Massive floating thrombus in the ascending aorta.

Coronary emboli causing ST elevation myocardial infarction (STEMI) is a rare condition. Intracardiac thrombus generated by valvular disease is the most common source of intracoronary embolism and mitral stenosis is frequently affected by intraatrial thrombus. Therapeutic strategy of coronary embolism is challenging because there were still no recommendation regarding coronary embolism published to day. We reported A 25 years old woman was admitted to the emergency department because of STEMI with complication of acute pulmonary edema and cardiogenic shock, and recurrent cardiac arrest. Angiographically showed total occlusion of left main artery with thrombotic lesions. Unfortunately after unfractionated heparin (UFH) was given and performed catheter cannulation, thrombus run to distal part of left coconary artery. Procedure is stopped and then patient transferred to cardiac care unit, but death shortly after arrival. Transthroracic echocardiography revealed mild to mild-modertae mitral stenosis with severe regurgitation due to mitral valve prolaps, aortic regurgitation, and left atrial and ventricular dilatation with no thrombus or spontaneous echo contrast, and failed to fi nd thrombus with in atrium. The presence af atrial dilatation and aortic regurgitation increased risk of thrombosis, meanwhile mitral regurgitation were reported as protective factor of atrial thrombosis. The pathophysiology of arterial thrombus or white thrombus involving platelet activation leads to double antiplatelets and GbIIb/IIIa inhibitior to be more cruciale in coronary embolism. Double antiplatelet dan UFH administration did not improve survival in these patients. So that further research was needed to make a consensus of therapy. Careful assessment of intracardiac thrombus and risk of thromboembolism were important to prevent systemic embolization. Keywords: STEMI, coronary embolism, mitral valve disease.

Objective By analyzing the early- and mid-term clinical results of type Ⅱ hybrid arch repair for the treatment of aortic A aortic dissection, the efficacy of hybridization technique in the application of type A aortic dissection was evaluated systematically. Methods We retrospectively studied the records of patients with DeBakey type I dissection who were admitted to the Beijing Fuwai hospital between January 2010 and December 2016. 122 continuous patients underwent hybrid aortic arch repair without deep hypothermic circulatory arrest, the landing zone of stent was located in ascending aorta (Zone 0) . All patients were followed up by clinic or telephone review, aortic computed tomography (CT) were checked before surgery and discharge time. All patients were reviewed by CT during 3-6 month after first discharge and once per year during follow up thereafter. Results The average age of all patients was (61±7) years, male patients accounted for 66.4%, patients with acute dissection accounted for 85.2%, there were 39 patients (32%) with different degree of preoperative poor organ perfusion. A total of 154 stents were implanted in 122 patients, sinus plasty was performed in 26 patients (21.3%) , valvuloplasty was performed in 39 patients (32%) , coronary bypass surgery was performed in 9 patients (7.4%) . The average time of cardiopulmonary bypass (CPB) time was (135.3±38.9) minutes, cross clamp time was (58.3±27.8) minutes, 117 patients (95.9%) were completed under non-stop circulation. There were 11 cases of early death (9%) , 19 cases of complex complication (15.6%) , and 28 cases of postoperative renal insufficiency (23%) . No cerebral infarction or paraplegia occurred after operation, 3 patients (2.5%) developed temporary spine cord paralysis. Multiple regression analysis showed that postoperative renal insufficiency (OR: 12.75, 95%CI: 1.77-38.30, P=0.034) and postoperative gastrointestinal insufficiency (OR: 24.03, 95%CI: 2.26-55.61, P=0.008) were the independent risk factors of death for all patients. Operative duration (OR: 2.36, 95%CI: 0.58-2.33, P=0.030) , postoperative renal insufficiency (OR: 20.18, 95%CI: 4.93-82.67, P<0.001) and postoperative gastrointestinal insufficiency (OR: 11.54, 95%CI: 2.29-58.08, P=0.003) were the independent risk factors of composited complication. Average follow-up time was 32.9±25.2 months. There were 92 cases of complete thrombus formation of false lumen in stent (86.8%) , 14 cases of partial thrombus formation (13.2%) , there were 9 cases of thoracic segment tumor like dilation (8.5%) , 9 cases of abdominal segment tumor like dilation (8.5%) . During follow up period, 7 cases died (6.6%) . The survival rates of 3, 5 and 7 years after operation were 94.7%, 91% and 91%, respectively, reintervention rate was 2.8% (3 cases) , the free from reoperation rates of 3, 5 and 7 years after operation were 98%, 92.4% and 92.4%, respectively. Conclusions This single-stage hybrid arch procedure offers an alternative approach to type A dissection and associated with acceptable early and midterm major morbidity and mortality. However, given the high rate of renal dysfunction, more attention is required for further application. Key words: Hybrid aortic repair; Aortic dissection; Deep hypothermic circulatory arrest

