As growth of the elderly population continues to increase alongside improvements in percutaneous and minimally invasive interventions, cardiac surgeons question the role of high-risk surgery in treating these patients. TAVR has transformed the management of symptomatic severe aortic stenosis in elderly patients, and has become standard therapy for patients greater than 80 years of age. With improvements in procedural risks and technical complications for both transcatheter valves and percutaneous interventions, should we rethink the operative strategies for octogenarians and nonagenarians, particularly as they apply to concurrent high-risk operations?
Tricuspid annuloplasty for moderate to severe TR (Class I, IIb) is the current standard of practice to restore the normal tricuspid annular dimension and function (1,2). The current controversy in atrioventricular surgery concerns the indication for concomitant TA in patients with moderate TR and significant annular dilatation of at least > 40 mm or at least 21 mm/m2 indexed for body surface area (Class IIb) during mitral valve surgery proposed by the American Heart Association/American College of Cardiology and European Society of Cardiology (1,2,3)
There is an increasing use of left ventricular assist devices (LVADs) as bridge to transplantation or permanent destination therapy in the heart failure patient population. Infection remains a common complication in LVADs, with Gram-positive skin flora as predominant pathogens implicated, including Staphylococcus aureus. While there is emerging evidence for synergistic antibiotic combinations with methicillin resistant Staphylococcus aureus, there remains a significant gap in the literature for persistent methicillin susceptible Staphylococcus aureus (MSSA) bacteremia. In this article, we describe the first successful treatment of persistent LVAD-related bacteremia with salvage oxacillin plus ertapenem. The salvage therapy described here must be balanced by the risks for toxicity, impact on resistance, microbiota disruption, drug shortages, and patient costs. This combination warrants further evaluation in the clinical setting to better establish its role in our expanding patient population.
Unicuspid aortic valves are rare congenital malformations. Surgical repair is feasible in aortic regurgitation, and in some cases of aortic stenosis. The standard surgical approach is a bicuspidization and symmetrization with pericardial patch augmentation of valve cusps. Herein, we are describing our original technique for bicuspidization of a unicuspid aortic valve without cusp patch augmentation. We also address the surgical management of a commissural diastasis.
The use of sutureless and rapid-deployment prostheses is generally avoided in patients with BAV due to anatomical concerns and the elevated risk of para-prosthetic leaks. Multiple studies have reported the use of these prostheses in patients with BAV with varying degrees of success. The focus of this review is to consolidate the available evidence on this topic. A scoping review was conducted using a comprehensive search strategy within Medline, Embase, and Cochrane Central Register of Controlled Clinical Trials for relevant articles. All abstracts and full texts were screened by two independent reviewers according to predefined inclusion and exclusion criteria. Of 1052 total citations, 44 underwent full text review and 13 (4 case reports, 6 retrospective analyses, and 3 prospective analyses) were included in the scoping review. Across all 13 studies, a total of 314 patients with BAV were used for data analysis. In sutureless and rapid-deployment prostheses, the mean postoperative aortic valvular gradients were less than 15mmHg in all studies with mean postoperative aortic valvular areas all greater than 1.3cm. There were 186 total complications for an overall rate of 59%. Individual complications included new onset atrial fibrillation (n=65), required pacemaker insertion (n=24), intraprosthetic aortic regurgitation (n=20), new onset atrioventricular block (n=18), and new onset paravalvular leakage (n=10). The use of sutureless and rapid deployment prostheses in patients with BAV showed comparable intraoperative and implantation success rates to patients without BAV. Various techniques have been described to minimize complications in patients with BAV receiving sutureless or rapid-deployment prostheses.
Here, we report a case of a dissected thoracoabdominal aortic aneurysm repair after frozen elephant trunk implantation, using aortic balloon occlusion technique to simplify the proximal anastomosis and avoid deep hypothermic circulatory arrest. In addition, detailed CT follow-up pictures showed that false lumen thrombosis is a time-dependent and reversible variable. Repeated measurements with time series analysis should be performed to explore false lumen remodeling.
