Alomari, Mohammad

Background Anomalous aortic origin of the right coronary artery (AAORCA) with an intramural course is a rare but potentially life-threatening anomaly due to its association with exertional ischemia and sudden cardiac death. Surgical correction aims to eliminate the ischemic mechanism. This study reports a single-center experience with adult patients who underwent right coronary artery (RCA) reimplantation for AAORCA. Methods A retrospective review was conducted of symptomatic adult patients with AAORCA who underwent RCA reimplantation between June 2017 and August 2024. Baseline clinical features, perioperative outcomes, and follow-up data were assessed. Results Forty patients (85% [34/40] male; median age 44 years) were included. The most common presenting symptom was exertional chest pain (82.5%, [33/40]), followed by dyspnea (45%, [18/40]) and syncope or presyncope (30%, [12/40]). Coronary computed tomography angiography (CCTA) was performed to diagnose the high-risk coronary features. All patients underwent RCA reimplantation into the right sinus of Valsalva. One patient also received a saphenous-vein graft to the distal-RCA. There was no in-hospital or follow-up mortality. At a mean follow-up of 30.3 ± 20.5 months, 8/40 patients (20%) reported recurrent symptoms, including chest pain (10%, [4/40]), dyspnea on exertion (5%, [2/40]), and palpitation (5%, [2/40]). Surveillance CCTA or invasive angiography performed in 14 patients, including 8 symptomatic patients, confirmed the widely patent RCA with no ostial stenosis or kinking. Post operative exercise testing in all these patients was negative. Conclusions In adults with AAORCA and an intramural or interarterial course; reimplantation of the RCA into the right-sinus of Valsalva achieves excellent early- to midterm outcomes, with low mortality, symptom resolution, and durable coronary patency.

Background: Breast reconstruction in de novo metastatic breast cancer (dnMBC) patients is a viable option. There remains no consensus on recommendations. We summarize postreconstruction clinical outcomes in dnMBC patients to identify surgical candidates. Methods: A systematic review was conducted across PubMed/MEDLINE, Scopus, and Web of Science from January 1, 1990, to November 1, 2024. The study methods were in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on patient demographics, disease characteristics, oncological treatment, surgical details, and clinical outcomes were collected. Results: A total of 7 studies (2635 breast cancer survivors) were identified. The average (SD) age was 47.5 (2.35) years, and most participants were White (n = 2080, 79.3%). Across studies, 39.0% (n = 761) of patients underwent implant-based reconstruction, 38.8% (n = 757) autologous reconstruction, 5.99% (n = 117) combined reconstruction, and 16.4% (n = 320) were not specified. Most cancers were invasive ductal carcinoma (81.3%) with estrogen-positive (73.1%) or progesterone-positive (48.4%) receptors and human epidermal growth factor receptor 2–positive (33.7%) status. Primary tumors most often metastasized to bone (44.4%) or lymph nodes (38.5%). Overall survival and breast cancer–specific survival rates were prolonged among reconstructed patients without increased predilection for complications or delay in tumor treatment. Conclusions: Reconstruction in dnMBC patients is an appropriate option, especially among younger patients with oligometastatic disease. Future studies are encouraged to investigate the impact on well-being and prolonged survival rates, which primarily seem to be limited to those with low disease burden and hormone receptor–positive tumor subtypes.

Background Assessment of gastric conduit perfusion during esophagectomy is crucial to determine its viability and identify the optimal site for anastomosis. Indocyanine green (ICG) fluorescence imaging is commonly used for this purpose, but it is contraindicated in patients with hypersensitivity to ICG, iodine, or shellfish. Oxygen saturation endoscopic imaging (OXEI) is a newer, non-pharmacologic technique for assessing perfusion. We report our experience with OXEI in 3 esophagectomy patients who had contraindications to ICG. Methods All 3 patients underwent robot-assisted esophagectomies. None of the conduits had ischemic areas identified by white light. Using a 5 mm laparoscopic specialized camera (ELUXEO Vision, FUJIFILM Healthcare Americas Corp., USA), OXEI was deployed for intracorporeal assessment of gastric conduit perfusion after pull-up into the chest. Postoperative outcomes including anastomotic leaks and complications were recorded. Results In two patients, OXEI revealed ischemic zones, which were resected to ensure optimal conduit viability. In the remaining patient, OXEI indicated robust vascularity throughout the conduit. All three patients experienced uneventful postoperative courses and were discharged within 10 days. There were no instances of anastomotic leaks or other major complications. Conclusion In our experience, OXEI is a viable method for intraoperative assessment of gastric conduit perfusion in patients with contraindications to ICG. Prospective studies are needed to validate its efficacy in preventing anastomotic complications and to compare it with other methods of perfusion assessment including gross visual and ICG dye in a larger patient population.

