Medicine and Health Sciences Commons^™

Infective Endocarditis Caused By Klebsiella Oxytoca In A Patient With Hemodialysis: A Care-Compliant Case Report And Review Of The Literature, Hanane Aissaoui, Youssef Hdidou, Ramia Bougrine, Nabila Ismaili, Noha Elouafi

Journal of the Saudi Heart Association

The rarity of endocarditis due to Klebsiella species limits its recognition. We report the case of a 63-year-old man, known to have a tight calcified aortic stenosis presenting with acute heart failure associated with high fever. Klebsiella oxytoca endocarditis was diagnosed based on three sets of positive blood cultures together with fluttering vegetation (11 mm x 14 mm) on the middle segment of the anterior leaflet of the mitral valve. After 6 weeks of intravenous ceftriaxone and gentamicin bi-therapy, the patient had completely recovered. This case illustrates how sporadic this condition is, for which early assessment and proper treatment are …

Bad Heart Luck: Myocardial Infarction Related To Iatrogenic Coronary Cameral Fistula In A Heart Transplant Patient, Badre El Boussaadani, Zakaria Raiss, Amine Qat, Pascal Goube

Journal of the Saudi Heart Association

Endomyocardial biopsy (EMB) remains the gold standard method for diagnosis of cardiac allograft rejection. Complications following EMB rarely occur, however, it can lead to coronary cameral fistulae (CCF). We describe the case of a 65-year-old patient admitted for lateral STEMI related to a fistula communicating the distal part of the left anterior descending artery (LAD) with the right ventricle after EMB biopsy, which was incompletely closed with a covered stent.

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Assessment Of Left Ventricular Mechanics In Patients With Severe Aortic Stenosis After Transcatheter Aortic Valve Implantation: 2-D Speckle Tracking Imaging Study, Hesham A. Naeim, Reda Abuelatta, Faisal O. Alatawi, Lamiaa Khedr

Journal of the Saudi Heart Association

Background: Chronic pressure overload secondary to severe aortic stenosis causes impairment of left ventricular myocardial deformation and associated with adverse outcome. The present study aimed to assess the response of myocardial mechanics after transcatheter aortic valve implantation (TAVI).

Methods: Assessment of myocardial mechanics by quantification of LV longitudinal, circumferential strain and rotational deformation (apical, basal rotation and twist) by 2-D Speckle-tracking echocardiography at baseline and at midterm follow-up post-TAVI. The patients were divided into 2 groups based on baseline left ventricular ejection fraction. 46 patients had preserved LV EF ≥50% preserved ejection fraction (PEF) and 34 patients had reduced left …

Impact Of Ramadan Fasting On Biochemical And Exercise Parameters Among Patients Undergoing Exercise-Based Cardiac Rehabilitation, Hazem Khorshid, Adel Shabana, Osama Rifaie, Yasser Abdellatif

Journal of the Saudi Heart Association

Background: Ramadan fasting is an important worship activity for Muslims. It is not known if fasting could have deleterious effect on cardiac patients joining cardiac rehabilitation (CR) program, especially during summer season.

Aim: To assess the effect of Ramadan fasting on biochemical and exercise parameters among patients undergoing 12- week exercise-based CR program. Patients and methods: 53 patients joining CR program in university hospital were included in the study. The patients were divided into two groups according to their Ramadan fasting status. Fasting group included 32 patients, while nonfasting group included 21 patients. All patients underwent supervised exercise-based CR during …

Percutaneous Coronary Interventions In Chronic Total Occlusion - Profile, Technique And Outcome -The Malabar Experience, Desabandhu Vinayakumar, Madhusudan Pramod Raikar, Kurukkanparampil Sreedharan Mohanan

Journal of the Saudi Heart Association

Introduction: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) remains a challenge. The reasons being that these procedures may be lengthy and complex, with elevated radiation exposure, increased contrast load, lower procedural success rate, and a higher risk of complication when compared with non-CTO elective PCI. Clarifying the long-term clinical outcomes of CTO-PCI is very important to justify potential investments in training and technology. However, there is a paucity of data from Indian subcontinent. Hence we decided to report the outcomes from a real-life cohort of consecutive patients undergoing elective PCI for CTO at our institution.

