Background and Aim: To review the anatomical details, diagnostic challenges, associated cardiovascular anomalies, and techniques and outcomes of management, including re-interventions, for the rare instances of transposition physiology with concordant ventriculo-arterial connections. Methods: We reviewed clinical and necropsy studies on diagnosis and surgical treatment of individuals with transposition physiology and concordant ventriculo-arterial connections, analyzing also individuals with comparable flow patterns in the setting of isomerism. Results: Among reported cases, just over two-thirds were diagnosed during surgery, after initial palliation, or after necropsy. Of the patients, four-fifths presented in infancy with either cyanosis or congestive cardiac failure, with complex associated cardiac malformations. Nearly half had ventricular septal defects, and one-fifth had abnormalities of the tricuspid valve, including hypoplasia of the morphologically right ventricle. A small minority had common atrioventricular junctions We included cases reported with isomerism when the flow patterns were comparable, although the atrioventricular connections are mixed in this setting. Management mostly involved construction of intraatrial baffles, along with correction of coexisting anomalies, either together or multi-staged. Overall mortality was 25%, with one-fifth of patients requiring pacemakers for surgically-induced heart block. The majority of survivors were in good functional state. Conclusions: The flow patterns produced by discordant atrioventricular and concordant ventriculo-arterial connections remain an important, albeit rare, indication for atrial redirection. The procedure recruits the morphologically left ventricle in the systemic circuit, producing good long-term functional results. The approach can also be used for those with isomeric atrial appendages and comparable hemodynamic circuits.
Extracorporeal membrane oxygenation (ECMO) has been adopted to support patients with acute severe cardiac or pulmonary failure that is potentially reversible and unresponsive to conventional management. In the presence of pulmonary embolism, mesenteric ischemia (MI) can present as a life-threatening disorder that leads to intestinal ischemia. Due to the nature and acuity of these conditions, determining adequate perfusion upon surgical intervention is challenging for the operating surgeon, especially in the presence of cardiogenic shock despite ECMO support. Indocyanine green fluorescent angiography (ICG-FA) has proven to be useful for real-time vascular perfusion assessment, which may potentially decrease the rate of development of perfusion-related complications. The case report here-in presented, breaks the paradigm of performing noncardiac surgical procedures on ECMO support via a pioneering visual aid technique. Learning objective Indocyanine green fluorescent angiography (ICG-FA) is a promising visual trans-operatory technique providing real-time feedback for the adequate identification and assessment of target tissue/organs. The high morbidity and mortality rates associated to MI and CS – particularly when concomitantly present – hinders salvage surgical therapy. The use of acute ECMO provides stabilization yet lacks any curative solutions. This case report highlights the importance of adequate surgical intervention under extracorporeal life support in the presence of both CS and MI. To the authors’ knowledge, said approach has never been attempted, yet trails a promising therapy for the improvement of associated mortality rates.
Primary repair was carried out in a neonate with an atypical form of double outlet right ventricle; with a non-committed ventricular septal defect and lack of the outlet septum between the semilunar valves. The aortic arch was right-sided. The procedure required a right ventricular incision. Intraventricular rerouting could be achieved concomitantly with the arterial switch maneuver. Retrospectively, several strategies were contemplated to seek whether any other approach could have been superior to our present choice.
Objective: To evaluate the perioperative clinical efficacy of preoperative human fibrinogen treatment in patients with acute Stanford type A aortic dissection (ATAAD). Methods: Data of 159 patients with ATAAD who underwent emergency surgical treatment in our hospital from January 2019 to December 2020 were retrospectively analyzed. Patients were divided into two groups according to whether human fibrinogen was administered before surgery. The preoperative clinical data, surgical data, postoperative data, complications related to the coagulation function, and mortality of the two groups were compared and analyzed. Results: The in-hospital mortality was similar in the two groups (2.9% versus 9.3%, P = 0.122). However, group A had a significantly shorter operation time (279.24±39.03 versus 298.24±45.90, P=0.008), lower intraoperative blood loss (240.48±96.75 versus 353.70±189.80, P＜0.001), and reduced intraoperative transfusion requirement of red blood cells (2.61±1.18 versus 6.05±1.86, P＜0.001). The postoperative suction drainage within 24 hours in group A was significantly decreased (243.24±201.52 versus 504.22±341.08，P=0.002). The incidence of postoperative acute kidney injury (AKI) in group A was lower than that in group B (3.8% versus 14.8%, P =0.023). Similarly, the incidence of postoperative hepatic insufficiency in group A was lower than that in group B (1.9% versus 9.3%, P =0.045). In group A, the mechanical ventilation time was shorter (47.68±28.61 versus 118.21±173.16, P=0.004) along with reduced ICU stay time (4.06±1.18 versus 8.09±9.42, P=0.003), and postoperative hospitalization days (19.20±14.60 versus 23.50±7.56, P=0.004). Conclusion: Preoperative administration of human fibrinogen in patients undergoing ATAAD surgery can effectively reduce the intraoperative blood loss, blood transfusion amount, shorten the operation time, reduce postoperative complications, and improve the early prognosis of patients, in addition to being highly safe.