Objectives: The purpose of this study is to assess the efficacy, short- and long-term cardiovascular and non-cardiovascular mortalities and postoperative morbidities of surgical pulmonary embolectomy (SPE) for patients with massive or submassive pulmonary embolism. Methods: A comprehensive literature review was performed to identify articles reporting SPE for pulmonary embolism. The outcomes included in-hospital and long-term mortality in addition to postoperative morbidities. The random effect inverse variance method was used. Cumulative meta-analysis, leave-one-out sensitivity analysis, subgroup analysis and meta-regression were performed. Results: Among the 1949 searched studies in our systematic literature search, 78 studies met our inclusion criteria, including 6859 cases. The mean age ranged from 42 to 65 years. The percentage of males ranged from 25.6% to 86.7%. The median rate of preoperative cardiac arrest was 27.6%. The percentage of contraindications to preoperative systemic thrombolysis was 30.4%. The preoperative systemic thrombolysis use was 11.5%. The in-hospital mortality was estimated to be 21.96% (95% CI: 19.21–24.98); in-hospital mortality from direct cardiovascular causes was estimated to be 16.05% (95% CI: 12.95–19.73). With a weighted median follow-up of 3.05 years, the late cardiovascular and non-cardiovascular mortality incidence rates were 0.39 and 0.90 per person-year, respectively. The incidence of pulmonary bleeding, gastrointestinal bleeding, surgical site bleeding, non-surgical site bleeding and wound complications was 0.62%, 4.70%, 4.84%, 5.80% and 7.2%, respectively. Cumulative meta-analysis showed a decline in hospital mortality for SPE from 42.86% in 1965 to 20.56% in 2024. Meta-regression revealed that the publication year and male sex were associated with lower in-hospital mortality, while preoperative cardiac arrest, the need for inotropes or vasopressors and preoperative mechanical ventilation were associated with higher in-hospital mortality. Conclusions: This study demonstrates acceptable perioperative mortality rates and late cardiovascular and non-cardiovascular mortality in patients who undergo SPE for massive or submassive pulmonary embolism.

Abstract Lung transplant recipients are at higher risk of developing COVID-19 infection compared to other solid organ transplants. The risk further increases in the unvaccinated patients. We present a case of a 43-year-old male who underwent bilateral sequential lung transplantation for pulmonary alveolar microlithiasis (PAM) and had an uneventful recovery. However, two years post-transplantation, the patient developed chronic lung allograft dysfunction (CLAD) with bronchiolitis obliterans syndrome and two episodes of COVID-19 infection. During the second episode of COVID-19 infection, the patient developed sepsis and multi-organ dysfunction ultimately resulting in death. Our case report highlights the increased susceptibility of PAM patients’ post-lung transplant to COVID-19 infection. Continuous follow-up of PAM patients’ post-lung transplantation is necessary to prevent unfavorable outcomes.

Abstract Background Amyloidosis is defined by abnormal protein folding and subsequent deposition in tissues. Cardiac involvement is usually related to misfolded monoclonal immunoglobulin light chains or misfolded transthyretin; however, apolipoprotein A-1–associated amyloidosis is a hereditary form of amyloidosis resulting from mutations in the AAPOA1 gene that can also result in cardiac amyloidosis. Although there have been advancements in noninvasive algorithms for the diagnosis of cardiac amyloidosis, endomyocardial biopsy (EMB) may still be warranted. All individuals undergoing EMB are susceptible to complications, including tricuspid valve injury resulting in severe tricuspid valve regurgitation. Case summary Our patient is a 70-year-old white man presented with symptoms of dyspnoea on exertion and decreased functional capacity, diagnosed previously with apolipoprotein A-I cardiac amyloidosis, confirmed by EMB. He developed progressive right-sided heart failure secondary to iatrogenic flail tricuspid leaflet related to the diagnostic EMB. He underwent a successful transcatheter tricuspid valve edge-to-edge repair with 4D intracardiac echocardiographic guidance. At the recent follow-up, the patient showed improved symptoms, with increased stamina, and transoesophageal echocardiography revealed a 65% ejection fraction and mild tricuspid regurgitation (TR). Discussion Tricuspid valve injury is one of the complications associated with EMB, which can result in severe TR. Transcatheter tricuspid valve edge-to-edge repair can be a useful option for patients considered too high risk for surgical intervention, such as those with advanced cardiac amyloidosis.