Materials and methods: …

Coronary Artery Ectasia With Acute Myocardial Infarction, A Case Report, Maysan Mohammed Almegbel, Fawaz Qabel Almutairi

Journal of the Saudi Heart Association

Coronary artery ectasia (CAE), also known as aneurysmal coronary artery disease, is defined as an abnormal diffuse (ectasia) or segmental (aneurysmal) dilatation of any branch of the coronary arteries. It is a well-recognized entity with 1.2-4.9% prevalence. Our case is a 46year old male with no prior medical problem who presented to the ER with inferior ST elevation myocardial infarction (STEMI). The Coronary angiogram revealed multiple ectatic segments in the right coronary artery (RCA) with 100% stenosis in the middle segment. Upon wiring the RCA a big clot burden was noted on the ectatic segment. We planned to keep him …

Post Myocardial Infarction Papillary Muscle Rupture In The Context Of Coronavirus Disease-2019 Pandemic, Nooraldaem Yousif, Vinayak Vadgaonkar, Helen Saunders, Mohammad Amin, Habib Tareif, Fuad Abdulqader

Journal of the Saudi Heart Association

Papillary muscle rupture is a very rare but often catastrophic complication of acute myocardial infarction. In this case we are sharing our experience in the context of the current COVID-19 pandemic, which rendered the management extremely challenging.

Giant Ascending Aortic Aneurysm With Painless Dissection In A Patient With Marfan Syndrome, Khaled D. Algarni, Amr A. Arafat, Adam I. Adam, Claudio Pragliola

Journal of the Saudi Heart Association

A female patient aged 17 years old presented with dyspnea grade III with no chest pain. The patient has Marfan Syndrome, and there was a history of mitral valve repair six years ago. Echocardiography showed an ejection fraction of 55%, severe aortic regurgitation, dilatation of the ascending aorta, and moderate tricuspid regurgitation. CT scan showed an ascending aortic aneurysm (92 mm in its maximum diameter) with dissection flap (Figure 1A and B). We performed a Bentall operation with an axillary cannulation (Figure 1C). The postoperative course was complicated with bleeding requiring re-exploration, and the patient was discharged with stable hemodynamics …

The Echocardiography Society Of Saudi Heart Association Recommendation On Quality And Laboratory Accreditation Guideline And Standards, Abdulhalim Jamal Kinsara, Sami Ghazal, Ahmad S. Omran, Esra Aleid

Journal of the Saudi Heart Association

Objective: To create the Saudi Arabian Society of Echocardiography Accreditation Commission Guidelines and Standards.

Method: A review of available the North American and European accreditation guidelines was conducted and a model, locally appropriate for Saudi echocardiography laboratories and applicable in the current settings, was developed.

Results: The document specifies the organizational setting as well as the following categories of personnel: medical director, technical director, medical staff, and technical staff. The guideline team also examined aspects related to the facility and the facility safety policies and protocols. Examination and procedural issues for Adult transthoracic echocardiography including instrumentation, archiving media, examination interpretation …

Atrial High-Rate Episodes, Subclinical Atrial Fibrillation And Short-Duration Clinical Atrial Fibrillation: Different Names For The Same Arrhythmia Or A New Player On The Pitch?, Juan Benezet-Mazuecos, Alvaro Lozano Rosado, Julian Crosa, Jose Antonio Iglesias

Journal of the Saudi Heart Association

No abstract provided.

Infected Coronary Artery Aneurysm - A Rare But Fatal Complication Of Percutaneous Coronary Intervention, Ajit Pal Singh, Harnoor Singh Pruthi

Journal of the Saudi Heart Association

A 43 year old male underwent successful Percutaneous Coronary Intervention (PCI) to LCX. 3 months after the procedure, he presented with NYHA class III-IV angina associated with low grade fever and reduced appetite. Biochemical parameters including complete blood count and renal function tests were normal. ECG showed ST segment depression in lateral leads. Echocardiography showed lateral wall hypokinesia with moderate Mitral valve regurgitation. Coronary angiogram revealed large mycotic aneurysms in LAD and LCX coronary arteries (Image 1). Blood culture showed growth of Pseudomonas aeruginosa. Infected coronary aneurysms are a rare and potentially fatal complication after drug eluting stent implantationand …