To explore the option and efficacy of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) with hostile aortic proximal landing anatomy. The clinical data of 51 AAA patients with hostile aortic proximal landing anatomy treated by EVAR from January 2010 to June 2012 at our hospital was retrospectively analyzed. There were 44 males and 7 females with a mean age of 73 years (range: 42 - 94). The anatomic measurements included a diameter of aneurysm body 32 - 100 mm, a length of proximal neck 0 - 50 mm, a width of proximal neck 15 - 40 mm and infrarenal angulation 15 - 80 degrees. In addition, there were calcification (n = 10) and thrombus lining with aortic neck (n = 15) and irregular shape of aortic neck (n = 5) respectively. The stent-grafts were deployed by 4 femoral arteries. Many types of aortic stent were used, such as Endurant (n = 9), Talent (n = 5), Zenith (n = 31), Hercules (n = 5), Palmaz/CUFF (n = 6) and multilayer bare-stent (n = 2). And 11 patients underwent fenestrated EVAR and 31 with chimney EVAR involving renal artery (39 branches), superior mesenteric artery (3 branches) and celiac trunk (3 branches). The primary technical success rate was 100%. The perioperative endoleak rate was 17.6%. During the mean follow-up period of 13 months (2 - 28), the primary patency of stent was 96.1% and the thrombus rate of aneurysm 82.4%. Two cases of new endoleak and 3 cases of residual endoleak underwent secondary intervention. In addition, long-term follow-up was required for 3 patients with stent-graft migration (< 10 mm). There was no case of death, infection, occlusions, ischemia of lower limbs, aneurysm expansion or rupture. A variety of EVAR options are both safe and efficacious in the treatment of AAA with hostile proximal landing zone.

Objective To summarize the experience and efficiency of coils in endovascular aortic repair. Methods From September 2008 to December 2013, 48 patients received endovascular aortic repair in combination of coil embolization including abdominal aortic aneurysm in 32 patients, and aortic dissection in 16. Results Coils were successfully implanted in all cases. One patient with ruptured abdominal aortic aneurism (AAA) underwent emergency endovascular aortic repair and died of multiple organ failure the day after surgery. One patient died of pulmonary artery embolization 3 hours after TEVAR. 44 patients were followed up ranging from 7 to 60 months. In AAA group, 25 patients received endovascular exclusion in combination with internal iliac artery embolization, four of them had claudication due to gluteal ischemia but without other severe complications. Post-operative CTA found endovascular thrombosis in aneurysm. In the aortic dissection group, one patient died of pulmonary infection. During the follow up, there was no AAA dissection, and AAA rupture. Post-operative CT confirmed thrombus in cavity. There were no scaffold and coil translocation and surrounding tissue injury. Conclusions Endovascular aortic repair in combination with coil embolization is a complementary treatment to aortic diseases. Key words: Aortic aneurysm, abdominal; Angioplasty; Coils

Objective To report the primary experience of open placement of triple-branched stent graft for acute Stanford type A aortic dissection. Methods Between June 2008 and September 2009, 20 well-selected patients with acute Stanford type A aortic dissection underwent open placement of triple-branched stent graft for total arch reconstruction. When core cooling to a 20℃ nasophageal temperature, perfusion to the lower body was discontinued and the ascending aorta was transected at the base of the innominate artery. Through a transverse incision, the triple-branched stent graft was inserted into the true lumen of the arch and descending aorta, and each side arm of the stent graft was positioned one by one into the arch branches.The transected stump of the ascending aorta was reconstructed by inner proximal stent-free dacron tube of the main graft and outer teflon felt, and subsequently continuous anastomosis to the 1-branched dacron tube graft was made. Results Open placement of triple-branched stent graft was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time and lower body arrest time were (163.2 ±19.2) min, (89.4 ±10.0) min and (32. 7 ±6. 6)min, respectively. Transient postoperative neurological dysfunction was observed in 1 patient and acute renal failure in 1 patient. All patients were discharged from the hospital. Their computed tomographic scans at 3 months postoperatively showed that all stent grafts were fully opened without distortion. In the vascular stent implantation site the dissected false lumen was eliminated. The false lumen of the descending aorta distal to the stent graft was closed with thrombus in 16 cases. Conclusion Open placement of triple-branched stent graft is a new effective technique for total arch reconstruction in acute type A aortic dissection. Patients have the indications of the extensive primary repair of the thoracic aorta without primary intimal tears in the arch may be the best candidates for this new technique. The size of the stent graft, the distances between two neighboring side arm grafts and the prevention of the intimal trauma during the placement are crucial for successful open placement of triple-branched stent graft. Key words: Aneurysm, dissecting; Blood vessel prosthesis; Stents; Aorta, thoracic

