Systemic right ventricular failure after physiologic repair for dextro-transposition of the great arteries can be managed with durable mechanical circulatory support; however, the right ventricular morphology, such as intervening papillary muscles, presents challenges to inflow cannula positioning. Papillary muscle repositioning is an innovative technique to circumvent the obstructive anatomy.
In the work by Zheng Quan MD et al. about the Use of Intraoperative Transit Time Flow Measurement Can Reduce Preoperative Myocardial Injury (1), the authors did a retrospective, observational study of the effects of exposure to the TTFM procedure . Fifty-nine people received TTFM, while 47 did not. In total, 7 (6.6%) had at least one grafting vessel obstruction. Only 1 patient where the TTFM was used had an occlusion graft vs. 6 patients where the TTFM was not used and had postoperative injury. In 2001, the use of TTFM techniques for assessing the quality of grafts intraoperatively, on the basis of the presence and volume of flow were clearly described) In conclusion, the work of Zheng Quan MD et al. remarks the importance of the use of TTFM to reduce the incidence of preoperative myocardial injury during off-pump coronary bypass surgery. support of, in some ways, the recent expert opinion to promote the use of TTFM
The hemispherical aortic annuloplasty reconstructive technology (HAART) is an internal geometric annuloplasty ring designed to restore a natural elliptical shape to the aortic annulus as part of aortic valve repair. We present 4D flow hemodynamic analysis before and after implementation of the HAART ring in patients undergoing ascending aortic replacement. HAART patients displayed similar or improved flow profiles when compared to a patient undergoing ascending aortic replacement alone.
Background Combined ONCAB and SAVR is the treatment of choice for concomitant severe aortic stenosis and coronary artery disease not amenable to PCI intervention. Extensive aortic calcification and atheromatous disease may prohibit cardiopulmonary bypass and aortic cross clamping. In these cases Anaortic OPCAB is a Class I (EACTS 2018) and Class IIA (AHA 2021) indication for surgical coronary revascularization. TAVR has similar benefits when compared to SAVR for this population (Partner 2 & 3). Herewith we describe a case series of concomitant Anaortic OPCAB and TAVR via the transfemoral approach for patients with coronary artery and valve disease considered too high risk for traditional CABG and SAVR due to severe aortic disease. Methods/Results Eight patients underwent anaortic OPCAB and transfemoral TAVR during the same anesthetic in a hybrid operating room. Seven patients with multi-vessel disease had anaortic OPCAB via a sternotomy using composite grafts, one patient with LAD disease had anaortic OPCAB using a Da Vinci assisted MIDCAB approach. All patients then had an Edwards Sapien 3 TAVR placed percutaneously via the common femoral artery. There was no thirty-day mortality or CVA in the series and all patients were discharged to home or a rehabilitation facility on day 4-13. Conclusions Combined anaortic OPCAB and transfemoral TAVR is a safe and feasible approach to treating concomitant extensive coronary artery disease and severe aortic stenosis. The aortic no-touch technique provides benefits in the elderly high-risk patients by reducing the risk of post-operative myocardial infarction and cerebrovascular stroke.
Outcomes of operations for total anomalous pulmonary venous connection (TAPVC) have improved.However, postoperative pulmonary venous obstruction (PVO) remains the most significant complication, with high morbidity and mortality. We introduce a window anastomosis technique for repair of supracardiac TAPVC in infants. The mainstay of the surgical technique is to resect the anterior wall of the pulmonary vein confluence(PVC) and part of the posterior wall of the left atrium to form a large and undistorted “window to window” anastomosis.
