We reported a case of a 3-month-old infant presented with supravalvular aortic stenosis with congenital right coronary artery deficiency. According to cardiovascular CT results, Doty technique was adopted to restore the aortic root geometry under cardiopulmonary bypass. An angioplasty was performed to establish right coronary blood flow at the same time. The patient had no abnormal cardiac symptoms after surgery.
We present a reply to the invited commentary by Jubouri and Abdelhaliem published in response to our original article titled: Prevention vs Cure: is BioGlue priming the optimal strategy against E-Vita Neo graft oozing? The authors highlight key issues associated with the E-Vita Open NEO aortic arch prosthesis, chiefly, the propensity for the prosthesis to exhibit post-anastomotic oozing. We read with great interest their commentary and concur that the issues highlighted therein are significant and warrant discussion.
Open surgery for chronic type B aortic dissection has been shown to have considerable risks of cerebrovascular complications. Because retrograde perfusion is a potential cause of intraoperative cerebrovascular events, we report our transapical cannulation strategy for descending aorta replacement in chronic type B aortic dissection repair with circulatory arrest. This technique provides an easy and quick establishment of cardiopulmonary bypass by way of a left thoracotomy, and prevention of cerebrovascular event. Transapical cannula can be also used as a vent to ensure a bloodless field during proximal anastomosis and to prevent extension of left ventricle during rewarming. Transapical cannulation is a useful option in open repair of the descending aorta for chronic type B aortic dissection by way of left thoracotomy.
Background and Aim of the Study: Congenital heart disease is the most common congenital defect among infants born in the United States. Within the first year of life, 1 in 4 of these infants will need surgery. Only one generation removed from an overall mortality of 14%, many changes have been introduced into the field. Have these changes measurably improved outcomes? Methods: The literature search was conducted through PubMed MEDLINE and Google Scholar from inception to October 31, 2021. Ultimately, 78 publications were chosen for inclusion. Results: The outcome of overall mortality has experienced continuous improvements in the modern era of the specialty despite the performance of more technically demanding surgeries on patients with complex comorbidities. This modality does not account for case-mix, however. In turn, clinical outcomes have not been consistent from center to center. Furthermore, variation in practice between institutions has also been documented. A recurring theme in the literature is a movement towards standardization and universalization. Examples include mortality risk-stratification that has allowed direct comparison of outcomes between programs and improved definitions of morbidities which provide an enhanced framework for diagnosis and management. Conclusions: Overall mortality is now below 3%, which suggests that more patients are surviving their interventions than in any previous era in congenital cardiac surgery. Focus has transitioned from survival to improving the quality of life in the survivors by decreasing the incidence of morbidity and associated long-term effects. With the transformation towards standardization and interinstitutional collaboration, future advancements are expected.
Background: This study was conducted to evaluate the surgical results of the arterial switch operation for Taussig-Bing variants, at a single institution in a lower-middle income country. Methods: Between June 2010 and December 2018, all consecutive patients diagnosed with Taussig-Bing variants who underwent the arterial switch operation and ventricular septal defect closure were included in the study. Results: A total of 72 patients of Taussig-Bing variants who underwent arterial switch operation and ventricular septal defect closure. There were 10 early deaths (13.9%) and 2 late deaths (2.8%). Intraoperative ventricular septal defect enlargement [hazard ratio (HR) 7.23, 95% confidence interval (CI) 3.1294-16.7167; P < 0.001], secondary aortic cross clamping (HR 28.38, 95% CI 4.8427-166.3484; P < 0.001), post-operative pneumonia (HR 5.64, 95% CI 1.2724-24.9917; P = 0.023), and post-operative sepsis (HR 5.28, 95% CI 1.3512-20.6553; p = 0.017) were risk factors for overall mortality by competing risk analysis. Sixty patients (83.3%) required septoparietal trabeculation division/resection during the arterial switch operation in an attempt to avoid right ventricular outflow tract obstruction. The reoperation rate for right ventricular outflow tract obstruction at last follow up was 6% (3 patients). The estimated freedom from reoperation for right ventricular outflow tract obstruction at 1 year, 5 year and 9 year was 98.3%, 91.9% and 91.9 , respectively. Conclusions: The results of arterial switch operation for Taussig-Bing variants were satisfactory in the operative setting of a lower-middle income country, and performing extensive septoparietal trabeculation division might reduce the reintervention rate for right ventricular outflow tract obstruction in these patients.