Objective To investigate the CT Manifestations andi diagnostic value of multislice spiral CT angiography (MSCTA) and its 3D-restruction in dissecting aneurysm of aorta.Methods 64-slice spiral CT enhancing scan of dissecting aneurysm of aorta was performed in 72 patients,and the data was transferred to ADW4.4 workstation for aortic vascular reconstruction image post processing including the maximum density projection (MIP),multiple planar reconstruction (MPR),curved planar reconstruction (CPR) and volume rendering (VR),the data of MSCTA were done and analyzed.Results The whole aorta and branches in 72 patients were displayed well by MSCTA.The location,extend,true lumen,false lumen and intimal flap of dissecting aneurysm were showed in all patients satisfactorily.In the 72 cases,thickening and calcification of the aortic wall were 51cases,intraluminal thrombus were 39cases.The results of postoperative review in 6 cases of patients with aortic stent placement dissection revealed that the location and shape of stent,the dilatation degree,the true and false lumen were also displayed satisfactorily.Conclusions MSCTA can clearly display the aortic dissecting aneutysm and its branches,and is a valuable tool in the assessment and diagnosis of aortic dissections,it has important clinical application value. Key words: Aneurysm; Aortic dissections; Multiple Slice CT ; Angiography

Objective Valve replacement is a conventional therapy for the mitral insufficiency caused by IE. Mitral valve repair as an optional procedure for the disease has become feasible in recent years. However, concerns from surgeons about the recurrence of endocarditis after mitral valve repair remained. in this study we evaluated the long-term clinical outcomes of patients treated with surgery for the mitral insufficiency caused by infective endocarditis (IE). Methods Between July 1990 and July 2007, 83 consecutive patients (male 62, female 21) with mitral valve IE were enrolled in this study. Forty-one (49.4% )patients received mitral valve repair ( MVP,group A) and 42(50. 6% ) patients received mitral valve replacement ( MVR, group B). Thirty-seven cases had concomitant aortic valve replacement; 1 patient had aortic valve repair; 4 cases had ventricular septal defect repair; 1 case had atrial septal defect repair, 12 cases had bicuspid valve repair; 2 cases had coronary artery bypass graft and 1 case had femoral artery thrombus. Intraoperative transesophageal echocardiography were performed in 18 cases for the evaluation of mitral valve regurgitation. Mean cardiopulmonary bypass time, aortic clamping time and postoperative ventilation time were recorded and analyzed. Mid- and long-term clinical and echocardiographic outcomes were assessed.Results Preoperative left ventricular end systolic diameter, left ventricular ejection fraction and the classification of New York Heart Association in group A were significantly lower than those in group B (P ＜ 0. 05), but no difference was observed between the 2 groups in the cardiopulmonary bypass time and the crossclamping time. However, the intubation time and ICU time were shorter in group A than those in group B ( P ＜ 0.05 ). More vegetations were seen in the MVR group than in the MVP group. Three (3.6% ) patients died after the operation in group B. All patients were assessed as in NYHA Ⅰ-Ⅱ at discharge.A follow-up was done between 1 to 165 months (mean 39 months) with a mean follow-up rate of 95%. In the MVR group, peri-valvular leakage happened in 1 case, cerebral hemorrhage happened in 2 cases and repetitive pleura! effusion in 1 case. One death happened in the MVR group and none in the MVP group. The 10-year survival rate (100% ) in group A was nonsignificantly higher in group A than that (75% ) in group B(P =0.081). Conclusion Mitral valve repair is feasible for treating mitral valve lesions caused by endocarditis, and may provide an optimistic long-term outcome to the patients. The indication for mitral valve repair is mild to moderate mitral valve lesion. Experienced cardiac surgeons, use of antibiotics before and after the operations based on drug-sensitivity test and blood test, as well as follow-up the patients yearly, are important factors for the favorite outcomes. Key words: Endocarditis; Mitral valve annuloplasty; Heart valve prosthesis implantation