Background: While prior data have suggested worse outcomes in women after acute type A aortic dissection (ATAAD) repair when compared to men, results have been inconsistent across studies over time. This study sought to evaluate the impact of sex on short- and long-term outcomes after ATAAD repair. Methods: This was a retrospective study utilizing an institutional database of ATAAD repairs from 2007 to 2021. Patients were stratified according to sex. Kaplan-Meier survival estimation and multivariable Cox regression were performed. Supplementary analysis using propensity score matching was also performed. Results: Of the 601 patients who underwent ATAAD repair, 361 were males (60.1%) and 240 (39.9%) were females. Females were significantly older, more likely to have hypertension, and more likely to have chronic lung disease. Females were also significantly more likely than males to undergo hemiarch replacement, while males were significantly more likely than females to undergo total arch replacement and frozen elephant trunk. Operative mortality was 9.4% among males and 13.8% among females, though this was not a statistically significant difference (p=0.098). Postoperative complications were comparable between groups. Kaplan-Meier survival estimates were similar for men and women, and, on multivariable Cox regression, sex was not significantly associated with long-term survival (HR 1.00, 95% CI: 0.73, 1.37, p=0.986). Outcomes remained comparable after supplementary propensity score matched analysis. Conclusion: ATAAD repair can be performed with comparable short-term and long-term outcomes in both men and women.
Background VIV-TAVR is established and provides good initial clinical and hemodynamic outcomes. Lacking long-term durability data baffle the expand to lower risk patients. For those purposes, the present study adds a hemodynamic 3-years follow-up. Methods A total of 77 patients underwent VIV-TAVR for failing aortic bioprosthesis during a 7-years period. Predominant mode of failure was stenosis in 87.0%. Patients had a mean age of 79.4±5.8 years and a mean logistic EuroSCORE of 30.8±15.7%. The STS-PROM averaged 5.79±2.63%. Clinical results and hemodynamic outcomes are reported for 30-days, 1-, 2- and 3-years. Completeness of follow-up was 100% with 44 patients at risk after 3-years. Follow-up ranged up to 7.1 years. Results Majority of the surgical valves were stented (94.8%) with a mean labeled size of 23.1±2.3mm and true-ID of 20.4±2.6mm. A true-ID ≤21mm had 58.4% of the patients. Self-expanding valves were implanted in 68.8% (mean labeled size 24.1±1.8mm) and balloon-expanded in 31.2% (mean size 24.1±1.8mm). No patient died intraoperatively. Hospital mortality was 1.3% and three-years survival 57.1%. All patients experienced an initial significant dPmean-reduction to 16.8±7.1mmHg. After 3-years mean dPmean raised to 26.0±12.2mmHg. This observation was independent from true-ID or type of TAVR-prosthesis. Patients with a true-ID ≤21mm had a higher initial (18.3±5.3mmHg vs. 14.9±7.1mmHg; p=0.005) and dPmean after 1-year (29.2±8.2mmHg vs. 13.0±6.7mmHg; p=0.004). There were no significant differences in survival. Conclusions VIV-TAVR is safe and effective in the early period. In surgical valves with a true-ID≤21mm inferior hemodynamic and survival outcomes must be expected. Nonetheless, also patients with larger true-ID’s showed steadily increasing transvalvular gradients. This raises concern about durability.
