in several disease and injury conditions. We tested the hypothesis that, compared with the commonly used C57Bl/6 (B6) strain, MRL mice would have less muscle fiber atrophy and fat accumulation, and be protected against the loss in force production that occurs after cuff tear. Adult male B6 and MRL mice were subjected to a rotator cuff tear, and changes in muscle fiber contractility and histology were measured. RNA sequencing and shotgun metabolomics and lipidomics were also performed. The muscles were harvested one month after tear. B6 and MRL mice had a 40% reduction in relative muscle force production after rotator cuff tear. RNA sequencing identified an increase in fibrosis-associated genes and a reduction in mitochondrial metabolism genes. The markers of glycolytic metabolism increased in B6 mice, while MRL mice appeared to increase amino acid metabolism after tear. There was an accumulation of lipid after injury, although there was a divergent response between B6 and MRL mice in the types of lipid species that accrued. There were strain-specific differences between the transcriptome, metabolome, and lipidome of B6 and MRL mice, but these differences did not protect MRL mice from weakness and pathological changes after rotator cuff tear. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:811-822, 2020.

Surgical Repair of Vesicovaginal Fistula: A Variation of the Flap-Splitting Technique

Video Objective To describe and demonstrate a variation of the flap-splitting technique for surgical correction of both small and medium sized vesicovaginal fistulas (VVF). Setting Patient A is a 51 year old woman who had undergone abdominal hysterectomy 10 years prior, and developed 2.5mm VVF, from which she experienced symptomatic leakage for many years. Patient B is a 53 year old woman who had undergone abdominal hysterectomy for cervical dysplasia and developed a 1cm VVF 2 months later. Both underwent successful surgical vaginal fistula repair. Interventions Surgical correction of vesicovaginal fistula via an alternative approach to the traditional flap-splitting technique. The 4 key steps consistent of exposure, lateral incision, mobilization of defect with multiple layer repair, and confirmation of adequate watertight seal. Conclusion Vaginal approach to repair should be considered whenever feasible. This variation to the flap splitting technique allows for adequate tissue mobilization without extension of defect.

AN UNUSUAL COMPLICATION OF PULMONARY BIOPSY: ATRAUMATIC LUNG HERNIATION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Lung herniation, in which lung tissue protrudes through its bounding structures, is a rare condition which may occur as a result of trauma, thoracic operations, increased thoracic pressure, or congenital abnormalities(1). CASE PRESENTATION: A 57-year-old African American man presented to the emergency department after one day of right-sided chest pain accompanied by worsening dyspnea after a coughing episode. He described a painful pressure-like sensation adjacent to the sternum that worsened with deep inspiration and was not relieved with positioning. The patient had a history of a sarcoidosis, daily marijuana use, and a prior thoracoscopic right anterior lung wedge resection for a pulmonary biopsy 2 years prior. On physical exam the patient had a heart rate of 108 beats per minute, blood pressure of 137/98 mmHg, respiratory rate of 18, and oxygen saturation of 95% on room air. He had tenderness to palpation of the right upper quadrant of his abdomen with no palpable mass in the chest or abdomen. There was no tenderness to anterior rib palpation. Chest x-ray was unremarkable except for post-surgical changes of the right hemithorax. A chest computed tomography scan revealed a partial herniation of the right middle lobe of the lung between the right fourth and fifth ribs anteriorly. After initial assessment by thoracic surgery, the patient elected for conservative management and was discharged from the hospital. Due to increasing chest pain, he underwent successful surgical repair of the hernia six months later with subsequent resolution of his chest pain. DISCUSSION: Postoperative intercostal hernias are more common after minimally-invasive surgeries, such as video-assisted thoracoscopy (VATS), compared to major thoracic interventions(2). This increased risk has been attributed to the limited access to tissue in minimally-invasive procedures and resultant inadequate closure of the chest wall. Challenges with wound closure leading to lung hernia have been reported in the literature related to VATS with an anterior approach(3). Our case presents a patient with lung herniation likely secondary to inadequate closure of his prior mediastinoscopy incision. Additionally, his underlying sarcoidosis may have predisposed him to inadequate wound healing, and his chronic coughing from marijuana use may have incited the herniation through increased intrathoracic pressure. CONCLUSIONS: In a patient with a history of minimally invasive thoracic surgery who is complaining of parasternal pleuritic chest pain, lung herniation must be on the differential diagnosis. Increasing size, worsening pain, or incarceration of the hernia are indications for urgent surgical intervention that physicians must keep in mind when treating patients with this rare cause of chest pain. Reference #1: Weissberg D. Lung hernia - a review. Adv Clin Exp Med. 2013. Reference #2: Temes RT, Talbot WA, Green DP, Wernly JA: Herniation of the lung after video-assisted thoracic surgery. Ann Thorac Surg. 2001. Reference #3: Vasileios K. Kouritas, Robert S. George, Alessandro Brunelli, Emmanouel Kefaloyannis; Lung herniation after uniportal video-assisted thoracic surgery lobectomy presenting with subcutaneous surgical emphysema, European Journal of Cardio-Thoracic Surgery. 2016. DISCLOSURES: No relevant relationships by Dave Gupta, source=Web Response No relevant relationships by Erica Sheline, source=Web Response No relevant relationships by Manasi Tannu, source=Web Response