Introduction Thoracic endovascular aortic repair (TEVAR) became the standard of care for treating type B aortic dissections and descending thoracic aortic aneurysms. We aimed to describe the racial/ethnic differences in TEVAR utilization and outcomes. Methods The National Inpatient Sample was reviewed for all TEVARs performed between 2010 and 2017 for Type B aortic dissection and descending thoracic aortic aneurysm (DTAA). We compared groups stratifying by their racial/ethnicity background in whites, black, Hispanic, and others. A mixed-effects logistic regression was performed to assess the relationship between race/ethnicity and the primary outcome, in-hospital mortality. Results A total of 25,260 admissions for TEVAR during 2010–2017 were identified. Of those, 52.74% (n= 13,322) were performed for aneurysm and 47.2% (n= 11,938) were performed for type B dissection. 68.1% were white, 19.6% were black, 5.7% Hispanic, and 6.5% were classified as others. White patients were the oldest (median age 71 years; <0.001), with TEVAR being performed electively more often for aortic aneurysm (58.8% vs. 34% vs. 48.3% vs. 48.2%; p<0.001). In contrast, TEVAR was more likely urgent or emergent for type B dissection in black patients (65.6% vs 41.1% vs 51.6% vs 51.7%; p<0.001). Finally, the black population showed a relative increase in the incidence rate of TEVAR over time. The adjusted multivariable model showed that race/ethnicity was not associated with in-hospital mortality. Conclusion Although there is a differential distribution of thoracic indication and comorbidities between race/ethnicity in TEVAR, racial disparities do not appear to be associated with in-hospital mortality after adjusting for covariates.
A 62-year-old man presents to the Cardiology Department with a two years history of angina on exertion. Invasive coronary angiography revealed a severe three vessels coronary artery disease. The “Hybrid Heart Team” successfully performed a fully robotically-assisted hybrid revascularization combining RE-MIDCAB on the LAD and R-PCI on non-LAD lesions.
Choosing to perform mitral valve (MV) repair or replacement remains a hot and highly debated topic. The current guidelines seem to be conflicting in this specific field and the evidences at our disposal are scarce, only one small randomized trial and few larger retrospective studies. The meta-analysis by Gamal and coworkers tries to summarize the current evidences, concluding that MV replacement for the treatment of ischemic mitral regurgitation is at least as safe as repair and certainly offers a more stable result over time than the latter. Obviously, the implantation of a prosthesis, especially a mechanical one, brings with it a series of problems, such as anticoagulation and, above all, a possible lack of ventricular remodeling, especially if a chordal sparing replacement is not performed. It must be said, on the other hand, that isolated annuloplasty cannot act as a counterpart to replacement, because ischemic MR cannot be considered only an annular disease. Therefore, wanting to mimic the nature that, after an infarction, enacts a series of changes involving also the mitral leaflets and chordae, the surgeons are called to act also on these two entities and not only to downsize the annulus. In a nutshell, a procedure should not be opposed in a fundamentalist way to another one, but we must accept the concept of armamentarium where both procedures are present and tail on the single patient, and also on the surgeon’s expertise, the technique guaranteeing the best possible result.
Aorto-tracheal fistulas are rare and highly lethal, with few reports of successful surgical intervention. We present a 48 year old man with aorto-tracheal fistula induced by radiation therapy for tracheal squamous cell carcinoma. He presented with hemoptysis and chest pain and workup revealed the aorta-tracheal fistula between the posterior aortic arch and anterior distal trachea. He was emergently taken to surgery. To our knowledge, this is the first report of an aorto-tracheal fistula successfully treated with a transverse aortic arch replacement and complex tracheal repair using autologous pericardium with an omental buttress.
TITLE: Letter to the Editor: Impact of antimicrobial selection for prophylaxis of left ventricular assist device surgical infections.ARTICLE TYPE: letter to the editorCORRESPONDENCE: 1. SYED ABDUL REHMAN SHAHContact; +92 3350238188 Email; [email protected]: Dow University of Health Sciences, karachiAddress; H#2 G#50/4/2/2 Umar bungalows A Rehman street garden east Karachi
Background— aortic regurgitation in a bicuspid aortic valve is a complex entity that involves not only the semilunar valve but also the structure of the aortic root which is functionally & pathologically in a very close relationship to it. Considering repairing a bicuspid valve mandates a mindful involvement of all related structures concurrently. Here We report an interested case of both bicuspid aortic valve and mitral valve regurgitation in a patient with history of infective endocarditis, that was successfully managed by double valves repair.
Objective: The aim of the study is to assess the therapeutic effect and applicability of pectoralis major muscle turnover flap reconstruction for treatment of deep sternal wound infection after cardiac surgery in infants and children. Methods: From march 2013 to october 2021, 23 patients with deep sternal wound infection after cardiac surgery underwent pectoralis major muscle turnover flap reconstruction.The data and outcomes of the patients were retrospectively analyzed. Results: 20 patients were treated with unilateral pectoralis major muscle turnover flap reconstruction,3 patients were treated by bilateral pectoralis major muscle turnover flap. All of the sternal wounds healed successfully. All patients survived and were discharged without evidence of infection. In a follow-up period, ranging from 15 to 83 months (mean 32.6 months), all patients demonstrated normal development with no limitations to limb movements. There were no signs of chronic sternal infection in all of them. Conclusion:Pectoralis major muscle turnover flap reconstruction is a simple,feasible and effective treatment of deep sternal wound infection after cardiac surgery in infants and children,with minimal developmental problems.