George and colleagues report their experience with a non-transplant left ventricular assist device program (1). This manuscript spans a decade’s experience with LVADs and clearly demonstrates that LVAD therapy is possible in centers without a heart transplant program. 100 LVADs were placed during this period. The positive findings from this report include that as volume increased, the complications of right heart dysfunction and bleeding decreased. Noteworthy is that 85 of the 100 patients were implanted with a fully magnetically levitated ventricular assist device. Given the superior performance of a fully magnetically levitated device to a rotary pump (2) these findings are relevant for all contemporary centers with LVAD programs.The authors importantly sought the resources of a transplant center to ensure that patients who were offered LVAD in their non-transplant center were indeed not candidates for cardiac transplantation. In addition to this fundamental necessity, three features are necessary for a successful non-transplant LVAD program. Firstly, the institution must offer robust infrastructure and support. Secondly there must be a strong surgeon-leader dedicated to overseeing the program. Lastly, cardiologists who are dedicated to heart failure are essential to guide patients to this therapy.The extension of LVAD therapy to patients in non-transplant centers is essential for durable mechanical circulatory support to remain as a vital part of advanced therapies for heart failure. VADs will continue to play an important role in the management of end-stage heart failure for patients who are not eligible for cardiac transplantation. The 2020 Society of Thoracic Surgeons INTERMACs report now offers patients a 5-year survival of 45%(3). The survival of patients with LVADs continues to increase. The data in this current report offer a new perspective and increased access to LVAD therapy for patients with end stage heart failure.ReferencesGeorge TJ, Aldrich A, Smith III RL, et al. Development of a Non-Transplant Left Ventricular Assist Device Program. J Card SurgMehra MR, Uriel Y, Naka Y, et al. A Fully Magnetically Levitated Left Ventricular Assist Device – Final report. N Engl J Med 2019:380:1618-27.Molina EJ, Shah P, Kierman MS, et al. The Society of Thoracic Surgeons Intermacs 202 Annual Report. Ann Thorac Surg 2021;111:778-92.
Prenatal diagnosis of hypoplastic aortic arch and coarctation of aorta is still challenging and remains one of the most difficult cardiac defect to diagnose. The results reveal significant improvement of prenatal diagnosis of hypoplastic arch and coactation of aorta. The data also shows the significant overlapping of fetal aortic isthmus z score between the infants who need the arch procedure and those who do not.
Based on Carpentier’s classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morpho-functional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets, but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.
For donation after circulatory death, procurement is performed after the heart has arrested. This technique has been employed and adopted by clinicians to overcome the shortage of available hearts for transplant. Warm ischemia time plays a pivotal role in the survival outcome of the heart recipients. We describe a fast and safe technique to flush the heart during recovery from circulatory death donors in order to shorten the warm ischemia time.
On Time Surgery Start: Is Standardization The Answer?Olufunke Folasade Dada MD, Tanaya Sparkle M.B.B.S.University of Toledo Medical Center, Anesthesiology Department,3000 Arlington Avenue, Toledo, Ohio, USACorresponding Author: Dr. Tanaya Sparkle, M.B.B.S.Address for correspondence:University of Toledo Medical Center, Anesthesiology Department,3000 Arlington Avenue, Toledo, Ohio - 43614E-mail: [email protected]: 419-383-3531
Background: Hemostatic disturbances with coronavirus disease 2019 (COVID-19) can predispose to tricuspid and right heart thrombi in very rare instances. Aim: We describe a 29-year-old female patient without previous cause of thrombosis who developed large tricuspid valve thrombus (TVT) and moderate-to-severe tricuspid regurgitation (TR) during the course of COVID-19 infection. Materials and methods: Persistant fever and tachycardia with thrombocytopenia and high D-dimer increased the index of suspicion. The diagnosis was made by bedside transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR). Surgery was performed for thrombectomy and tricuspid valve replacement with a tissue valve. Discussion and conclusion: Detection of TVT in COVID-19 patients on the basis of high index of suspicion, bedside TTE and non-invasive CMR helps early surgical treatment and subsequent reduction of mortality and hospital stay.
Background: Heart transplant from controlled donation after circulatory death (cDCD) is an emerging strategy that is rapidly expanding and may help increase the heart donor pool. Materials and Methods: The use of thoracoabdominal normothermic regional perfusion (TANRP) with extracorporeal membrane oxygenation device has allowed to perform cardiac transplantation after cDCD. Several experiences have been carried out in recent years, however the maximum cold ischemia time is still unknown. We present a successful case of heart transplantation using a graft from cDCD from another hospital with 201 minutes of cold ischemia time, the longest published in Europe. Discussion and conclusion: Heart transplant from cDCD could be a good alternative to brain dead donation. This experience suggests than nonlocal cardiac donation in controlled asystole could tolerate long periods of cold ischemia time and break the main barriers in cardiac donation after circulatory death.