Case of the Month- LAD Endarterectomy on the Beating Heart.

The goal of coronary bypass surgery is complete revascularisation. This entails bypassing all coronary arteries 1mm or more in diameter with 50% or more obstruction and supplying viable myocardium. In patients with diffuse coronary artery disease this is possible only with the help of endarterctomy. In this technique vessels with less than 1mm lumen or no lumen is opened up by coring out the intima and part of medial layer of the vessel. The long arteriotomy is then patched with the bypass conduit, restoring flow to the native vessel.
Several studies have demonstrated that endarterectomy of the LAD not only relieves symptoms but also increases long term survival.

Case of the Month- Left atrial Myxoma- Commonest Tumor of the Heart.

Left Atrial Myxoma.

Tumors of the heart are rare. The commonest  tumor of the heart is a myxoma which accounts for 40-50% of primary cardiac tumors. Majority of the myxomas(90%) are solitary and pedunculated and nearly 75% occur in the left atrium. Myxomas are lobulated gelatinous in appearance. They are benign in nature but local recurrence has been reported after inadequate resection. majority of the myxomas are sporadic, 10% are familial

Myxomas can produce symptoms either by mechanical obstruction or embolisation. Symptoms of mechanical obstruction include left or right sided heart failure, depending on the site of the tumor. Syncope and dizziness may also occur. Embolic phenomenon may present as stroke, seizures and peripheral embolisation leading to infarction and gangrene.

Echocardiography is the diagnostic investigation of choice. The site and size of the tumor are clearly delineated.

The treatment is surgical excision. The tumor along with its stalk and a rim of surrounding normal tissue is excised. The prognosis is excellent. The recurrence rate is 1-3%, the familial variety  has a recurrence rate of up to 20%.

Excised gelatinous tumor with stalk and margin of interatrial septum.

Carotid Endarterctomy with PTFE patchplasty.

A 54 year old gentleman presented with recurrent right sided TIA's. MR angiography revealed a tight obstruction at the left carotid artery bifurcation. He was taken up for carotid artery stenting but the procedure was unsuccessful and resulted in a peri-procedural right upper limb monopareisis. He was then referred to us for carotid endarterectomy. 

Pre-op MR angio showing tight lt carotid bifurcation stenosis.

Post-operative CT angiogram.

He underwent a left carotid endarterectomy under general anesthesia. A carotid shunt was used and a PTFE patch arterioplasty was performed. He made an uneventful recovery and was discharged the next day. At one month follow up his is recovering well and a CT angiogram shows a widely patent carotid bifurcation with no residual obstruction.

Comment- Despite the advances in carotid stenting, carotid endarterectomy still remains the gold standard for treating carotid artery obstruction. 

Removed ulcerated plaque.

Aortic Arch Aneurysm- Management Using Endovascular Stent grafting.

 A 74 year old gentleman presented with history of hoarseness of voice for last 3 months. He consulted many physicians which led to a CT chest. The CT scan revealed a 2 X 1 cm aneurysm arising from the inner curvature of the arch. the site of the aneurysm was 2cm distal to the origin of the left subclavian artery. On investigation the patient was also diagnosed to have chronic renal failure with a serum creatinine of 2.4. His cardiac evaluation was normal. The site of the aneurysm was ideal for an endovascular procedure. The age and CRFalso pushed the decision towards an endovascular repair.

CT Aortogram Showing saccular aortic arch aneurysm with surrounding hematoma.

CT Aortogram images showing the location of the aneurysm.

Diagram showing stent placement.

The patient underwent a successful aneurysm repair using a Gore thoracic endovascular graft. In ths procedure a covered stent of appropriate size is positioned inside the aorta thus occluding the neck of the aneurysm. The approach is through the femoral artery. He was discharged the next day.

Three months post-op the patients hoarseness has improved remarkably. The CT aortogram shows a well placed stent with complete isolation of the aneurysmal sac.

