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After surgical excision of myxoma recurrence usually happens adjacent to the initial origin site. We report a case of recurrent myxomas in a young male patient that had biatrial recurrence with one tumor originating very unusually from the base of the anterior mitral leaflet. Intraoperative transesophageal echocardiography was instrumental in localizing the site of the origin of left atrial myxoma from the base of the anterior mitral leaflet and in detecting an additional myxoma attached to the wall of the right atrium.

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.

Background: Pleomorphic liposarcoma (PLS) is a very rare type of primary pulmonary sarcoma. Clinical data about these tumors are limited, and optimal treatment has not yet been defined. Case Report: A 32-year-old male presented with pain and heaviness over the right chest. Contrast-enhanced computed tomography (CECT) of the chest showed a heterogeneous hypodense pleural-based mass and a mediastinal mass. The patient was treated with chemoradiotherapy, followed by excision and adjuvant chemotherapy. Seven months after completion of treatment, he presented with an abdominopelvic mass and soft tissue peritoneal deposits. The mass was resected, and second line chemotherapy resulted in a partial response. The patient was routinely followed. Six months after completion of the second round of chemotherapy, CECT showed multiple soft tissue deposits in the right lumbar region, right hemipelvis, and presacral region with no evidence of pulmonary disease. Chemotherapy elicited a partial response. Three years from the date of diagnosis, the patient was alive with stable disease. Conclusion: This case is unique because of the rare primary site of PLS presentation and the rare presentation of peritoneal metastasis. Citing such cases would help us to define adequate treatment protocols for this aggressive tumor.

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.

Background Aorto-oesophageal fistula (AOF) is a rare, catastrophic disease with an extremely poor prognosis. A ruptured thoracic aortic aneurysm is a common aetiology for AOF. The clinical presentation is usually massive haematemesis and collapse. Timely diagnosis and appropriate treatment are crucial in managing AOF.Case summary We hereby report two cases of AOF, who underwent successful emergency thoracic endovascular aortic repair (TEVAR) to control active bleed and exsanguination. Case 1, an elderly lady with atherosclerotic aneurysm had TEVAR followed by open surgery for oesophageal rent and necrosed left main bronchus. Case 2 had mycotic tubercular aneurysm who later had infected graft-stent following TEVAR.Discussion Open surgery is the conventional treatment for AOF; however, TEVAR can be an alternative and less invasive approach in selected high-risk patients. Various management issues related to TEVAR with AOF have been discussed in the article.

The extension of aortic dissection into common carotid arteries can cause thrombus formation in false lumen. This may result in perioperative cerebral malperfusion and stroke. At present there are no specific management guidelines in this situation. We report our experience of operative and non-operative management of thrombosis of carotid arteries in type A acute aortic dissection in 3 patients.

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder characterized by the accumulation of surfactant in the alveolar spaces resulting in hypoxemic respiratory failure. Whole lung lavage (WLL), the preferred treatment for PAP, physically removes the lipoproteinaceous material from the alveolar spaces. Since its initial description in 1963, the WLL procedure has undergone various modifications. However, the procedure has not been standardized yet. After securing a double lumen endotracheal tube, we perform WLL under general anesthesia. One lung is ventilated, while the other is lavaged using one-liter aliquots of pre-warmed saline. We use gravity-assisted drainage of the lavaged lung after each cycle till the milky white and opaque fluid becomes clear (usually 15-20 cycles). Herein, we describe the step-by-step procedure, precautions, and monitoring of WLL. We also provide videos demonstrating one-lung ventilation and bronchoscopic confirmation of lung isolation.