In total arch replacement, using frozen elephant trunk (FET) or elephant trunk techniques ensures proximalization of the distal anastomosis. However, in some cases, the left subclavian artery (LSCA) is deeply located and difficult to visualize. Therefore, surgeons face technical challenges during the LSCA reconstruction. We report an end-to-side anastomosis technique that enables safer and easier anatomical reconstruction of the LSCA.
Introduction Extracorporeal membrane oxygenation (ECMO) is implemented as a rescue therapy in COVID-19 related acute distress respiratory syndrome (ARDS) and refractory hypoxemia. Google trends (GT) is an ongoing-developing web-kit providing feedback on specific population’s interests. This study uses GT to analyze the United States (US) general population interest in ECMO as COVD-19/ARDS salvage therapy. Methods GT was used to access data searched for the term ECMO and COVID-19. The gathered information included data from March 2020 through July 2021 within US territories. Search frequency, time intervals, sub-regions, frequent topics of interest, and related searches were analyzed. Data was reported as search frequency on means, and a value of 100 represented overall peak popularity. Results The number of Google searches related to the terms ECMO and COVID-19 has surged and sustained interest over time ever since the initial reports of COVID-19 in the US, from an initial mean of 34% in March 2020 to a 100% interest by April 2020, resulting in an up-to-date overall average of 40% interest. Over time West Virginia, Gainesville, and Houston, lead the frequency of searches in sub-region, metro and city areas, respectively. Top search terms by frequency include: ECMO machine, COVID ECMO, what is ECMO, ECMO treatment and VV ECMO. Parallel to this, the related rising terms are: COVID ECMO, ECMO machine COVID, ECMO for COVID, ECMO machine coronavirus, and ECMO vs ventilator. Seemingly, medical-relevant websites fail to adequately address these for patient therapeutic education (PTE) purposes. Conclusions GT complements the understanding of interest in ECMO for COVID-19. When properly interpreted, the use of these trends can potentially improve on PTE and therapy awareness via specific medical relevant websites.
Background and aim of the study Objective of this analysis was to use coronary computed tomography in patients with normal tricuspid aortic valves to perform detailed aortic root and aortic valve geometric analysis with focus on asymmetry of the three leaflets. Materials and methods We analyzed aortic valves in 70 anonymized coronary computed tomography angiograms. Mean patient age was 53 ± 11 years. All aortic valves were tricuspid, without calcifications and aortic roots were of normal dimensions. Asymmetry of the three leaflets in individual patients was assessed by calculating absolute and relative differences between the largest and the smallest of the three leaflets. Results Some degree of asymmetry was present in all analyzed valves. Absolute and relative differences for free margin length were 3.2 ± 1.4 mm and 9.3 ± 3.8%, respectively. The largest relative difference was noted in coaptation area (36.5 ± 16.5%) and the smallest in leaflet effective height (6.1 ± 4.8%). Using predefined cut-off criteria for absolute differences in leaflet dimensions, 86% of the valves were classified as asymmetric. Conclusions Equal free margin length of the three leaflets is not needed for normal tricuspid aortic valve function. Aligning the leaflet free margin length in standardized aortic valve repair may not be necessary in tricuspid aortic valve repair, whereas equalization of effective leaflet heights is.
Background. A staged thoracotomy unifocalization approach has not been the dominant option over the past 20 years primarily due to the introduction of midline one-stage complete unifocalization. Methods. In this issue of the Journal of Cardiac Surgery, van de Woestijne and colleagues publish their experience over the past 30 years in 39 consecutive patients with “consistent” staged unifocalization through a lateral thoracotomy in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (PA/VSD/MAPCA). Results. They report definitive repair completion in 76.3% of the patients and an overall survival after definitive repair of 96% at 20 years despite the study period ranging from 1989 to the present. Conclusion. Given the multiple variations one could have with PA/VSD/MPACA, a midline unifocalization approach may not always be possible. Surgeons should be familiar with the lateral thoracotomy unifocalization staged approach to PA/VSD/MAPCA.