Perioperative Management Of Pheochromocytoma Resection In A Patient With A Continuous Flow Left Ventricular Assist Device, Arif Albulushi Md, Ronald Zolty Md Phd, Brian Lowes Md, Phd, Amy L. Duhacheck-Stapleman Md, Tal Sandler Md, James N. Sullivan Md, Douglas Stoller Md Phd

Journal of the Saudi Heart Association

Current generation LVADs provide continuous blood flow which has been shown to increase sympathetic tone. Pheochromocytoma is a rare neuroendocrine tumor which classically presents with episodic hypertension, palpitations and headaches. Careful perioperative management with alpha blockade is required to prevent cardiovascular complications, specifically hypertensive crisis. Here we present a description of perioperative management of pheochromocytoma in a patient with a continuous flow LVAD. Traditional assessment of sympathetic tone is challenging in LVAD patients due to the presence of continuous circulatory flow. Invasive management via an arterial line was useful in perioperative management, allowing for accurate circulatory monitoring and hemodynamic control. …

Fatal Heart Failure Induced By Pazopanib In A Sarcoma Patient Previously Treated With Gemcitabine, Daniela Di Lisi, Girolamo Manno, Clarissa Filorizzo, Tommaso Guarino, Giulia Santanelli, Monica Lunetta, Giuseppe Badalamenti, Antonio Russo, Giuseppina Novo

Journal of the Saudi Heart Association

Gemcitabine is commonly used for various solid organ malignancies with rarely reported cardiac side effects such as cardiomyopathy. Pazopanib usually can cause arterial hypertension but cases of heart failure have recently been reported. We describe a case of fatal heart failure after treatment with gemcitabine and pazopanib in a 55-year-old female with sarcoma. Patient developed left ventricular dysfunction after gemcitabine treatment and acute heart failure after 22 days of pazopanib treatment which led to death. Physicians should be aware of the cardiotoxicity risk when managing the use of pazopanib especially in patients previously treated with other cardiotoxic drugs.

Anomalous Drainage Of Persistent Left Superior Vena Cava To The Left Atrium: Case Series And Literature Review, Mustafa Abdulwahab, Abdulhameed Ali Alnajja, Ali Edris Jelly, Aitizaz Eldien Syed, Mohamed Mofeed Fawaz Morsy, Mansour Bader Al-Mutairi, Alassal Ahmad Alkodami

Journal of the Saudi Heart Association

Persistent left superior vena cava (PLSVC) draining into the coronary sinus is not uncommon, but to the left atrium is a rare condition. Such anomaly may be a cause of unexplained hypoxia in all age groups. It is often diagnosed accidentally during cardiovascular diagnostic work-up or in a contest of other cardiac investigations. We report two cases of these rare PLSVC associations with subsequent medical and surgical management.

Editorial Management Of Cardiac Patients During The Covid-19 Pandemic, Günter Breithardt, Hani K. Najm, Marko Turina, Ahmed A. Arifi

Journal of the Saudi Heart Association

No abstract provided.

Health Care Delivery For Heart Failure Patients During The Covid-19 Pandemic; A Consensus Of The Saudi Heart Failure Working Group (Saudi-Hf), Abeer Bakhsh, Maryam Alqaseer, Fakhr Alayoubi, Rima S. Bader, Kamal Alghalayini, Abdelfatah Elasfar, Waleed Alhabeeb

Journal of the Saudi Heart Association

The Coronavirus disease 2019 (COVID-19) pandemic led to global and national rapid health system changes to treat the affected patients and prevent the spread of the virus. The social distancing, redirecting resources, and nationwide lockdown led to the cancellation of non-urgent hospital visits and interruption of continuity of care for patients with chronic cardiac conditions such as heart failure (HF). This consensus document addresses the domains of health care delivery that are affected by the pandemic. It explains the current situation of health care delivery to heart failure patients and further recommendation on how to overcome this. Thus, maintaining quality …

Validity Of The Stent Thrombosis Risk Score In Predicting Early Stent Thrombosis After Primary Percutaneous Coronary Intervention, Rajesh Kumar, Sahar Tariq, Madiha Fatima, Tahir Saghir, Mahesh Kumar Batra, Musa Karim, Jawaid Akbar Sial, Naveedullah Khan, Syed Nadeem Hasan Rizvi

