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Literature on COVID-19-associated pulmonary mucormycosis (CAPM) is sparse. Pulmonary artery pseudoaneurysm (PAP) is an uncommon complication of pulmonary mucormycosis (PM), and rarely reported in CAPM. Herein, we report five cases of CAPM with PAP managed at our center and perform a systematic review of the literature. We diagnosed PM in those with clinico-radiological suspicion and confirmed it by microbiology or histopathology. We encountered five cases of CAPM with PAP (size ranged from 1 × 0.8 cm to ~ 4.9 × 4.8 cm). All subjects had diabetes and were aged 55–62 years (75% men). In two cases, COVID-19 and mucormycosis were diagnosed simultaneously, while in three others, COVID-19 preceded PM. One subject who underwent surgery survived, while all others died (80% mortality). From our systematic review, we identified one additional case of CAPM with PAP in a transplant recipient. CAPM with PAP is rare with high mortality. Early diagnosis and multimodality management are imperative to improve outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s11046-021-00610-9.

Standard donor lung preservation with cold flush and storage allows up to six hours between retrieval of lungs from the donor and transplantation in the recipient. Ex vivo lung perfusion (EVLP) systems mimic physiological ventilation and perfusion in the donor lungs with potential for prolonged lung preservation and donor lung reconditioning. In this study, it was aimed to perform EVLP on discarded donor lungs using a locally developed EVLP system.Equipment that are routinely used for cardiac surgeries were collected and a functional EVLP system was assembled. This system was used on five pairs of lungs retrieved from brain-dead organ donors. The lungs were ventilated and pulmonary circulation was continuously perfused with a solution containing oxygen and nutrients for four hours. The system was tested without red blood cells (RBCs) added to the solution (acellular group; n=3; A1, A2 and A3) and also with RBCs added to the solution (cellular group; n=2; C1 and C2).The EVLP system was successfully used in four (A1, A2, A3 and C2) of the five lung pairs. Mechanical and gas exchange functions of the lungs were preserved in these lung pairs. One lung pair (C1) worsened and developed pulmonary oedema. Histopathological examination of all five lung pairs was satisfactory at the end of the procedure. Major challenges faced were leakage of solution from the system and obstruction to drainage of RBCs containing solution from the lungs.The results of the present study suggest that, it is possible to maintain the lungs retrieved for transplantation in a physiological condition using a locally prepared EVLP system and a solution without RBCs.

Pulmonary mucormycosis has been associated with high mortality (reported up to 100%) in renal transplant recipients.This was a retrospective analysis of renal transplant patients with pulmonary mucormycosis between April 2014 and March 2020, who underwent surgical resection of the affected lung along with liposomal amphotericin therapy. Patients with lower respiratory illness features underwent chest X-ray, high-resolution computed tomography of the chest, and those with suspicious findings underwent analysis of bronchioloalveolar fluid and transbronchial lung biopsy. Patients with histological or microbiological evidence of mucormycosis were started on liposomal Amphotericin B. Tacrolimus and mycophenolate mofetil were stopped at the time of diagnosis.Ten patients underwent combined management, while five patients were managed medically. At last follow up, seven out of ten patients (70%) who underwent combined management and two of the five patients (40%) who were managed medically, had a mean survival of 28.86 months (sd = 15.71, median = 25) and 14.17 months (sd = 12.21, median = 18), respectively, post-diagnosis of pulmonary mucormycosis.Surgical resection combined with antifungals in the perioperative period and decreased immunosuppression may improve the outcomes in renal transplant patients with pulmonary mucormycosis.

Introduction: Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract. Methods: Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery. Results: The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR. Conclusion: The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.