Impact of prior sternotomy on survival and allograft function after heart transplantation: a single-center matched analysisPrior sternotomy versus primary heart transplantEditorialE. Potapov, J. SteinIn the presented study, the authors showed that prior sternotomy in heart transplant candidates does not impact survival after heart transplantation (reference). The analysis was performed between 106 propensity score-matched pairs (212 patients).The results of published studies are contradictory and confusing. The small, single-center study published by Sert D, 2020, showed an increased early mortality in HTx recipients with prior sternotomy1, with no increased bleeding risk and a similar 4-year survival. In contrast, yet another single-center study with a similar design –no sternotomy vs. VAD-supported vs. prior sternotomy other than for VAD– published by Gaffey in 2015 showed no differences regarding early and long-term mortality, but a significantly higher risk of postoperative bleeding and a greater use of blood products2. A further single-center study with a comparable number of patients published in 2018 by Still S yet again showed that HTx recipients with prior sternotomy required more blood transfusions and showed an increased incidence in postoperative pneumonia, wound infection, and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of primary graft dysfunction with a subsequently higher short-term and 1-year mortality3. However, in these studies the impact of confounding variables was not eliminated.Having said that, the presented study attempts to overcome imbalances in confounding variables by comparing survival and complications between propensity score-matched patient groups. The matching procedure was based on established risk factors including recipients’ baseline characteristics, donor age, sex mismatch, risk scores, ECLS, PVR, serum creatinine, and serum bilirubin, and ultimately produced 106 matched pairs. However, the benefit of balanced confounders is achieved at the cost of a reduced number of patients and therefore less power to detect differences between patient groups. The lack of significant differences in this study cannot merely be explained by a low power, but is instead due to the similarity of effects: Authors report a 30-day mortality of 5.7 % for prior sternotomy vs. 7.5 % for first-time sternotomy and no impact of prior sternotomy on long-term survival with an HR of 0.87 [95% CI: 0.57, 1.56]. Contradicting the above-mentioned studies, these results do not even come close to indicating a trend towards worse long- and short-term survival for patients with prior sternotomy. This also holds true for long-term survival in the unmatched population of 131 patients with and 381 patients without redo surgery.Now how about a larger registry-based analysis? An analysis based on the UNOS database comprising 11,266 patients showed that prior sternotomy was associated with an excess 3.3 % mortality and higher morbidity within the first 60 days after heart transplantation, as measured by the frequency of dialysis, drug-treated infections, and strokes. Conditional 5-year survival after 60 days is unaffected by prior sternotomy4. Five years later, another group performed an analysis of the same UNOS database (meanwhile comprising 14,730 patients) and showed again that prior sternotomy is a risk factor for worse survival after cardiac transplantation, mainly due to an increased early postoperative mortality5.Why are we interested in knowing the effect of prior sternotomy on post-transplant outcomes? Since a prospective, randomized study is not possible due to ethical reasons, we have to rely on retrospective analyses. From a practical perspective, a comparison is meaningless – patients with prior sternotomy would never be refused for HTx due to this fact alone, even if we knew that morbidity and mortality in these patients may be higher.In our opinion, such an analysis may be performed to identify and support the advantages of less invasive LVAD implantation regarding the outcome of later HTx, as was performed in a first analysis of 46 patients (sic!, the lowest number of patients among the discussed studies) published by Riebandt J, 20216. The study showed that patients supported with LVAD implanted via full sternotomy required more packed red blood cells with no increased risk of bleeding, and subsequently developed more donor-specific antibodies, however, without any impact on short- and long-term survival, similar to the studies discussed above2,3.However, the virgin chest is not comparable to that of patients supported with an LVAD implanted via a less invasive approach, even if no7 or partial sternotomy8 is performed. In either of the groups the pericardium remains intact. Regardless of the technique used, the left pleura is opened, as is the pericardium around the ascending aorta and the apex of the right and left ventricles, and the graft is placed into the pericardial space, causing adhesions making any efforts to suggest, that the HTx in the “virgin chest”is similar to that after less invasive LVAD implantation not appropriate.Finally, the authors should nonetheless be congratulated on their outstanding surgical experience and the resulting very good outcomes in HTx – better than in the majority of centers worldwide.References1. Sert DE, Kervan Ü, Kocabeyoğlu SS, et al. Early and long-term results of heart transplantation with reoperative sternotomy. Turk gogus kalp damar cerrahisi dergisi 2020;28:120-6.2. Gaffey AC, Phillips EC, Howard J, et al. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. The Annals of thoracic surgery 2015;100:542-9.3. Still S, Shaikh AF, Qin H, et al. Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation. Interactive cardiovascular and thoracic surgery 2018;27:343-9.4. Kansara P, Czer L, Awad M, et al. Heart transplantation with and without prior sternotomy: analysis of the United Network for Organ Sharing database. Transplantation proceedings 2014;46:249-55.5. Axtell AL, Fiedler AG, Lewis G, et al. Reoperative sternotomy is associated with increased early mortality after cardiac transplantation. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2019;55:1136-43.6. Riebandt J, Wiedemann D, Sandner S, et al. Impact of Less Invasive Left Ventricular Assist Device Implantation on Heart Transplant Outcomes. Seminars in thoracic and cardiovascular surgery 2021.7. Potapov EV, Kukucka M, Falk V, Krabatsch T. Off-pump implantation of the HeartMate 3 left ventricular assist device through a bilateral thoracotomy approach. The Journal of thoracic and cardiovascular surgery 2017;153:104-5.8. Nersesian G, Potapov E, Starck CT, et al. Surgical Implantation Techniques of Modern Continuous Flow Ventricular Assist Devices. Surgical technology international 2021;37:263-9.
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: Michael.Bowdish@med.usc.eduConflicts 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.