Background: Intraextracardiac Fontan procedure aimed to combine the advantages of lateral tunnel and extracardiac conduit modifications of the original technique. Herein, we present our experience in our patients with intraextracardiac fenestrated Fontan Procedure. Methods: A retrospective analysis was performed in order to evaluate intraextracardiac fenestrated Fontan patients between 2014 and 2021. Seventeen patients were operated on with a mean age and body weight of 9.1 ± 5.5 years and 28.6 ± 14.6 kg. Results: Sixteen patients (94%) were palliated as univentricular physiology with hypoplasia of one of the ventricles. One patient (6%) with well-developed two ventricles with double outlet right ventricle and complete atrioventricular septal defect had straddling of the chordae prohibiting a biventricular repair. All of the patients had cavopulmonary anastomosis prior to Fontan completion, except one case. Fenestration was performed in all cases. Postoperative mean pulmonary artery pressures and arterial oxygen saturation levels at follow up were 10 ± 2.4 mmHg and 91.3 ± 2.7 %, respectively. Mean duration of pleural drainage was 5.4 ± 2.3 days. All of the fenestrations are patent at a mean follow up period of 4.8 ± 7.7 years, except one case. Any morbidity and mortality were not encountered. Conclusions: The mid-term results of intraextracardiac fenestrated Fontan procedure are encouraging. This procedure may improve the results in a patient population who should be palliated as univentricular physiology, especially in cases with complex cardiac anatomy.
Background: Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 hours post-ECMO on neurological outcome in VA-ECMO patients. Methods: This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 hours post-ECMO. Primary outcome was good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. Results: Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 hours of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 hours while 18 of those 88 patients (14.2%) had a mean temperature<36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (Odds Ratio [OR]=1.16, 95% Confidence Interval [CI]=1.04-1.31, p=0.01) after adjusting for age, severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-hour PaO 2. Neither duration of mild hypothermia (OR=0.93, CI=0.84-1.03, p=0.17) nor mean temperature (OR=0.78, CI=0.29-2.08, p=0.62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p=0.47) and mean 24-hour temperature (p=0.76) were not significantly associated with frequency of systemic hemorrhages. Conclusions: In this single center study, longer duration of mild hypothermia during the first 24 hours of ECMO support was significantly associated with improved neurological outcome. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.
Comprehensive clinical and imaging-based surveillance represents a fundamental aspect in the management of thoracic aortic aneurysms (TAAs), affording the opportunity to identify intermediate-sized TAAs before the onset of worrying symptoms or devastating acute aortic dissection/rupture. Currently, size-based indices are favoured as the major determinants driving patient selection for surgery, as supported by aortic guidelines, although it is recognised that smaller sub-threshold TAAs may still confer substantial risks. Prophylactic aortic surgery can be offered within set timeframes at dedicated aortic centres with excellent outcomes, to mitigate the threat of acute aortic complications associated with repeatedly deferred intervention. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery which highlights important socio-economic disparities in TAA surveillance and follow-up.
Cardiac angiofibroma is a very rare diagnosis when a patient develops an intracardiac mass. It is a primary benign cardiac tumor with a scarcity of information in the literature. This case report illustrates a 26-year-old man with a complaint of chronic chest tightness who was firstly diagnosed with right ventricle tumor by echocardiography then underwent cardiac MRI which confirmed the presence of a highly-vascular tumor with radiologically benign behavior. Then his tumor was excised, his postoperative course was uncomplicated and he was well within almost 2 months after discharge. Ultimately the histopathologic findings demonstrated vascular and stromal tissue in favor of angiofibroma and excluded the other diagnoses with IHC and trichrome staining. Angiofibroma is a benign, highly vascular tumor, mostly discovered in the nasopharynx. When it is found in the heart, CMR and pathology are pivotal to rule in its diagnosis. It is isointense in T1 weighted and hyperintense in T2 weighted sequences with intense enhancement following contrast injection. Its pathology contains an admixture of vasculatures with CD31 positive immunoreactivity for endothelial cells and fibrotic tissue with bluish coloration in trichrome staining. Eventually, its treatment includes merely surgical excision given its benign nature.