Introduction In patients with total anomalous pulmonary venous connection (TAPVC), left atrium (LA) is small and suprasystemic pulmonary artery (PA) pressures may be present in some patients. In our study, we studied the relationship between surgical LA enlargement and patent foramen ovale (PFO) creation separately on the outcomes of patients with TAPVC. Materials and methods Out of the 130 patients operated in our institute between January 2014 and December 2020, LA was enlarged in 60 patients. LA enlargement was done using a larger patch for atrial septal defect (ASD) closure. Thus, the LA volume was increased by shifting the patch towards the right atrium (RA). Suprasystemic or high PA pressures were present in 60 patients. In 33 patients, PFO was created. Early surgical outcomes were determined on the basis of vasoactive inotropic score (VIS), hours of ventilation, hours of inotropic support, intensive care unit (ICU) stay, and hospital stay. Result Between the LA enlarged and nonenlarged group there was statistically significant less VIS score (18 [13-27.5] vs. 24 [18-30], p value .019), hours of ventilation (23 [16-46.5] vs. 26 [18-60], p value .039), hours of inotropic support (45.5 [30-72] vs. 55 [38-84], p value .038), and ICU stay (7 [5-9] vs. 8 [7-10] p value .0352) and statistically nonsignificant less hospital stay (11.5 [9-13] vs. 12 [9-14], p value .424). In patients with preoperative suprasystemic or high PA pressures, there was a statistically significant less VIS score (16 [11-23.5] vs. 18 [13-25], p value .044), hours of ventilation (20 [14-37] vs. 22 [18-39], p value .038), hours of inotropic support (34 [29.5-71] vs. 38 [30-78], p value .042), and hospital stay (9 [5-12] vs. 11 [9-14], p value .038) and statistically nonsignificant less ICU stay (7 [5.5-9] vs. 7 [6-9], p value .886) in the group with a PFO with respect to the other group in which no PFO was created. Conclusion In patients with TAPVC, LA can be enlarged by using a large ASD patch and thus shifting the septum towards RA. Early surgical outcomes were improved with LA enlargement. In patients with suprasystemic or high PA pressures, leaving a PFO improved the postoperative outcomes.

Coronary artery congenital fistulas are rare disorders. Transcatheter closure is the primary method of closure. Device migration is a known complication, for which surgical retrieval is required.

Tetralogy of Fallot with unilateral absence of the pulmonary artery is a rare congenital cardiac disorder that makes the ipsilateral lung susceptible to opportunistic infections. This disorder adds to the complexity of the case and tests the surgical and decision-making skills of the surgeon. We present an adult male patient with tetralogy of Fallot and absent left pulmonary artery who underwent physiologic exclusion of the left lung for aspergilloma along with intracardiac repair as a single stage procedure.

Left atrial mass after excision of a left atrial myxoma may occur due to residual or additional masses, such as biatrial or multicentric myxomas and inverted left atrial appendage. In this E-challenge, the authors present a case where intraoperative transesophageal echocardiography allowed visualization of a left atrial mass after excision of a left atrial myxoma. Detailed examination demonstrated that the mass was due to left atrial dissection that progressed to rupture, allowing its early detection and repair. A high index of suspicion, as well as coordination between the surgeon and the perioperative echocardiographer, played a crucial role in the detection and management of this complication.

A 31-year-old woman presented with progressive breathlessness since 1 year. Flexible bronchoscopy revealed a vascular tumor completely occluding the right main bronchus. A diagnosis of primary endobronchial myxoma was made. Tumor debulking was performed using rigid bronchoscopy. This enabled right lower lobectomy. A literature search yielded 12 cases of primary pulmonary myxoma, and only 2 previous reports of endobronchial myxoma. Most tumors were incidentally detected and were cured surgically. Endobronchial myxomas are rare and are usually asymptomatic. Treatment involves surgical excision. Rigid bronchoscopy serves as a bridge to surgery and can reduce the extent of surgery.

A patient with right atrial myxoma may remain asymptomatic or present late with embolic symptoms. Silent emboli from these villous myxoma may become oraganized resulting in raised pulmonary artery pressure and right ventricular dysfunction, necessitating detailed preoperative investigations and continous monitoring during intraoperative period. Transesophageal echocardiography may provide very crucial information in this setting. We report a case of right atrial myxoma where transesophageal echocardiography showed multiple organized emboli in both right and left pulmonary artery that was not detected on preoperative magnetic resonant imaging done 5 months back and immediate preoperative transthoracic echocardiogram, there by changing the surgical plan in favour of endarterectomy.