Journal of the Saudi Heart Association

Background: The thrombosis of the stent is one of the most important complications of percutaneous interventions, resulting in complete occlusion of the stented vessel. Aim of this study was to determine the validity of Stent Thrombosis Risk Score (STRS) in predicting early stent thrombosis (ST) after primary Percutaneous Coronary Intervention (PCI)

Methods: For this study, 569 consecutive patients undergone primary PCI from July 2018 to December 2018 were recruited. Early ST was defined as ST occurred during or within 30 days after the procedure. The STRS was calculated as proposed, developed, and validated in a past study. The …

Heart Failure In The Middle East Arab Countries: Current And Future Perspectives, Abdelfatah Elasfar, Waleed Alhabeeb, Salma Elasfar

Journal of the Saudi Heart Association

For many years, data about heart failure (HF) was only limited to Western countries but in the last few years, well designed heart failure registries have been conducted in many developing countries. The purpose of this review is to summarize the current status regarding the epidemiology and management of heart failure in Middle East Arab countries (MEACs) by analysis of the results of the latest HF registries performed in these countries and to anticipate future perspectives, quality initiatives and areas of research and development. Data has shown that the average age of affected individuals is at least 10 years younger …

The Prognostic Impact Of Pulse Pressure In Acute Heart Failure: Insights From The Hearts Registry, Alwaleed Aljohar, Khalid Alhabib, Hussam Alfaleh, Ahmad Hersi, Waleed Al Habeeb, Anhar Ullah, Abdelfatah Elasfar, Ali Almasood, Abdullah Ghabashi, Layth Mimish, Saleh Alghamdi Alghamdi, Ahmed Abuosa, Asif Malik, Gamal Abdin Hussein, Mushabab Al Murayeh, Tarek Kashour

Journal of the Saudi Heart Association

Background: Low pulse pressure predicts long-term mortality in chronic heart failure, but its prognostic value in acute heart failure is less understood. The present study was designed to examine the prognostic value of pulse pressure in acute heart failure.

Methods: Pulse pressure was tested for its impact on short- and long-term mortality in all patients admitted with acute heart failure from October 2009 to December 2010 in eighteen tertiary centers in Saudi Arabia (n ¼ 2609). All comparisons were based on the median value (50 mmHg). Heart failure with reduced ejection fraction was defined as less than 40%.

Results: Low …

Association Between Off-Hour Presentations And In-Hospital Mortality For Patients With Acute St-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention, Elnaz Javanshir, Elham Darzi Ramandi, Samad Ghaffari, Babak Nasiri, Haleh Bodagh, Ghiti Davarmoin, Naser Aslanabadi, Ahmad Separham

Journal of the Saudi Heart Association

Objectives: This study aimed to assess the effect of the admission time (on-hours versus off-hours) on in-hospital mortality in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) in a region without STEMI network.

Methods: We analysed in-hospital the mortality among 300 consecutive ST-segment elevation myocardial infarction (STEMI) patients treated with PPCI between March 2012 and February 2017. Patients were divided according to admission time into on-hours admission (08:00 AM until 08:00 PM on weekdays) versus off-hours admission (08:00 PM until 08:00 AM on weekdays and 24 h on weekends and holidays). Demographic and clinical …

Cardiac Screening To Mitigate The Risk Of Sudden Cardiac Death In Middle Eastern And African Competitive Athletes. A Systematic Review, Yusuf Hallak, Umberto Battistin, Ahmad Mustafa Al-Masaeed

Journal of the Saudi Heart Association

Objective: The study aims to review the literature regarding abnormalities predisposing to Sudden Cardiac Death (SCD) in young Middle Eastern and African competitive athletes between the years 2009e2019 and aims to assess cardiac pre-participation screening methods.

Methods: A PubMed search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search targeted articles that reported the prevalence of cardiac abnormalities found in Middle Eastern and African athletes, and it also focused on comparing cardiac screening methods for assessment of athletes. Results: our studies fell within the inclusion criteria and were included in the …

The Carpentier-Edwards Classic And Physio Annuloplasty Rings In Repair Of Degenerative Mitral Valve Disease: A Retrospective Study, Abubakari I. Sidiki Md, Alexandr G. Faybushevich Md, Phd, Alexandr N. Lishchuk Md, Phd, Alexandr N. Koltunov Md, Phd, Ekaterina A. Roshchina, Jonas Atulebire Akambase

Journal of the Saudi Heart Association

Objectives. Physio ring (SR) is considered an improved version of the Classic rigid ring (RR). Today, SR is more widely used in mitral valve (MV) repair. We sought to compare the long-term outcomes of repair with RR and SR in degenerative mitral valve disease.