Response to Letter to Editor Regarding: Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease. J Card Surg. 2021; 36:2636-43.Authors: Ramsey S. Elsayed, MD MS1, Brittany Abt, MD1, and Michael E. Bowdish, MD MS1,2Institutions and Affiliations: 1Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA2Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USAAddress for Correspondence: Dr. Michael E. Bowdish, Associate Professor of Surgery and Preventive Medicine; Department of Surgery, Keck School of Medicine of USC; University of Southern California; 1520 San Pablo Street, HCC II Suite 4300; Los Angeles, CA 90033; Phone: (323)-442-5849; Email: [email protected] of Interest/Competing Interests: NoneFunding: Research reported in this publication was supported by the Department of Surgery of the Keck School of Medicine of USC. MEB is partially supported by UM1-HL11794 from the National Heart Lung and Blood Institute of the National Institutes of Health.To the editor,We would like to thank Song et. al. for their letter regarding our recent publication in the Journal of Cardiac Surgery titled “Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease”1. They asked some important questions and brought up valuable points that are worthy of discussion.Regarding the selection criteria we use for operative approach for mitral valve repair operations, it is primarily based on collective surgeon-patient decision making. However, patients with a previous history of cardiac surgery or peripheral vascular disease (which would render peripheral cannulation difficult), and those in need of concomitant cardiac procedures such as coronary artery bypass grafting, aortic replacement, or biatrial ablation, are not offered a minimally invasive approach. Regarding the role of artificial chordae (neochordae) in mitral valvuloplasty, we use elongated polytetrafluorethylene made of interrupted GoreTex (Gore-Tex, WL Gore and Associates, Inc., Flagstaff, AZ) sutures placed in a horizontal mattress fashion. These neochordae are routinely used to repair elongated or ruptured chordae causing mitral valve prolapse or regurgitation.2 Typically, the neochordae are used in the anterior leaflet of the mitral valve. The etiologies of degenerative mitral valve disease are comprised of myxomatous degeneration of the MV, fibroelastic deficiency including so called Barlow’s valves, and dystrophic calcification of the mitral annulus.3 While the etiologies are not mutually exclusive and may overlap, myxomatous degeneration and fibroelastic deficiencies resulting in severe, symptomatic MR were the most common indications for operation in our patient population. As mentioned by Song and colleagues, the success and durability of MVr can vary depending on etiology, particularly on how much of the valve apparatus is affected by pathology. While not examined in this paper specifically, previous papers (including Tatum et al. conducted at our institution), have demonstrated that anterior leaflet repair is significantly associated with recurrence and progression of MR after surgery, whereas isolated posterior repair is protective.3,4The operative team was similar in all cases, whereas the senior author (VAS) performed over 85% of the total procedures and nearly 100% of the minimally invasive procedures. The success rate of the minimally invasive cohort was 100% (as defined by the Society of Thoracic Surgeons). There was one conversion to conventional sternotomy in the minimally invasive cohort (.003%) for bleeding control.Finally, Song and colleagues are to be congratulated on their robotic and thoracoscopic mitral valvuloplasty results. Their 10-year total robotic mitral valve valvuloplasty results showing excellent cardiac function with 93% of patients in NYHA classes I and II.5 Furthermore, their early thoracoscopic results were very good with one operative mortality and only two reoperations demonstrating thoracoscopic mitral valvuloplasty is a technically feasible, safe, effective, and reproducible technique.6References:Bowdish ME, Elsayed RS, Tatum JM, Cohen RG, Mack WJ, Abt B, Yin V, Barr ML, Starnes VA. Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease. J Card Surg. 2021 Aug;36(8):2636-2643. PMID: 33908645.Bortolotti U, Milano AD, Frater RW. Mitral valve repair with artificial chordae: a review of its history, technical details, long-term results, and pathology. Ann Thorac Surg. 2012 Feb;93(2):684-91. PMID: 22153050.David, Tirone E. ”Durability of mitral valve repair for mitral regurgitation due to degenerative mitral valve disease.” Annals of cardiothoracic surgery 4.5 (2015): 417.Tatum, James M., et al. ”Outcomes after mitral valve repair: a single-center 16-year experience.” The Journal of thoracic and cardiovascular surgery 154.3 (2017): 822-830.Zhao H, Gao C, Yang M, Wang Y, Kang W, Wang R, Zhang H. Surgical effect and long-term clinical outcomes of robotic mitral valve replacement: 10-year follow-up study. J Cardiovasc Surg (Torino). 2021 Apr;62(2):162-168. PMID: 33302613.Cui H, Zhang L, Wei S, Li L, Ren T, Wang Y, Jiang S. Early clinical outcomes of thoracoscopic mitral valvuloplasty: a clinical experience of 100 consecutive cases. Cardiovasc Diagn Ther. 2020 Aug;10(4):841-848. PMCID: PMC7487400.