Background: Selection of adequate size double lumen tube (DLT) is complicated by marked inter-individual variability in morphology and dimensions of tracheobronchial tree. Computerized tomography (CT)-guided left bronchus width measurement has been used to predict adequate size DLT in European and Singapore population; however, no such data exist for Indian population who are racially different. We compared the effect of DLT size selection based on CT-guided bronchial width measurement to the conventional method of DLT selection on the adequacy of both lungs isolation and on the safety margin of right-sided DLT. Methods: Fifty-five adults scheduled to undergo thoracotomy were enrolled in this prospective observational study. An appropriate size left- or right-sided DLT with outer diameter 0.5–1 mm smaller than the CT-measured bronchial width was selected for the isolation of lungs. Adequacy of separation was checked using fiberoptic bronchoscope. The safety margin of selected right-sided DLT size was calculated from CT-measured right upper lobe bronchus width and diameter of right upper lobe ventilation slot of the DLT. Results: Adequate separation of lungs was achieved in 92.7% of studied population, 90.9% in males, and 95.4% in females. Among these, 54.9% patients required different sized DLT as compared to conventional method. Overall safety of margin of right-sided DLTs was comparable between two methods of DLT selection (median [IQR] 4.8 (3.5–6.8) vs. 6.59 (3.5–7.8), P = 0.317). DLT size with adequate isolation of lung correlated with height, tracheal width (TW) on chest X-ray, and age of the patients. A formula to calculate DLT size based on these variable was derived. Conclusion: CT-measured bronchial width predicts the appropriate DLT size better than conventional method. In the absence of CT scan facility, patient height, age, and chest X-ray TW may be used to predict DLT size with reasonable accuracy.

OBJECTIVES The association between the extent and degree of perfusion-metabolism mismatch and improvement in perfusion and left ventricular ejection fraction (LVEF) after revascularization was assessed. The secondary aim was to identify the best precoronary artery bypass graft surgery (pre-CABG) PET parameter, if any, to predict the improvement in the perfusion and LVEF after CABG. METHODS AND RESULTS Overal, 31 patients (mean age: 58+8.3 years) with ischemic left ventricle dysfunction underwent NH3 and F-FDG PET for the assessment of myocardial viability. CABG was performed in these patients and after a mean interval of 3 months, NH3 PET was repeated. The percentages of viable myocardium (VM), hibernating myocardium, degree of mismatch, and LVEF in pre-CABG PET were calculated. These were compared, the median [INCREMENT]LVEF and percent increase in perfusion being 5 (interquartile range: 3-9) and 78.7 (interquartile range: 51.3-100), respectively. No significant association was observed between the severity or extent of perfusion defect/mismatch and improvement in perfusion or LVEF after CABG. Patients with at least 65% VM predicted a 5-unit increase in LVEF at 88.9% sensitivity (P=0.1). CONCLUSION There was no significant relation between the severity and extent of perfusion-metabolism mismatch with improvement in perfusion and LVEF after CABG. After CABG for ischemic left ventricle dysfunction, VM shows a tendency toward better improvement in LVEF.

A 54-year-old woman with poorly controlled diabetes mellitus presented with haemoptysis >400 mL over the last 12 hours. She had been experiencing fever and a productive cough for the past 20 days. She was a non-smoker and had no other illness in the past other than diabetes mellitus. CT of the

The aims of this study were to determine the utility of transesophageal echocardiography (TEE) for identifying spinal canal structures and epidural catheter position and to assess the effect of catheter position on intraoperative hemodynamics and quality of postoperative analgesia. Twenty-six adult patients undergoing thoracic surgery were included in this prospective, observational study. An epidural catheter was inserted 7.5 cm or more into the thoracic epidural space using a midline approach and a loss-of-resistance technique. A pediatric TEE probe was inserted after induction of general anesthesia. It was used to identify the spinal canal structures, the catheter tip position in the epidural space, and the spread of injected local anesthetic. Intraoperative hemodynamics, postoperative visual analogue scale (VAS) pain scores, and the need for rescue epidural doses were recorded and compared between groups determined by their catheter position. Two subjects were excluded from the study because of an intrathecally positioned epidural catheter. The remaining 24 subjects were divided into two groups based on TEE-determined epidural catheter position: posterior (Gr-P) or lateral (Gr-L). Spinal canal structures and the epidural catheter was successfully identified in all patients. The epidural catheter was located posteriorly in 20 (83%) patients and laterally in four (17%) patients. The spread of the local anesthetic was bilateral in all Gr-P patients, whereas it was unilateral in all but one of the Gr-L patients. Compared to Gr-P patients, Gr-L patients had higher heart rates and blood pressures at various time points after local anesthetic administration until the end of surgery (P = 0.02 to < 0.001). Postoperative VAS scores (P = 0.02) and the median number of rescue analgesic doses required during the intraoperative and postoperative periods were also higher in Gr-L patients (P < 0.001). Transesophageal echocardiography reliably identified spinal canal structures and the position of epidural catheters in the epidural space in adult patients. Posteriorly located epidural catheters appear to provide better epidural analgesia than laterally situated catheters.