Methods. In a computerized registry of our institution, 306 patients had MV repair with either RR (139 patients) or SR (167 patients) ring between 2005 and 2015. Fifteen of them had concomitant tricuspid valve repair. Ninety-two (30.1%) had Barlow’s disease and 214 (69.9%) had fibroelastic deficiency. The patients had similar demographic and echocardiographic characteristics. …

Tricuspid Valve Regurgitation After Heart Transplantation: A Single-Center 10-Year Experience, Khaled D. Algarni, Amr A. Arafat, Claudio Pragliola, Yahya S. Alhebaishi, Latifa A. Alfayez, Khaled Alotaibi, Abeer M. Bakhsh, Ahmed A. Amro, Adam I. Adam

Journal of the Saudi Heart Association

Background: Tricuspid valve regurgitation may affect the outcomes after heart transplantation. There is a paucity of data reporting the outcomes of heart transplants in our region. The objectives of this study were to report the occurrence of tricuspid regurgitation after heart transplantation, its course, and its effect on survival.

Methods: From 2009 to 2019, 30 patients had heart transplantation at our cardiac center. Their age was 36.73± 13.5 years, and 25 (83.33%) were males. Indications for transplantation were dilated cardiomyopathy (n= 21; 72.41%), ischemic cardiomyopathy (n= 8; 26.67%) and hypertrophic cardiomyopathy (n=1; 3.45%). Cardiopulmonary bypass time was 157.24± 34.6 minutes, …

The Trans-Septal Approach In Transcatheter Mitral Valve-In-Valve Implantation For Degenerative Bioprosthesis, Mohammed Al Otaiby, Turki A. Al Garni, Abdullah Alkhushail, Abdulrahman Almoghairi, Sondos Samargandy, Monirah Albabtain, Amr A. Arafat, Hussein Alamri

Journal of the Saudi Heart Association

Background: Transcatheter Mitral Valve-in-Valve Implantation (TMViVI) has recently emerged as a novel therapy for degenerated mitral valve bioprosthesis. Re-operative mitral valve surgery is associated with a substantial risk of mortality and morbidity. The objective of this study was to describe the outcomes of transcatheter mitral valve-in-valve implantations in our cardiac center.

Methods: Twenty-two patients underwent the valve-in-valve procedure because of bioprosthesis degeneration from March 2017 to October 2018. Clinical, echocardiographic, procedural details and survival at follow up were assessed.

Results: Eight patients refused re-operative cardiac surgery while others were deemed a high risk for conventional re-operative sternotomy. All patients had …

Aortopulmonary Window: Types, Associated Cardiovascular Anomalies, And Surgical Outcome. Retrospective Analysis Of A Single Center Experience, Mohammed Bin-Moallim, Hussam K. Hamadah, Fahad Alhabshan, Abdullah A. Alghamdi, Mohamed S. Kabbani

Journal of the Saudi Heart Association

Objective: Aortopulmonary window (APW) is a rare congenital heart defect. It occurs as an isolated cardiac lesion or in association with other cardiac anomalies and rarely with abnormal coronary arteries. The spectrum of cardiovascular anomalies associated with APW and overall management and outcome in the current era were reviewed.

Methods: Between 2001 and 2018, all patients diagnosed with APW were included. Based on associated cardiovascular anomalies, those patients were divided into 2 groups: simple APW group and complex APW group (APW with asso- ciated other cardiovascular anomalies). All cases were followed longitudinally. The outcomes are described.

Result: Twenty patients underwent …

Cardiac Catheterisation Interventions In Neonates And Infants Less Than Three Months, Ali A. Alakhfash, Ali Jelly, Abdulrahman Almesned, Abdullah Alqwaiee, Mansour Almutairi, Sherif Salah, Mahmoud Hasan, Mustafa Almuhaya, Abdulhamid Alnajjar, Mohammed Mofeed, Bana Nasser

Journal of the Saudi Heart Association

Introduction: Pediatric cardiac catheterization interventions become an established way of care for selected patients with congenital heart diseases. Cardiac catheterization for neonates and small infants can be challenging. The indications for diagnostic cardiac catheterization have decreased with the advent of advanced non-invasive imaging modalities.