Multiple ventricular septal defects (m-VSD), are a challenging clinical problem. m-VSD can be onerous to manage. Besides the inability to close all the defects in one operative setting due to inadequate visualization, previously undetected defects may become clinically apparent after the closure of the dominant defects, leading to inadequate ventricular septation. This increases the morbidity from the progression of pulmonary hypertension, persistence of congestive cardiac failure, higher incidence of postoperative heart block, and the need for reoperations.
Mitral valve repair (MVR) is undisputedly associated with better clinical and functional outcomes than any other type of valve substitute. Conventional mitral valve surgery in dedicated high-volume centers can assure excellent results in terms of mortality and freedom from mitral regurgitation (MR) recurrence but requires cardiopulmonary bypass (CPB) and cardioplegic heart arrest. Trying to replicate the percentage of success of surgical MVR is the aim of all new transcatheter mitral dedicated devices. In particular transapical beating-heart mitral valve repair by artificial chordae implantation with transesophageal echocardiography (TEE) guidance is an expanding field. The safety and feasibility of the procedure have already been largely demonstrated with Neochord and more recently with Harpoon systems. Wang et al. present the outcomes of the first-in-human experience using a novel artificial chordae implantation device, the Mitralstitch system. Despite a quite small cohort of only 10 patients treated, 1-year results are satisfying and comparable to the early experience with former devices (4 patients with moderate or more MR recurrence). The comparison with surgical MVR is still unfavorable and requires further studies and significant procedure improvement. However, the device permits the treatment of anterior and posterior leaflets prolapse and performs quite easily edge-to-edge reparation. It will be interesting to evaluate longer follow-up in larger cohorts of patients as well as the possibility to shift to the transfemoral approach.
Background The aim of this study was to analyse the perioperative results and long term survival of re-sternotomy for surgical aortic valve replacement (SAVR) in octogenarians. Methods This is a retrospective, single centre study (Apr 2000 – Dec 2019). Perioperative data were compared for re-sternotomy with isolated SAVR (Isolated redoSAVR) and re-sternotomy with SAVR and concomitant cardiac procedure (Associated redoSAVR). Regression analyses were performed to identify predictors of in patient mortality. Hazard ratios were calculated, and Kaplan Meier survival curves were compared for groups. Results There were 163 patients (Isolated redoSAVR; 69, Associated redoSAVR; 94). Mean age was 83±3 years and mean logEuroSCORE was 21±12. Follow up was 4.2±3.5 years. Inpatient mortality was 4.9% (1.4% versus 7.4% for Isolated redoSAVR and Associated redoSAVR respectively, p=0.08). TIA/stroke rate was 8% (9% versus 7% for Isolated redoSAVR and Associated redoSAVR respectively, p=0.78). COPD was a predictor of inpatient mortality (OR; 8.86, 95%CI; 1.19, 66.11, p=0.03). Survival was 88.7% at 1 year, 86.4% at 2 years, 70.1% at 5 years, 49.5% at 7 years and 26.3% at 10 years. There was no survival difference between Isolated redoSAVR and Associated redoSAVR (logrank p=0.36, Wilcoxon p=0.84). Significant predictors of adverse long term survival were COPD, postoperative TIA/stroke and length of stay. Survival is lower than age and gender matched first time SAVR and general population of UK. Conclusions RedoSAVR in octogenarians is associated with acceptable but significant morbidity and mortality. Shared decision making should consider emerging transcatheter therapies as viable options in selected patients.