Rheumatic heart disease (RHD) is an autoimmune sequel of pharyngitis and rheumatic fever that leads to permanent heart valve damage, especially the mitral valves. The mitral valves, which are responsible for the binding of auto-antibodies during immune response generation, lead to valve scarring and eventually valves dysfunction. Recently, exosomes (EXOs), the nano-sized vesicles, which range in size from 30 to 150 nm, are reported in various cardiovascular physiological and pathological processes. These vesicles are found in several body fluids such as plasma, serum, and also in cell culture media. Exosomal cargo contains proteins, which are taken up by the recipient cells and modulate the cellular characteristics. The role of exosomal proteins in RHD is still obscure. Hence, the present study has been designed to unveil the exosomal proteins in disease severity during RHD. In this study, the exosomes were isolated from biological fluids (serum and pericardial fluid) of RHD patients as well as from their respective controls. Protein profiling of these isolated exosomes revealed that alpha-1 antitrypsin is up-regulated in the biological fluids of RHD patients. The enhanced levels of exosomal alpha-1 antitrypsin, were further, validated in biological samples and mitral valve tissues of RHD patients, to correlate with the disease severity. These findings suggest an association of increased levels of exosomal alpha-1 antitrypsin with the RHD pathogenesis.

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.

Lung transplantation is the only modality that offers a long-term solution for end-stage lung diseases. Few centers in India have an active lung transplant program. Preoperative and postoperative considerations in lung transplantation may be different in the developing countries when compared to the developed world. In the early posttransplant period, infection could be the major consideration in developing countries, unlike graft rejection, that is usually the primary concern in the developed world. Herein, we report the first lung transplantation from a public sector hospital in India. The patient was a 33-year-old female, who underwent bilateral lung transplantation at our center, but succumbed to surgical and infectious complications in the early posttransplant period.

Hardware loss and entrapment during percutaneous coronary intervention is one of the important complications, which an interventionist should anticipate in his practice. Basic knowledge about various extraction methods is essential to bail out in such situations. We describe a 74-year-old male, in whom a used thrombuster device got stuck in struts of an already deployed stent in the right coronary artery. The device could not be retrieved via various percutaneous maneuvers, necessitating an emergency surgical device retrieval and concomitant coronary bypass.

Introduction: Warfarin is widely used and will continue to be prescribed especially in developing countries due to its low cost. Given the huge patient load requiring anticoagulation, there is a need to develop strategies to optimize warfarin therapy for ensuring safe and effective anticoagulation. In the present work, we aimed at elucidating the association of genetic and nongenetic variables with warfarin dose requirement in patients attending the cardiovascular clinic in a tertiary care center of North India. Methods: This was a prospective study conducted over 1 year. Patient demographic and clinical details were captured in customized case record forms. Genotyping was done using the polymerase chain reaction-restriction fragment length polymorphism method. Pharmacogenetic influence of CYP2C9 (rs1799853 and rs1057910) and VKORC1 (rs9923231) variant alleles was studied. The association of genetic and nongenetic factors with warfarin dose was quantified using a stepwise multivariate linear regression model. Results: Two hundred and forty patients were screened. Data from 82 eligible patients were used for quantifying the association of genetic and nongenetic factors with warfarin dose. A descriptive model based on CYP2C9*3 (rs1057910) and VKORC1 (rs9923231) variant alleles and BMI was developed. The model explains nearly half of the interindividual variation in warfarin dose requirement. Conclusion: The model explains nearly half of the interindividual variation in warfarin dose in patients with atrial fibrillation and or requiring valve replacement.

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.

Background: Functional tricuspid regurgitation (FTR) is often neglected. No clear consensus has been reached on superiority of preoperative transthoracic (TTE) or intraoperative transesophageal echocardiography (TEE) in assessment of tricuspid regurgitation (TR) in rheumatic heart disease. There is still debate when to consider for surgical repair of FTR and its benefits. Methods: A total of 50 patients with rheumatic heart disease involving mitral, aortic or both valves with moderate and severe TR were included in the study. TR was assessed using preoperative TTE and intraoperative TEE. 36 out of 50 patients underwent tricuspid valve repair. Two patients died in postoperative period. Results of tricuspid valve repair were studied in 34 patients after six months of surgery. Results: TTE was superior in assessing tricuspid annulus size, central jet area, vena contracta, right atrium size and right ventricle systolic pressure. Patients undergoing tricuspid valve repair had better quality of life with significant improvement in grade of dyspnea, angina, pedal edema and hepatomegaly. The annulus size, jet velocity and right ventricle systolic pressure were significantly lower in patients who underwent tricuspid valve repair. Tricuspid valve should be repaired in all cases of moderate to severe TR with significant annular dilation (>38 mm). Conclusions: FTR is better assessed by TTE compared to intraoperative TEE. Concomitant TR correction (even in moderate degree of TR with tricuspid annulus ≥ 38 mm) should be strongly considered at the time of left side valve surgery resulting in better quality of life. Keywords: Functional tricuspid regurgitation, Preoperative transthoracic echocardiography, Intraoperative transesophageal echocardiography, Tricuspid ring annuloplasty, De Vegas annuloplasty