SURGICAL REPAIR OF PERIPHERAL PULMONARY ARTERY STENOSIS

Peripheral pulmonary artery stenosis (PPAS) is a rare form of congenital heart disease and is typically associated with Williams or Alagille syndrome. However, there are patients without either syndrome who present with PPAS. The purpose of this study was to review our surgical experience in those patients. This is a retrospective review of 30 patients without either Williams or Alagille syndrome who underwent surgical repair of PPAS at a single institution. Median age at surgery was 3.6 years (range 0.3-18.8 years). Seventeen of the 30 patients (57%) had undergone previous cardiac operations and 16 patients (53%) previously underwent peripheral pulmonary artery balloon angioplasty or stent implantation. Concomitant anatomical diagnoses were found in 20 patients (67%) and included: supravalvar aortic stenosis (n=8), tetralogy of Fallot (n=4), d-transposition of the great arteries(n=2), truncus arteriosus (n=2), hypoplastic left heart syndrome (n=2), ventricular septal defect (n=1) and patent ductus arteriosus (n=1). Additional medical diagnoses were found in 15 patients (50%) and included: elastin arteriopathy (n=9), pulmonary artery calcinosis (n=1), arterial tortuosity syndrome (n=1), DiGeorge syndrome (n=1), Noonan syndrome (n=1) and others (n=2). The mean number of peripheral pulmonary stenoses surgically addressed was 19±8. Median duration of cardiopulmonary bypass was 369 minutes (IQR 292 to 515 minutes). With surgical repair, mean right ventricle-to-aortic systolic pressure ratio decreased from 0.95±0.2 pre-operatively to 0.28±0.08 post-operatively (p < 0.0001). Similarly, mean right ventricle systolic pressure decreased from 81±22mmHg to 26±8mmHg (p < 0.0001). Survival to hospital discharge was 100% and there was no mortality at a mean follow-up of 2.3 years. Post-operatively, 4 patients underwent balloon dilation of peripheral pulmonary arteries and no patient required cardiac reoperation. Freedom from pulmonary artery catheter-based reintervention was 95% and 80% at 12 and 36 months, respectively. This cohort of patients with PPAS underwent successful surgical repair with a significant reduction in right ventricle to aortic pressure ratios, achieving absolute right ventricular systolic pressures within the normal range. Various medical and anatomic diagnoses may be associated with PPAS. These results suggest a surgical approach should be considered the first-line treatment for PPAS.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

P4643Pulmonary hypertension incidence is higher than systemic arterial hypertension in children after aortic coarctation repair