Nitric oxide has been used to treat respiratory failure in post-pediatric cardiac surgical patients. High frequency oscillator ventilation is used to rescue infants who have failed conventional ventilation. In this issue a study is presented showing the benefit of combining these two therapies for improved outcomes in infants with hypoxic respiratory failure after congenital heart surgery
The surgical ventricular restoration is an evolution of treatment of left ventricle aneurysm. The aetioloy of left ventricle aneurysm and the dilated post AMI cardiomiopaty is the same; the difference is in the extension of scarred tissue and in the quality of remote zone. Because in this anatomical situation the geometry of left left ventricle can be deeply affected, it can very difficult to have point of reference as position of apex or papillary mussles. Using a sizer and combine different surgical thecniques allow to rebuilt a ventricle with appropriate volume and shape.
Robotic totally endoscopic techniques to perform the LITA to LAD graft, coupled with PCI, provides the least invasive option to achieve hybrid coronary revascularization (HCR). Shorter hospital stay and reduced need for blood transfusions have been consistently being reported by several studies along with similar long-term outcomes. Considerable variations exist in the definition of HCR which can be single or two-staged with surgical revascularization being carried out after PCI or vice versa. Variations also exist with respect to usage of cardiopulmonary bypass, surgical incisions, and use of minimally invasive robotic techniques. The different strategies of HCR do not lead to similar outcomes and the findings of one strategy cannot be extrapolated to the entire group. Studies reporting different strategies of HCR, should ideally provide more granular data when reporting outcomes.
Patients with a bicuspid aortic valve (BAV) are at increased risk of valvular regurgitation compared to their counterparts with a tri-leaflet aortic valve. There is now increasing emphasis to offer BAV repair to mitigate the risks of prosthesis-related complications, including thromboembolism, haemorrhage and endocarditis, as well as structural valve deterioration and future re-operation with conventional valve replacement, particularly in younger populations. Furthermore, over the preceding two decades, our greater understanding of the functional anatomy of the BAV, pathophysiological mechanisms of BAV insufficiency and the development of a functional classification of aortic regurgitation have significantly contributed to the evolution of aortic valve reconstructive surgery. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery comparing external annuloplasty and subcommissural annuloplasty as techniques for BAV repair.
Background The European CE Mark approval study and the MOMENTUM 3 trial demonstrated safety and a reduction in hemocompatibility-related adverse events with use of HeartMate 3 (HM3) device. This single center study investigated the real-world experience in HM3 patients since FDA approval. Methods This retrospective, observational study included patients implanted with the HM3 LVAD as a primary implant between October 2017-March 2020. Patients were divided into trial group and postapproval group. Primary endpoint was survival at 6 months. Secondary endpoints were adverse events including pump thrombosis (requiring pump exchange), stroke, renal failure, acute limb ischemia, re-exploratory for bleeding, gastrointestinal bleeding, right ventricular failure, and driveline infection. Results A total of 189 patients were implanted with HM3 device during the study period. 174 patients met the inclusion criteria: 82 patients in the trial group and 92 patients in the postapproval group. The postapproval group had younger patients, higher pre-operative mean international normalized ratio, and greater numbers of patients with bridge to transplant (BTT) indications, IINTERMACS profile 1, and use of mechanical assist devices (other than IABP) than the trial group. Other characteristics between the two groups were comparable. Overall survival at 6 months in the postapproval group was 93.3% vs. 93.8% ( p=0.88). The postapproval group demonstrated a statistically significant lower incidence of re-explorative surgery for bleeding (10.9% vs 46.3, p=0.01) than the trial group. Conclusion In this single-center study, the real-world 6-month survival in the postapproval group was comparable to the trial results. Further studies are needed to monitor long-term outcomes.