The aneurysmal disease, although more rarely, can also affect arterial districts other than those traditionally involved the evolution aneurysm. After the vessels of large caliber also the visceral arteries originating from abdominal aorta may be the site of aneurysmal dilatation or pseudoaneurysm. The involvement of the renal and splanchnic vessels, although rare with an incidence from 0.1 to 2%, it can also cause catastrophic outcomes. The data reported in the literature are the case reports with limited evidence-based medicine. Autopsy studies suggest that there may be more frequent than in aortic: 10% versus 0.5%. The prevalence is 2% of the population. The age at which most frequently occurs detection of a visceral aneurysm, varies between 60 and 70 years. The vessels involved are those that emerge from abdominal aorta and go respectively to spray the kidneys (renal artery), spleen (splenic artery), liver (hepatic artery), stomach, duodenum, pancreas and intestine (celiac superior mesenteric artery, pancreatic-duodenal artery, gastroduodenal artery and gastro-epiploic arteries jejunal and ileo-colic, inferior mesenteric artery and its branches). As can be seen from the data in the literature, the incidence of aneurysms is as follows: renal artery aneurysm: 1-3%, splenic artery aneurysms: 60%; Hepatic artery: 16-20%; the superior mesenteric artery: 5.5%; of the celiac trunk: 4%; pancreatic-duodenal artery: 3%; gastroduodenal artery and gastroepiploic: 4%; of the jejunum and ileum-colic arteries: 3%; inferior mesenteric artery and its branches: 3.5%. In a third of cases of aneurysm of the splenic artery is an association between multiple arterial districts, appearing in multiple form. The evolution of the aneurysm is similar to that of the artery aneurysms of medium and large caliber and is characterized by progressive expansion and by the formation of thrombi, contributing to the three major complications: rupture, events thrombo-embolic ischemic, and compression or erosion of the neighboring structures. The rupture is the most frequent and letal complication.

Background: Tuberculosis (TB) remains a public health concern in the Third World countries. Though TB is a fairly common cause of pericardial disease in our country, myocardial tuberculosis is extremely rare and often not diagnosed during life. Aim: To highlight a poorly clinically recognized form of tuberculosis as an important cause of sudden death . Material: A case report and literature review.. Results: Case 1: A 38 year old fit, kickboxer and a known steroid user collapsed and died while presenting with shortness of breath for the first time in casualty. At autopsy, a large nodular aneurismal fibrous thickening in the mitral valve cusp was noted, with extensive fibrous thickening of the tricuspid valve cusp and multiple small infiltrative abscesses proximal to aortic valve cusp and extending to the myocardium. Histology examination showed necrotizing granulomatous inflammation involving the myocardium and paratracheal lymph node. Acid fast bacilli were noted There was no evidence of TB in the lungs and other organs. Case 2: 21 year old male, nausea and vomiting for one day, collapsed and died, whilst vomiting inside the toilet. At autopsy, a firm, hollow yellowish mass with a thrombus within its cavity, just below the aortic outflow tract in the left ventricle. Lungs were normal, but paratracheal ymph nodes enlarged. Zielh Neelsen stain: No acid fast bacilli noted. (Literature review shows that myocardial tissue specimens often fail to reveal acid-fast bacilli and definitive diagnosis rests on seeing typical histological changes) Conclusion: Myocardial tuberculosis is very rare, often not diagnosed clinically and most of the literature is based on autopsy reports.

Ultrasonic detection and evaluation of abdominal aortic aneurysms.

Coronary Obstruction During Transcatheter Aortic Valve Replacement: Related to Calcification or Thrombus?

Objective To evaluate the hemocomaptiblity, biocompatibility, performance and reliability of a left ventricular assist device in vivo. Methods The VADS were implanted into 6 healthy sheep without stopping the beating heart by constructing blood bypass of left ventricle→ventricular assist device→descending aorta and worked for up to 30 days. Blood samples were collected until elective termination and were performed for chemistry, hematology and coagulation profiles. After termination, we examined whether there was thrombosis in blood pump, grafts and anastomotic stoma. Macroscopical and histopathological examinations were performed in major organs to check for congestion and infarction. Results All 6 sheep survived for 30 days without any complications. Hematology results were within the normal ranges. There were no formations of thrombi and blood clots inside the pump, in outflow grafts and anastomotic sites in all cases. Pathological analysis showed no lesions in main end-stage organs except for slight lobular pneumonia in some left lung tissues. Conclusion The ventricular assist device showed considerable in vitro and in vivo blood compatibility, biocompatibility, performance and reliability. Key words: Heart-assist devices; Animal experimentation; Materials testing

Embolic floating thrombus in the aortic arch: another success of antioagulante therapy

Postpartum Preeclampsia—A Diagnosis Not to Be Missed

Aortic disease is not as prevalent in India as in the West. Apart from the usual presentations of aortic disease viz. aneurysms, occlusions and dissections, a vast spectrum of disease is prevalent. This includes Takayasu Arteritis with it sequale, Tuberculous and non-specific arteritis, Primary Aortic Mural Thrombosis and aortic tropical infections. The open and endovascular management of these entities is well developed in India. We present the aortic experience of 2 of the largest centres in India.