Post op CT Aortogram

Comment- Aneurysms of the aortic arch are a difficult subset to manage. Conventional surgery requires median sternotomy/thoracotomy with cardio-pulmonary bypass with deep circulatory arrest. The procedure is high risk with prolonged stay in the hospital. In the recent years, endovascular grafting is becoming the procedure of choice for these patients. The patient can be discharged in a day or two and can resume normal activities.

Case of the Month- Hydatid Cyst of the Lung

A 28 year old lady presented with the complaints of persistent cough, low grade fever and malaise for 6 months. On investigation she was found to have a cystic lesion in the right upper lobe of the lung abutting the oblique fissure. She also had a cystic mass in the right lobe of the liver. The radiological findings were consistent with the diagnosis of hydatid disease of the lung and the liver.
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Chest X Ray before surgery.

Chest X Ray at initial presentation.

CT images

She was advised surgery which she refused and was sent home on oral albendazole therapy. She returned after one month a repeat chest x-ray showed that the cyst fluid had drained and it was now empty.

She underwent a right thoracotomy. The cyst was located in the right upperlobe abutting the oblique fissure. After isolating the adjoining areas with sponged soaked in hypertonic saline(scolicidal agent), the cyst was incised. The white ectocyst was removed completely (photograph below). On water testing two areas of bronchial leaks were found. They were secured with polypropylene stitches. The cyst cavity was then obliterated with multiple purse string sutures. The chest was then closed.

Removed ectocyst (germinal membrane).

Comment- hydatid disease or Echinococcosis is a zoonotic infection caused by the tapeworm of the Echinococcus species. In humans E.granulosus is the most common. Humans are accidentaly infected by ingesting food contaminated with embyonated cysts. Theoretically any organ may be involved ,bur liver and lung account for nearly 90% of the cases. The symptoms depend on the site involved and are due to pressure or mass effect and cyst complications. Cyst complications include allergic reactions due to leakage and infection.
Diagnosis is usually made by the classic radiological appearance. The indirect haemagglutination test and ELISA have a sensitivity of  90% in hepatic echinococcosis, 40% in pulmonary echinococcosisand are the initial screening tests of choice.

Antibodies to antigen 5 on IE confirm the diagnosis. The historical Casonis intradermal test is no longer used.
The treatment of this condition is surgical. The cyst is aspirated using high suction. the cavity is sterilised using scolicidal agents. Peri and post op Albendazole/Mebendazole therapy is recommended upto 6 months to prevent recurrence.

Case of the Month- One Stage Correction of Ascending Aortic Aneurysm and Coarctation of Aorta in an adult.

A 38 year old gentleman presented with the complaints of chest pain and dyspnea on exertion (NYHA II) for 3 months. He was evaluated by his GP and found to be hypertensive. Cardiomegaly was observed on chest X Ray and he was sent for further evaluation.

Echocardigrphy revealed a bicuspid aortic valve with severe incompetence with dilated ascending aorta. A CT angiogram was performed which revealed a 8.5 cm aneurysm of the ascending aorta involving the aortic sinuses. The arch was hypoplastic with evidence of tight coarctation of aorta just after the origin of the left subclavian artery.( Image Below)

Post operative photo.

The patient underwent a single stage correction of the defect via a median sternotomy. Innominate artery was used formarterial cannulation. A 8mm dacron graft was used to cannulate this artery. Bicaval venous cannulation was used for venous return. Custodial cardioplegia was used for myocardal protection. A Bentalls procedure was performed with a size 23 valve conduit. With the heart arrested it was retracted to the right using the Starfish retractor. The descending aorta was dissected out posterior to the pericardium. A size 20 dacron graft was sutured to it end to side. This graft was then brought over the diaphragm, IVC and the right atrium to the right side of the heart. It was then connected to the aortic valved conduit in an end to side fashion. An extra anatomic bypass of the coarctation was therefore created.(Images below). There was no gradient of pressures between the upper and lower limbs post op.