Background: Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterised by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimised cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that Thoracic Endovascular Aortic Repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. Aims: This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention. Methods: We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus in order to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. Results: TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodelling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. Conclusions: Further research is required into both short and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines.
Objectives: Subclavian (SC) and transapical (TA) approach are the main alternatives to the default femoral delivery for transcatheter aortic valve implantation (TAVI). Aim of this study was to compare, complications and morbidity/mortality associated with SC and TA in a long-term time frame. Methods: From January 2007 to July 2015, 1,506 patients underwent TAVI surgery in 36 United Kingdom TAVI centres. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival. Results: The enrolled patients were distributed as follows: 1,216 in the trans-apical (TA) group and 290 in the subclavian (SC) group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, paravalvular leak, balloon post dilatation, cardiac tamponade, stroke, renal replacement therapy, vascular injuries, and 30-days mortality among the groups. Conversely, the rate of permanent pacemaker implantation (p = 0.02), the procedural time duration (p = 0.04), and the 12-month mortality (p = 0.03) was higher in SC than in TA, while in-hospital length of stay was reduced in SC than in TA (p = 0.01). Up to 8-years, the long-term mortality was not different among groups (p = 0.77), and no difference in long-term survival between self vs balloon expandable device was found (p = 0.26). Conclusions: According to our results, TA provided the best 12-months survival compared to SC, while the long-term survival up to 2, 900 days is not significantly different between groups, so SC and TA may both represent a safe non-femoral access if femoral is precluded.
Background The ideal aortic valve replacement strategy in young- and middle-aged adults remains up for debate. Clinical practice guidelines recommend mechanical prostheses for most patients less than 50 years of age undergoing aortic valve replacement. However, risks of major hemorrhage and thromboembolism associated with long-term anticoagulation may make the pulmonary autograft technique, or Ross procedure, a preferred approach in select patients. Methods Data were retrospectively collected for patients 18 to 50 years of age who underwent either the Ross procedure or mechanical aortic valve replacement (mAVR) between January 2000 and December 2016 at a single institution. Propensity score matching was performed and yielded 32 well-matched pairs from a total of 216 eligible patients. Results Demographic and preoperative characteristics were similar between the two groups. Median follow-up was 7.3 and 6.9 years for Ross and mAVR, respectively. There were no early mortalities in either group and no statistically significant differences were observed with respect to perioperative outcomes or complications. Major hemorrhage and stroke events were significantly more frequent in the mAVR population ( p < 0.01). Overall survival ( p = 0.93), freedom from reintervention and valve dysfunction free survival ( p = 0.91) were equivalent. Conclusions In this mid-term propensity score-matched analysis, the Ross procedure offers similar perioperative outcomes, freedom from reintervention or valve dysfunction as well as overall survival compared to traditional mAVR but without the morbidity associated with long-term anticoagulation. At specialized centers with sufficient expertise, the Ross procedure should be strongly considered in select patients requiring aortic valve replacement.
The authors present an revolutionary study aiming to evaluate the effect of alterations in potassium concentrations in transfused packed red blood cells (PRBC) on neonate and infant potassium levels after congenital cardiac surgery. By establishing a strict protocol which restricts the rate of transfusion, the age of the transfused PRBC, and not transfusing a PRBC with a potassium level above 15 mmol/L, they accomplished to suggest a safe and easy way for preventing transfusion associated hyperkalemia.