Objective: We tested the feasibility and effectiveness of a percutaneous atrial transseptal extracorporeal membrane oxygenation (ECMO) cannulation strategy in a right ventricular failure (RVF) model. Methods: We performed 4 nonsurvival porcine experiments. Percutaneous transseptal access was achieved using a steerable introducer. For guidance, we used fluoroscopy, transesophageal echocardiogram (TEE), and intracardiac echocardiography (ICE). A ProtekDuo rapid deployment cannula (LivaNova, London, UK) was advanced across the septum into the left atrium by 2 to 3 cm. Pulmonary hypertension (PH) was induced by partially clamping the pulmonary artery. ECMO flow was cycled from high (2 to 3 L/min) to low (0.2 to 0.3 L/min) over 2 to 3 hours. Results: Transseptal access using TEE and fluoroscopy was successful in 1 animal and unsuccessful in 1 animal. ICE provided optimal visualization for the remaining 2 animals. Mean arterial pressure (MAP) was associated immediately and consistently with high versus low ECMO flow rate (mean difference: 29 ± 3.1 mm Hg, P = 0.004) but was not restored to baseline values. RV pressure values were dynamic. Given time to equilibrate, mean RV pressure was restored to a baseline level. Conclusions: Percutaneous right atrium to left atrium transseptal cannulation relieved PH-RVF. MAP was restored to a viable level, and mean RV pressure was restored to a baseline level. Transseptal ECMO shows promise as a cannulation strategy to bridge patients with PH-RVF to lung transplant.

Abstract A 64-year-old man with interstitial pulmonary fibrosis and a small patent foramen ovale with right-to-left shunting underwent bilateral lung transplant without closure of the patent foramen ovale. Postoperatively, the patient remained persistently hypoxemic with partial response to high-flow oxygen. Investigations revealed the presence of a large patent foramen ovale with right-to-left shunting on echocardiography and a shunt fraction of 21% on cardiac catheterization. Two months after the lung transplantation, primary surgical repair of the patent foramen ovale was performed with immediate improvement in oxygenation. Three years postoperatively, the patient remained oxygen independent.

e15626 Background: Studies have shown the effectiveness of immune checkpoint inhibition (ICI) in patients with tumors demonstrating microsatellite instability (MSI-H) and an associated defect in DNA mismatch repair (dMMR). In particular, KEYNOTE-177 demonstrated significant survival benefit for patients with unresectable or metastatic colorectal cancer with MSI-H or dMMR. Recently published case reports and series have demonstrated similar outcomes for patients with locally advanced and resectable rectal cancer. We report on the experience of patients with locally advanced, resectable rectal adenocarcinoma treated across the Mayo Clinic Health System. Methods: We conducted a retrospective analysis of patients treated at Mayo Clinic since 2015 A search of the Mayo Clinic database was done to include parameters for confirmed rectal adenocarcinoma, dMMR in pathology reports. Patients receiving ICI treatment including pembrolizumab, nivolumab/ipilimumab and durvalumab in any combination with chemotherapy and/or radiation were included. Patients with metastatic disease at the time of surgical intervention or ICI were excluded. Clinical data was assimilated. Results: Twenty-one patients met criteria for inclusion in our analysis. Fifteen patients had de novo disease. Six patients had local recurrence and had been treated previously with chemotherapy, radiation (RT) and surgery. None of the patients included had prior ICI therapy. Fifteen patients had Lynch syndrome. The median age of diagnosis was 41.5 years. Seven patients underwent surgical intervention. of the seven patients received surgery upfront followed by immunotherapy. The remaining six had neoadjuvant immunotherapy alone or in combination with chemotherapy and/or radiation. Prior to surgery, all patients demonstrated radiographic partial response (rPR). 67% of these demonstrated a pathologic complete response (pCR) while 33% had residual disease. The patient who received surgery upfront and adjuvant ICI continues to have radiographic stable disease after 1 year of treatment. For patients who did not have surgery, 50% had radiographic “complete or near complete” response (rCR), 43% had rPR and 7% had radiographic stable disease. Ten patients received RT and ICI with 70% demonstrating rCR and 30% rPR. Overall, the objective response rate was 90 Response to treatment was observed upwards of 75 months. Only 1 person in the study had progression of disease that occurred after 14 months of therapy. Conclusions: Similar to KEYNOTE-177, patients with locally advanced MSI-H/dMMR rectal cancer have significant and durable response to immunotherapy alone or in combination with chemotherapy, radiation and surgery. Further large prospective trials are needed to validate these findings and determine a standardized approach.