Patients and method: Between June 2012 and July 2017 patients less than three months who had cardiac catheterization in two centers were reviewed

Results: During the study period, 174 patients underwent interventional cardiac catheterization,83.3% of them had CHD with two-ventricle circulation and 29 patients (16.7%) had single ventricle pathophysiology. Procedures include diagnostic cath, BAS, balloon pulmonary …

A New Scoring System Detecting The Supraventricular Tachycardia Inducibility And Radiofrequency Ablation With High Specificity In Electrophysiological Study, Savas Ozer, Mustafa Çetin, Ali Gokhan Ozyildiz, Ramazan Gengorü, Oguzhan Ekrem Turan, Meltem Pusuroglu, Bülent Bahçeci, Turan Erdogan

Journal of the Saudi Heart Association

Aim: The relationship between arrhythmia induction and ablation with palpitation characteristics has been demonstrated in electrophysiological study (EPS) patients. However, there is insufficient data on palpitation characteristics and their sensitivity and specificity. We aimed to identify the relationship between scoring composed of palpitation characteristics with the supraventricular tachycardia (SVT) induction and the success rate of the procedure.

Method: A total of 119 patients, diagnosed as paroxysmal supraventricular tachycardia (PSVT) by electrocardiography, rhythm Holter or symptoms, and underwent EPS, were enrolled in the study. A psychiatrist administered the Hospital Anxiety and Depression Score (HADS) questionnaire.

Results: In SVT induced group, palpitation …

Pacemaker Detected Prolonged Atrial High Rate Episodes – Incidence, Predictors And Implications; A Retrospective Observational Study, Pratheesh George Mathen, David Chase

Journal of the Saudi Heart Association

Introduction: Atrial tachyarrhythmias especially atrial fibrillation are the most commonly encountered arrhythmias in clinical practice. Most atrial tachyarrhythmia episodes are subclinical. Cardiac implantable electronic devices with atrial sensing function enable detection of atrial tachyarrhythmias through means of atrial high rate event algorithms. Prolonged atrial high rate episodes(AHRE) above a defined rate and duration threshold represent episodes of atrial fibrillation, atrial flutter, and longer atrial tachycardias that correlate strongly with risk for thromboembolic events.

Objective: 1. To examine the occurrence of prolonged AHRE in dual-chamber pacemaker recipients over the study period. 2. To examine the factors which influence the occurrence of …

Comparison Of The Effects Of Ticagrelor And Clopidogrel On Heart Rate Variability And Heart Rate Turbulence In Patients With Percutaneous Coronary Interventions, Pinar Yagcioglu, Selma Ari, Hasan Ari, Mehmet Melek

Journal of the Saudi Heart Association

Introduction: Clopidogrel and ticagrelor are commonly used, antiplatelet agents. Ticagrelor has an effect of enhancing the plasma level of adenosine that may alter the autonomic function. The aim of this study is to compare the effects of ticagrelor and clopidogrel on heart rate variability (HRV) and heart rate turbulence (HRT).

Methods: Thirty subjects who performed percutaneous coronary intervention (PCI) were included in the randomized, crossover study. These patients were divided into two groups. Clopidogrel or ticagrelor was administered in two different testing sessions (1-month treatment for each session). In group 1, clopidogrel and ticagrelor treatment were used while in group …

Delayed Repair Of Aortic Dissection In Sickle Cell Anaemia As A Combined Cardiac And Vascular Surgical Approach, Massimo Capoccia, Maziar Mireskandari, Nicholas J. Cheshire, Ulrich P. Rosendahl

Journal of the Saudi Heart Association

We discuss a patient who presented with a type B aortic dissection with a retrograde progression in the context of sickle cell anaemia. Given the involvement of the superior mesenteric artery and concern for bowel ischaemia, a delayed approach was considered. Subsequently, a frozen elephant trunk was performed in the hybrid theatre with the back-up of the vascular surgeon for mesenteric protection. A technically demanding procedure followed by a prolonged and challenging postoperative course finally led to a successful outcome. We argue that the case presented is an example of how a close cooperation between professionals can offer additional options …