Objective: The 2015 WHO classification classifies neuroendocrine tumours (NET) of the lung into typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma and small cell carcinoma based on morphology alone. Mitosis is the major parameter for this classification, and thus several studies have focused on the role of Ki67 in these tumours but without conclusive results. The aim of the study was to categorize neuroendocrine tumours of the lung based on morphology and to assess the utility of Ki67 in diagnosis. Material and Method: The study included 42 cases (23 biopsies and 19 lobectomy specimens) of neuroendocrine tumours (excluding small cell carcinoma). Haematoxylin & eosin stained sections, immunohistochemistry for neuroendocrine markers and Ki67 were studied. Results: Based on WHO criteria, cases were classified as typical carcinoids (83.3%), atypical carcinoids (12%) and large cell neuroendocrine carcinomas (4.7%). The Ki67 index ranged between 1%-10% (mean 2.6%), 10%-30% (mean 19%), 35%-50% (mean 42.5%) in typical carcinoid, atypical carcinoid and large cell neuroendocrine carcinoma respectively. Using the ROC curve, the cut off value of Ki67 for typical and atypical carcinoids was 7.5% (P value0.05). Conclusion: Morphological features are the gold standard for subtyping of neuroendocrine tumours. Ki-67 is a potentially meaningful marker for sub-categorization of lung NETs, especially in small biopsies. However, the size and infiltrative pattern of the tumours are independent of the proliferation index.

Pulmonary gangrene is a life-threatening condition, which represents the fulminant end of the infectious lung diseases usually caused by polymicrobial infection. Aerobic and anaerobic bacteria act synergistically to produce massive tissue necrosis which might be augmented by the angioinvasive nature of fungi like Mucor. We report a successfully treated case of pulmonary gangrene in a poorly controlled diabetic patient, which was associated with polymicrobial infection. It was caused by Rhizopus spp., Staphylococcus aureus, Klebsiella pneumoniae and unusual anaerobic organism Sarcina. This is the first report describing the presence of Sarcina organisms in a case of pulmonary gangrene. Adequate glycemic control, treatment of coexisting polymicrobial infection and prompt antifungal therapy along with surgical intervention were useful in the index patient. This case also highlights the effectiveness of combined medical and surgical intervention in a case of pulmonary gangrene.

Intrapericardial teratomas are rare after infancy. An accurate diagnosis can only be made with a high index of suspicion. Most of the time, a mediastinal teratoma ruptures/perforates the pericardial cavity, thus causing either pericardial effusion or life-threatening tamponade. These factors emphasize the importance of an early surgical excision even for extrapericardial locations. This report presents the case of a 16-year-old girl with intrapericardial teratoma who presented with cardiac tamponade which is a rare complication of this rare tumor with only eight cases reported so far beyond infancy. This patient presented with recurrent tamponade, and underwent multiple procedures of pericardiocentesis and developed pyopericardium and polyserositis. This intrapericardial teratoma was not detected by imaging modalities.

Open heart surgery is the gold standard for the closure of atrial septal defects (ASDs). Percutaneous transcatheter closure is used to close simple ostium secundum ASDs. As this method avoids sternotomy, the post-procedural morbidity is lower. These procedures are associated with complications which can be life threatening and require urgent surgical intervention. We report a rare case which required surgical removal of the Amplatzer septal occluder and closure of the ASD four years after the initial percutaneous transcatheter closure due to displacement of the device.

Objectives The percutaneous coronary artery angioplasty is routinely being used worldwide for the management of short and discrete coronary artery stenosis. The purpose of this report is to address the potentially lethal complication among the variety of surgical problems in conjunction with this procedure. The case also illustrates the potential pitfalls in the management of CAD. Methods A 60-year-old man had a broken and retained percutaneous transluminal coronary angioplasty (PTCA) balloon catheter entrapped in the left anterior descending artery and portion of it was lying in the ascending aorta. The patient underwent retrieval of this catheter through the standard coronary arteriotomy for coronary anastomosis without aortotomy on cardiopulmonary bypass. Results It was found that the PTCA balloon catheter was entrapped in the entire LAD and portion of it was lying in the ascending aorta, which could be delivered through the standard coronary arteriotomy for coronary anastomosis, thus avoiding the aortotomy. Conclusions PTCA balloon catheter entrapped in the entire LAD and portion of it lying in ascending aorta could be delivered through the standard coronary arteriotomy for coronary anastomosis, thus avoiding the aortotomy.

Acquired pulmonary stenosis is rare. When it occurs, it usually results from compression of the pulmonary artery or the heart by a mediastinal tumour. As these masses rarely cause compression that results in murmurs, it is hard to make a diagnosis. We describe a 23-year-old female patient who presented with dull, aching chest pain lasting for 6 months. Echocardiography showed a large anterior mediastinal cystic mass compressing the main pulmonary artery. She was operated through a left anterolateral thoracotomy and had an uneventful recovery.