Abstract Introduction Coarctation of the aorta (CoA) is characterized by diffuse arteriopathy which can persist to upward of the aortic isthmus, even after successful surgical correction. This arteriopathy can also occur in the pulmonary vasculature, leading to pulmonary hypertension (PH), a strong risk factor of poor prognosis in CoA population. Purpose The purpose of this study was to determine the incidence of systemic and pulmonary hypertension in a CoA paediatric population after surgical repair, as well as the impact of PH in right ventricular function. Methods This cross-sectional study included children after successful surgical repair of the CoA in a tertiary centre [1996, 2009] up to the first year of age. Children with other cardiac structural lesions or recoarctation were excluded. Systemic arterial hypertension was defined as blood pressure in the 95th percentile or higher. PH was considered if the estimated pulmonary systolic arterial pressure (PSAP) was higher than 30mmHg. Pulse wave velocity, ambulatory 24 hours blood pressure monitoring, echocardiographic assessment of right ventricle (RV) and blood tests were performed 11±4 years after surgical procedure. Echocardiographic variables were normalized and evaluated by z-scores. One sample t test or sign test was used to estimate the deviation of measured/observed values from the normality/expected values (defined by z-score=0). Results We included 38 children with a mean age of 12±4 years (63% male). Late arterial hypertension was diagnosed in 29% of the children and PH incidence was 68% with a mean PSAP of 37±5mmHg. The mean of A' wave (z-score: 0.34±0.93, p=0.030) and median of E/E' ratio (z-score: 0.46 [−1.32; 3.68], p=0.004) z-scores were increased comparing with expected normal values in paediatric population. Moreover, E' wave (z-score: −0.35±0.98, p=0.034) and RV index of myocardial performance (z-score: −0.20±0.41, p=0.006) were decreased. Regarding RV systolic function, TAPSE z-score was significantly increased (z-score: 2.06±2.33, p&lt;0.001), being outside the z-score normal range. Conclusion Children submitted to CoA surgical repair before the first year of life showed a higher PH incidence than late systemic hypertension occurrence. Also, they already present with significant RV functional abnormalities when compared to the normal paediatric population. These abnormalities can underlie pulmonary vascular remodelling after left ventricular pressure overload in CoA population that seems irreversible after pressure overload relief. Acknowledgement/Funding AFF are supported by FCT (SFRH/BD/138925/2018)

A direct method for measuring surface area of polymer mesh using synchrotron x-radiation microComputed tomography: a pilot study

Mesh products are critical for successful long term surgical repair of many anatomic defects, including hernias and pelvic prolapse. Biocompatibility of polymeric mesh depends on the foreign body response- how the tissues react to physicochemical properties, including porosity and mesh ‘weight’. We postulate that effective surface area, the total filament area in contact with the tissues, is an important variable for long-term repair strength. We present a technique utilizing synchrotron x-radiation microComputed Tomography (microCT) to calculate the effective surface area of polymeric meshes. Six representative polypropylene-based hernia meshes, including composite meshes, were studied: Ethicon PROLENETM, Ethicon PROLENETMSoft Mesh, Ethicon PHYSIOMESHTM, Ethicon ULTRAPROTM, Atrium PROLITETM Mesh, and Bard® Soft Mesh. Ethicon PROLENETM , a heavy weight mesh, had the highest effective surface area at 6.44 cm2 cm−2 and Ethicon ULTRAPROTM, a composite light-weight mesh, had the lowest effective surface area at 0.62 cm2 cm−2. We conclude that this technique can reliably be used to further classify mesh, as manufacturers and surgeons continue to optimize the safety profile of these implants.

Cannulation strategies, circulation management and neuroprotection for type A intramural hematoma: tips and tricks.

The circulation management strategies and operative techniques that are essential for the successful surgical repair of acute type A intramural hematoma (ATAIMH) are similar to those utilized for acute type A aortic dissection. This article reviews the neuroprotection strategies and arterial cannulation sites used in the treatment of patients with ATAIMH.

Understanding the role of social factors in recovery after hip fractures: A structured scoping review.

