Cardiac papillary fibroelastomas are rare cardiac tumors and have been considered a 'benign' incidental finding that may have significant clinical manifestations. In this paper we report two cases of mitral valve fibroelastoma: one was discovered by chance with transthoracic echocardiography in a young healthy man, the other was an intraoperative incidental finding in a middle aged man with a recent history of acute myocardial infarction. The mitral valve was repaired in both cases after excising the tumor. The patients did well and remain asymptomatic. A literature review was compiled which comprises previous case reports of 34 patients with mitral valve papillary fibroelastomas. Most were asymptomatic, but when symptoms occurred, they could be disabling, such as stroke, cardiac heart failure, myocardial infarction, and sudden death. Papillary fibroelastoma is amenable to simple surgical excision or in addition to mitral valve repair or replacement. Recurrence has not been reported.
trast to the findings of Melo and colleagues, 1 and despite the younger age of our patients, we found no significant difference in the incidence of AF between the two well-matched groups in our study.Melo and colleagues 1 failed to come up with a convincing reason for the claimed effectiveness of the technique. Anatomically, the route taken by autonomic nerves to the heart is highly variable 2 ; a lesser but significant and variable proportion of autonomic nerves reaches the heart along the pulmonary veins and the back of the heart, so the actual denervation achieved in quantitative terms is not consistent or comparable between patients unless the innervation is mapped out before denervation. The inclusion of patients with diabetes (26% in the VCD group and 27% in the control group in their study and 16% and 13%, respectively, in our own study) and patients receiving -blockers (75% in the VCD group and 81% in the control group in their study and 69% and 72%, respectively, in our study) gives rise to additional problems. Many patients with diabetes already have partial denervation from preexisting autonomic neuropathy, and it is debatable how much additional denervation is achieved surgically with the technique. -Blockers themselves have antiarrhythmic effects and produce a state of near-total pharmacologic sympathetic denervation. Long-term -blockade causes -receptor hypersensitivity, necessitating reintroduction of -blockers after the operation. The reintroduction of -blockers in most cases in the postoperative period results in total cardiac sympathetic denervation and partial parasympathetic denervation, which raises questions about the whole hypothesis.One can only meaningfully assess the effectiveness of the technique through a prospective, randomized multicenter trial excluding patients with diabetes and those receiving -blockers. Histologic quantification of the amount and type of nerve fibrils in the excised fat pads is also necessary.
We congratulate Dr Randall and coworkers for the low incidence of neurological complications described in their article focused on a staged "hybrid" approach, consisting of carotid stenting before cardiac operations in patients with concurrent disease. 1 We applied a similar strategy in 21 selected patients with no death or permanent stroke and would like to point out several aspects related to this specific issue.In the authors' experience, 49/52 consecutive patients underwent staged revascularization. Three remaining patients died of cardiac causes while awaiting for cardiac surgery, 24, 56 and 59 days after carotid stenting, respectively, accounting for a 5.8% mortality rate. More specifically, 1 death occurred within 30 days in a patient with multiple high-risk cardiac conditions (coronary artery disease, aortic valve disease, heart failure), whereas 2 deaths occurred almost 2 months after stenting: all deaths might thus have been avoided by not delaying myocardial revascularization. Although unstated, the interval between the procedures (2 to 60 days) could be dictated by bleeding risk considerations. In this respect, patients are possibly at relatively low-risk during the first month after stenting, ie, while on a double antiplatelet regimen (this applies to 82.7% of patients). The cardiac operation should thus be preferably planned immediately after discontinuing antithrombotic drugs, or on a more urgent basis in higher-risk patients, despite a higher incidence of postoperative bleeding. Interestingly, a similar strategy, including percutaneous coronary intervention and valve surgery within 2 weeks, has been suggested to reduce the operative risk in patients with complex coronary/valve disease. 2 Indications for preoperative duplex ultrasound varies according to the operating cardiac surgeon. The authors correctly indicate this as a potential bias, but do not state how many patients (if any) were not assessed because of a clinical cardiac priority (unstable angina, left main disease, etc), and what was the incidence of neurological complications. Although only a minority of patients (7.6%) showed cerebrovascular symptoms during the preceeding 6 months, it is probably unwise not to screen higher-risk populations (older age, diabetes, peripheral vascular disease, unstable angina). [3][4][5] Furthermore, the potential role of off-pump coronary revascularization, which likely reduces the incidence of neurological and bleeding complications, 6 is not discussed. In fact, most of our cardiac operations after carotid stenting (13/21, 61.9%) were performed with this technique.This represents a consecutive series. Thus, no carotid operation was performed in cardiac surgical candidates since 1998. According to the authors, the usefulness of stenting before cardiac surgery, versus staged or concurrent carotid endarterectomy, would help to limit "additional workload" with "overstretched vascular services." However, 49 procedures during a 7-year interval imply 7 operations/ year at the authors' institution, which re...
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