IgG4-related inflammatory pseudotumor (IPT) and inflammatory myofibroblastic tumor (IMT) share morphological features like a prominent fibroblastic/myofibroblastic proliferation and the presence of inflammatory cells. Since IPT is managed conservatively and IMT is treated by surgical excision, it is important to differentiate these two lesions. The aim of this study is to highlight morphological and immunohistochemical features that distinguish IPT and IMT. Clinicopathological characteristics of cases diagnosed as pulmonary IPT or IMT from 1997 to 2013 were reviewed. The histological features were studied on hematoxylin and eosin-stained sections. Immunohistochemistry was done for IgG, IgG4, ALK-1, SMA, desmin, and CD34 for classification into IPT and IMT. Of the ten patients, seven were male and the age ranged from 4 to 58 years. The tumor size ranged from 1.5 to 4.0 cm in diameter. Histologically, proliferation of bland-looking spindle cells along with fibrosis and an inflammatory infiltrate comprising of lymphocytes and plasma cells were the common morphological features of both lesions. The spindle cell proliferation was more marked in IMT whereas lymphoplasmacytic infiltrate was more prominent in IPT. Obstructive phlebitis was observed only in cases of IPT. IgG4 expression was noted in IPT, and the number of IgG4-positive plasma cells and the ratio of IgG4+/IgG+ plasma cells were significantly lower in IMT than in IgG4-related IPT. Expression of anaplastic lymphoma kinase (ALK) was observed only in IMT, but not in IgG4-related IPT. The proportion of proliferating spindle cells, lymphoplasmacytic infiltrate, obstructive phlebitis, IgG4+ plasma cells and the ratio of IgG4+/IgG+ plasma cells, and ALK expression are helpful in differentiating these morphologically similar but biologically different lesions, which require different treatment modalities.

The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 34.3 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years. Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results. (J THORAC CARDIOVASC SURG 1996;112:727-30)

Cardiopulmonary bypass (CPB) in a patient with glaucoma is a challenge. The glaucomatous eye is at risk during CPB. We report a case of ostium secundum atrial septal defect that was not amenable to device closure. The unique feature in the patient was the presence of congenital glaucoma. She was blind in the left eye, and the visual acuity in the other eye was decreased because of glaucoma. She underwent direct closure of the atrial septal defect under CPB and fibrillatory arrest, with intraoperative monitoring of intraocular pressure. There was no change in visual acuity after 1 year of follow-up.

Sternal cleft is a rare visually dramatic congenital anomaly. It results from failure of fusion of the 2 lateral mesodermal sternal bars by the 8 weeks of gestation. Superior clefts are more frequent than inferior ones, and isolated central clefts are extremely rare. We describe the case of a 4-year-old girl with a central sternal cleft that was closed autogenously with pectoralis major advancement flaps.

We report a 30-year-old man with superior vena cava syndrome due to fibrosis from a previously irradiated malignant thymoma. The patient presented 4 years after the initial treatment, after having been lost to follow-up. Investigations revealed total obstruction of the superior vena cava, and right subclavian and right internal jugular vein. The patient underwent an extra-anatomic bypass (ringed polytetrafluoroethylene graft 10-mm diameter) between the left internal jugular vein and the left femoral vein brought in a subcutaneous tunnel over the anterior chest and abdominal wall. Entry to the thoracic cavity was avoided due to extensive fibrotic changes visualized in the computed tomographic chest scan. Follow-up Doppler at 2 months, 6 months, 1 year, and 3 years showed a patent graft. An internal jugular vein to the femoral vein bypass is a simple method for palliation of superior vena cava syndrome.

A simple, inexpensive, and easy-to-use method for exposure of the left internal mammary artery is described. Two blades of the conventional four-blade sternal spreader hooking the Adson forceps, which passes through the loops of sternal wires, provides excellent exposure of the IMA. The same retractor is used for the rest of the procedure.

OBJECTIVES We wish to share a unique occurrence of disconnection of the aortic cannula tip from the rest of the cannula while still on bypass. METHODS This complication was encountered while conducting a coronary artery bypass surgery. RESULTS We managed to control the situation and resuscitate the patient. No major after-effect was observed and the patient made an uneventful recovery. CONCLUSIONS Such a complication should be kept in mind and the disposables used in every surgery should be checked before using them.