Poor recovery among older adults with hip fractures can occur despite successful surgical repair and rehabilitation, suggesting other factors might play a role in recovery, such as social factors. The aim of this scoping review was to provide an overview of the literature on the role of social factors in older adult's recovery after hip fracture. This review followed the York Framework and its modifications and recent reporting guidelines. Two independent researchers searched main medical databases (CINAHL, EMBASE, Medline, PsycINFO and the Cochrane libraries) from inception to June 2017, for studies investigating social factors and recovery post hip fracture. Studies were excluded if they were qualitative, perspective papers or if participants were<65years or they were not living in the community. We screened 2,503 unique abstracts in total and 19 studies fulfilled the inclusion criteria. Social factors investigated in the included studies were social support, socioeconomic factors and living arrangement. We classified outcomes in the studies into three subgroups: physical functional recovery, mortality and other outcomes (pain, hospital length of stay and quality of life). We found evidence that social support and socioeconomic factors (e.g. socioeconomic status) were significantly associated with an increase in functional recovery, a decrease in mortality and other outcomes, but conflicting evidence was found for the effect of one's living arrangement. Only two included studies were randomised controlled trials. To conclude, social factors, such as social support and socioeconomic status, affect physical functional recovery and mortality in older adults with hip fractures. However, this is an under researched area that lacks rigorously designed studies and would benefit from more studies with rigorous designs.

Exercise Capacity in Asymptomatic Adult Patients Treated for Coarctation of the Aorta

A reduced exercise capacity is a common finding in adult congenital heart disease and is associated with cardiovascular morbidity and mortality. However, data on exercise capacity in patients after repair of coarctation of the aorta (CoA) are scarce. Furthermore, a high rate of exercise-induced hypertension has been described in CoA patients. This study sought to assess exercise capacity and blood pressure response in asymptomatic patients long-term after CoA repair in relation to left ventricular and vascular function. Twenty-two CoA patients (age 30 ± 10.6 years) with successful surgical repair (n = 12) or balloon angioplasty (n = 10) between 3 months and 16 years of age with a follow-up of > 10 years underwent cardiopulmonary exercise testing at a mean follow-up of 23.9 years. Exercise capacity (peak oxygen uptake; VO2peak) and blood pressure response were compared to age- and gender-matched reference values. Left ventricular function and volumetric analysis was performed using cardiovascular magnetic resonance imaging. CoA patients showed preserved exercise capacity compared to the healthy reference group, with a VO2peak of 41.7 ± 12.0 ml/kg/min versus 44.9 ± 6.7 ml/kg/min. VO2peak/kg showed a significant association with age (p < 0.001) and male gender (p ≤ 0.001). Exercise-induced hypertension occurred in 82% of CoA patients, and was strongly related to left ventricular mass (p = 0.04). Of the 41% of patients who were normotensive at rest, 78% showed exercise-induced hypertension. No significant correlation was found between peak exercise blood pressure and age, BMI, age at time of repair, LVEF, or LV dimensions. Exercise capacity is well preserved in patients long-term after successful repair of coarctation of the aorta. Nevertheless, a high number of patients develop exercise hypertension, which is strongly related to systemic hypertension. Regular follow-up, including cardiopulmonary exercise testing, and aggressive treatment of hypertension after CoA repair is strongly advised.

Treating nasoethmoidal encephalocele in a low-resource country: a surgical experience from a Philippine multidisciplinary craniofacial team.

It was described that nasoethmoidal encephalocele repair in the Philippines has been limited by insufficient resources, financial constraints, and a lack of surgical expertise. The purpose of this study was to report initial results and complications of Philippine patients with nasoethmoidal encephalocele surgically managed with an approach adapted to an environment with limited financial resources. All patients (n = 21) with nasoethmoidal encephalocele who underwent intracranial and extracranial repairs (frontal wedge osteotomy to access the encephalocele cyst and cranial base defect, dural defect repair, split frontal grafts fixed with polydioxanone sutures to reconstruct the cranial defect and nasal dorsum, and medial canthopexy) from January 2015 to May 2017 were included. The correlations between sizes of masses and cranial defects with the occurrence of complications were tested. The surgical results were classified based on a previously published outcome grading scales I-IV on the need for additional surgery. Nineteen patients (90.5%) had unremarkable post-operative course. Two patients (9.5%) presented with complications (cerebrospinal fluid leak and surgical site infection) which were successfully managed with no additional surgery. The sizes of masses and cranial defects were not correlated (p > 0.05) with complications. The overall rate of surgical results ranked according to the need for additional surgery was 2.4 ± 0.5 (between categories II and III). We reported successful surgical repair of nasoethmoidal encephaloceles in Philippine patients by a local multidisciplinary craniofacial team.