Post operative CT.

Comment- Coarctation of the aorta may occassionaly be diagnosed in adulthood. It sis often associated with disease of the aortic root and valve. Traditionalyl, a staged operation requiring a median sternotomy and thoracotomy were performed to correct this defect. In the recent years a single stage approach as described above is recommended. The morbidity is less and the fragile area of the coarctation is not touched at all.  

Case of the Month- Pulmonary Embolism Masquerading As Acute Decompensation In A Patient With Severe Aortic Stenosis.

A 58-year-old gentleman with known aortic stenosis, presented with acute onset of New York Heart Association Class IV dyspnoea and bi-ventricular failure. His transthoracic echo revealed severe calcific aortic stenosis, severe pulmonary arterial hypertension with severe bi-ventricular dysfunction. There was also a large mobile mass in the right atrium projecting into right ventricle the presence of which was confirmed on trans-esophageal echocardiography (Fig.1).

The patient was taken up for urgent surgery. Per-operatively, a linear clot, measuring eighteen centimeters was found in the right atrium (Fig.2). It was extending through the tricuspid valve into the right ventricle. The clot was removed. A small patent foramen ovale was present which was closed directly. Aortotomy was then performed and aortic valve replacement was done with a mechanical valve.

After the patient was shifted to ICU, a peripheral venous Doppler revealed bilateral deep vein thrombosis extending into femoral veins. An inferior vena caval filter was deployed.

The patient was discharged on oral anticoagulation.

This case demonstrates that in patients with pre-existing heart disease who present with sudden de-compensation, acute pulmonary embolism should also be considered and investigated for.

 

Figure1.

 

Figure 2.

Case of the Month - Solitary Fibrous Tumor of the Pleura(SFTP)

 

Case History-

A 70 year old lady presented with worsening dyspnea over last 3 months. For the last 2 weeks she was unable to perform her daily chores.

She was evaluated by her GP and a chest x-ray and CT Chest were done (image below).

 

 

The chest X ray showed opacification of the left hemithorax with shifting of the mediastinal structures to the right.
The CT chest showed a large mass (17cm X 8cm X 7cm) occupying the anterior portion of the left hemithorax. It was of homogenous density with areas of calcification. The upper lobe of the lung was completely obliterated. The mass was abutting the left hilar vascualr structures without any evidence of invasion. The mediastinal structures were shifted to the right due to the mass effect.
A FNAC of the mass was performed at another hospital was neagative for malignant cells.

The patient was taken up for surgery after necessary work up. In view of the close proximity to the hilar structures, I decided to open the chest with the clamshell approach(B/L thoracotomy- figure below). The hilar structures (left pulmonary artery and vein) were controlled intrapericardially with vessel loops. The tumor was then dissected out. It was non adherent to the vascular structures and could be delivered out of the chest cavity after lysing flimsy adhesions to the chest wall and the lung. There was a vascular pedicle from the lingula region which was ligated and divided. The left uppel lobe of the lung which was compressed by the tumor was spared and expanded fully once ventilation was restored.
The tumor weighed 1.75kg (figure below).
The gross findings were suggestive of a solitary fibrous tumor of the pleura (SFTP) and the histopathology report was confirmatory. The tumor showed uniform spindle cells with connective tissue in between. There was no evidence of malignancy.

Clamshell Incision



Comment- Solitary fibrous tumor of the pleura is a mesenchymal tumor that has been increasingly recognised over the past few years. Majority of these tumors have a benign course cured by simple excision. About 12% have malignant course and may recur. The case above is a classical presentation of this tumor. The main differential diagnosis include - pleural mesothelioma, neurogenic sarcoma, synovial sarcoma, hemangiopericytoma, fibrosarcoma and malignant fibrous histiocytoma. Immunohistochemical staining can be used to confirm the diagnosis.