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.

Introduction Experience regarding course and outcome of Covid-19 infection in heart transplant recipients is limited. Case fatality rate of 25% of covid-19 infection in adult recipients of heart transplant and mild and self-limited disease in young heart transplant patients have been reported in small case series. We describe a case where a 13 year old patient contracted covid-19 infection on 7th post-operative day after undergoing heart transplant and was subsequently discharged from hospital uneventfully. Case Report A 13 year old boy, with dilated cardiomyopathy underwent orthotopic heart transplant surgery. In the immediate pre-operative period, the real-time polymerase chain reaction (RTPCR) of nasopharyngeal swabs of both the recipient and the brain-dead organ donor were negative for severe acute respiratory syndrome coronavirus type 2 (SARS CoV 2). The intraoperative and immediate postoperative periods were uneventful. The recipient got weaned off from mechanical ventilation on the 1st postoperative day and O2 support was weaned off on 4th postoperative day. He was put on immunosuppressive regimen consisting of mycophenolate mofetil, tacrolimus and prednisone. On 7th postoperative day, he complained of fever, sore throat and dry cough. Nasopharyngeal swab for RTPCR was sent. It reported positive for SARS CoV 2. He was shifted to isolation facility. He maintained more than 94% saturation on pulse oximetry in room air. Immunosuppressive regimen was continued. He was administered 5-day course of remdesivir. Inotropic support was weaned off on 10th postoperative day. On serial bedside echocardiography, the allograft function was found to be normal throughout. He was kept on prophylactic antimicrobial, antifungal and anti-cytomegaloviral therapy and on prophylactic dose of low molecular weight heparin. There was initial rise in neutrophil lymphocyte ratio (17), C reactive protein (58 mg/l), ferritin (871 ng/ml), D-dimer (1904 ng/ml), Troponin T (227 pg/ml) levels, which gradually came down to within normal limits. He was discharged on 38th postoperative day to a home isolation facility as his RTPCR for SARS CoV 2 was still positive, although he remained completely asymptomatic for the last 21 days. Summary The course of Covid-19 infection in the immediate post-transplant period of this young heart transplant recipient was largely uneventful.

Solitary fibrous tumor is a ubiquitous neoplasm that arises most commonly from the pleura. Solitary fibrous tumor arising within lung parenchyma has rarely been reported. It is therefore not well recognized. We present here a case of 30-year-old man with large intrapulmonary solitary fibrous tumor of right lower lobe with review of literature. Patient underwent wedge resection of tumor through right posterolateral thoracotomy via 6th intercoastal space using a stapling device. Patient had satisfactory postoperative recovery. Keywords: Intrapulmonary, Solitary fibrous tumor, Immunohistochemistry, Wedge resection, Posterolateral thoracotomy

Congenital cystic adenomatoid malformation (CCAM) is characterized by adenomatoid proliferation of bronchiole-like structures and cysts formation. It isan uncommon cause of respiratory distress in infants. Most common presentation is in first two years of life with complaints of respiratory distress.Presentation in adulthood is rare. Surgical intervention is the mainstay treatment.We describe two cases of atypical CCAM presenting in adulthood with past history of tuberculosis. To our knowledge only one case of CCAM with tuberculosis has been reported in literature.

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.