Faculty Bibliography

Coronary artery aneurysms (CAAs) are rare, with giant CAAs being even rarer. The precise pathophysiology of this phenomenon is still unknown. CAAs are seldom reported life-threatening abnormalities of the cardiovascular system. We herein present a case of a 74-year-old man who presented at the hospital complaining of chest pain. An adenosine thallium scan revealed a small, reversible defect in the inferior wall of the left ventricle extending into the apex, consistent with ischemia. Echocardiography uncovered a large right coronary artery (RCA) aneurysm, measuring 5.6 × 7.5 cm. Diagnostic coronary angiography confirmed the presence of a large RCA aneurysm and aneurysmal dilation of the left anterior descending and circumflex arteries with no flow-limiting lesions. A reversed saphenous vein interposition graft was placed from the ascending aorta to the right posterior descending artery. The RCA aneurysmal sac was resected and sent to pathology, which uncovered myxoid degeneration of the media as well as thrombus formation. No complications were encountered during the procedure. Early diagnosis is vital to avoid fatal complications of CAAs, and therapeutic approaches are currently individualized in view of absence of evidence-based management strategies.

Left ventricular outflow tract obstruction (LVOTO) can be caused by multiple factors. One of the rare causes of LVOTO is preserved anterior mitral valve leaflet and chordal apparatus after mitral valve replacement. We describe a case of a patient with worsening chronic congestive heart failure secondary to LVOTO from systolic anterior motion of residual native anterior mitral leaflet. In this patient, LVOTO was surgically corrected by excision of anterior leaflet and chordal apparatus through the aortic root.

Sutureless bioprosthetic valves such as the Sorin Perceval S valve (SPV) have been used in patients with aortic stenosis that require surgical aortic valve replacement (SAVR). These prostheses have been marketed on the basis of their rapid implantation techniques with avoidance of sutures and reduced aortic cross-clamp times. We report a case of an early failure of a SPV nearly 4 years after implantation in a 58-year-old woman who was low-risk. While the patient's symptoms initially improved with SAVR with a sutureless bioprosthetic valve, they progressively worsened as the valve degraded, and the leaflets became increasingly calcified and stenotic ultimately, requiring reoperative SAVR with a St. Jude mechanical valve. This case raises the issue of the lack of much-needed data describing the long-term durability and hemodynamic performance of these valves, particularly in a low-risk patient with excellent functional status. We hope to shed further insight into the lack of long-term studies on patients with SPV to assess their longevity and long-term effectiveness, as well as elucidation of possible prevention and monitoring of these potential complications. The use of newer generation prostheses, although attractive for their ease of implantation, potentially carries higher long-term risk due to shorter durability leading to reintervention to address valve deterioration. This is especially true in low-risk patients who are young and active. Cardiology and cardiothoracic surgery societies need to develop a universal registry with follow-up of all valves in order to track and study the durability of these valves, and to evaluate for incidence of known and potential complications.

Thoracic aortic aneurysms (TAA) have remained a formidable operative challenge. Open surgical techniques have been associated with high rates of morbidity and mortality. Thoracic endovascular aneurysm repair (TEVAR) has produced results equal to or better than the traditional open surgical approach. This report presents a patient with a complex thoracic aortic aneurysm involving the ascending, transverse, and proximal descending thoracic aorta. This patient was successfully managed by the creation of Landing Zone-Zero, arch vessel debranching, and endografting the entire aortic arch without the need for hypothermic circulatory arrest or cerebral perfusion strategies. Computer tomographic images demonstrate the repair to be durable at 18 months.

Type B aortic dissections have remained a difficult management problem. Open surgical techniques have had a very high perioperative mortality, and medical management has not produced satisfactory long-term results. Endovascular grafting techniques may provide a favorable alternative therapy. However, there are currently no endovascular stents approved by the United States Food and Drug Administration for treating Type B aortic dissections. Also, there is very little data from United States centers on the long-term efficacy of endovascular stents used "off-label" to treat aortic dissections. This report discusses the care of a patient with a Type B aortic dissection successfully treated by an endograft in a community hospital. In addition, serial follow-up computerized tomography demonstrates the durability of this repair at three years.

We examined the safety of performing synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in specific groups of patients with coexistent cerebral and coronary vascular disease. Between 1981 and 2003, 8,277 patients who underwent CABG in our institution had noninvasive screening for carotid disease. Two hundred seventy-seven (3.34%) patients were found to have severe (>70%) carotid stenosis. This patient population was divided into three subgroups: group A had unilateral carotid disease (n = 200), group B had bilateral carotid disease (n = 55), and group C had contralateral carotid occlusion (n = 22). In 29 patients (10.4%), the carotid disease was symptomatic. A simultaneous CABG and CEA was performed in all three subgroups. Patients in group B underwent initially repair of the most dominant lesion, soon followed by contralateral CEA. Patients who underwent only CABG (n = 8,000) served as controls. Overall combined hospital mortality regardless of etiology for the combined group was 3.61% vs. 1.7% for the patients who had CABG only (P > 0.1). The stroke and/or myocardial infarction-associated mortality for the simultaneous CEA-CABG group was 2.52%. There were six deaths in group A (3%), two in group B (3.6%), and two in group C (9.09%). Early stroke complicated the course of four (2%) patients in group A, one (1.8%) patient in group B, and three (13.64%) patients in group C compared to a stroke rate of 1.28% in controls. Overall stroke rate in the combined group was 2.8%. History of previous stroke and age 70-80 were the most important predictors of postoperative stroke and death. In the combined surgery group, the postoperative myocardial infarction rate was 0.72% vs. 0.58% in the control group. The mean length of hospital stay was 9 days for patients who had the combined procedure vs. 8.1 days for patients who had CABG only. Use of the combined procedure for patients with concomitant carotid and coronary artery disease was justified in the patients under study.