Distal Adductor Longus Avulsion: A Technique for Successful Repair

Strains of the adductor muscle are common among athletes, but avulsion at its insertion is rare. Likewise, the diagnosis and management of distal ruptures of the adductors are infrequently reported in the literature. Presented here are the common presenting clinical findings of chronic distal adductor longus tendon ruptures and a description of how these can be successfully treated with a previously undescribed surgical technique. Preoperative and postoperative magnetic resonance imaging can be compared for verification of successful surgical repair. Also reviewed are common sports and mechanisms that elicit this injury pattern, adductor longus muscle function, relevant surgical anatomy, and treatment strategies.

Idiopathic Acquired Lacrimal Canalicular Obstruction.

Acquired lacrimal canalicular obstruction has a variety of causes. In a small proportion of patients, no cause can be identified. This article describes a cohort of 27 patients with idiopathic acquired lacrimal canalicular obstruction encountered over a 28-year period. The diagnostic database of the senior author was analyzed to identify all cases of idiopathic acquired lacrimal canalicular obstruction seen from 1990 to 2017. Demographic, clinical, and treatment details were analyzed. Patients with primary lacrimal punctal stenosis or closure were excluded from the analysis. The authors encountered 27 patients with idiopathic acquired lacrimal canalicular obstruction (17 female, 63%) aged 34 to 91 years (median: 65 years). The level of canalicular obstruction ranged from 1 to 10 mm from the punctum. Canalicular obstruction involved 1 canaliculus in 4 patients, 2 in 14 (ipsilateral in all except one), 3 in 3, and all 4 in 6. One patient who presented with ipsilateral upper and lower canalicular obstructions developed contralateral upper and lower obstructions several years later, and another patient redeveloped obstructions after initial successful surgical repair. In all cases, there were no features on history or examination to suggest a cause for the canalicular obstruction. Follow up ranged from 1 to 260 months (mean: 39 months). Sixteen patients underwent surgical repair, 11 with a dacryocystorhinostomy and placement of a Lester Jones glass bypass tube, 2 had a canaliculo-dacryocystorhinostomy (anastomosis of the canaliculus to the nose), 2 had dacryocystorhinostomy and trephination of the canalicular obstruction with silicone intubation, and 1 had a dacryocystorhinostomy alone to try and improve drainage through a single patent canaliculus. Idiopathic acquired lacrimal canalicular obstruction is uncommon and occurs more frequently in older women. The condition may be slowly progressive and can affect one or more canaliculi at any level. Treatment is the same as for any other cause of acquired lacrimal canalicular obstruction.

Giant unruptured aneurysm of the left coronary sinus of Valsalva presenting as acute coronary syndrome: a case report.

BackgroundSinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can be congenital or acquired. Unruptured aneurysms may be asymptomatic but can present as malignant arrhythmias, acute chest pain, and even sudden cardiac death. Both ruptured and unruptured SVAs may have fatal complications, thus prompt diagnosis and surgery is critical.Case summaryWe report a successful surgical repair of an unruptured aneurysm of the left sinus of Valsalva presenting as acute coronary syndrome. Coronary angiography (CAG) and cardiac multislice computed tomography (CT) revealed a large unruptured aneurysm of the left sinus of Valsalva. Surgical repair was performed by resection of the aneurysm, aortic valve replacement with composite graft, and coronary artery bypass.DiscussionAneurysm of the left sinus of Valsalva is an extremely rare condition. Correct diagnosis can be done by echocardiography, CAG, or CT. Non-ruptured aneurysms should be surgically repaired if they are associated with significant symptoms or if their size enlarge rapidly.