Background: Bicuspid aortic valve is the most common congenital heart defect and predisposes patients to developing aortic stenosis more frequently and at a younger age than the general population. However, the influence of bicuspid aortic valve on the rate of progression of aortic stenosis remains unclear. Methods: In 236 patients (177 tricuspid aortic valve, 59 bicuspid aortic valve) matched by initial severity of mild or moderate aortic stenosis, we retrospectively analyzed baseline echocardiogram at diagnosis with latest available follow-up echocardiogram. Baseline comorbidities, annualized progression rate of hemodynamic parameters, and hazard of aortic valve replacement were compared between valve phenotypes. Results: Median echocardiographic follow-up was 2.6 (IQR 1.6-4.2) years. Patients with tricuspid aortic stenosis were significantly older with more frequent comorbid hypertension and congestive heart failure. Median annualized progression rate of mean gradient was 2.3 (IQR 0.6-5.0) mmHg/year vs. 1.5 (IQR 0.5-4.1) mmHg/year (p=0.5), and that of peak velocity was 0.14 (IQR 0-0.31) m/s/year vs. 0.10 (IQR 0.04-0.26) m/s/year (p=0.7) for tricuspid vs. bicuspid aortic valve, respectively. On multivariate analyses, bicuspid aortic valve was not significantly associated with more rapid progression of aortic stenosis. In a stepwise Cox proportional hazards model adjusted for baseline mean gradient, bicuspid aortic valve was associated with increased hazard of aortic valve replacement (HR: 1.7, 95% CI [1.0, 3.0], p=0.049). Conclusion: Bicuspid aortic valve may not significantly predispose patients to more rapid progression of mild or moderate aortic stenosis. Guidelines for echocardiographic surveillance of aortic stenosis need not be influenced by valve phenotype.
Background: Takotsubo cardiomyopathy (TC) is defined as a temporary and reversible systolic abnormality of the left ventricle’s apical area resembling myocardial infarction (MI) in the nonexistence of coronary artery disease (CAD).Only a few cases have been reported after cardiac operations or after pericardiocentesis. Aims: To emphasize the need to be aware of the possibility of the occurrence of this potentially fatal complication after cardiac surgery. Materials and methods: A-66-year old man underwent pericardiectomy.Postoperative he endured TC and progressed exacerbation of hemodynamic instability.finally, he had to be supported by intra-aortic balloon pump（IABP),extracorporeal membrane oxygenation（ECMO). Results: Patient’s left ventricle function recovered fully in two weeks. Discussion: we discussed the pathogenesis and treatment of postoperative TC. Conclusion:TC has to be carefully considered in differential diagnosis in case of acute left ventricle dysfunction following cardiac surgery. Keywords: pericardiectomy; takotsubo cardiomyopathy.
Background & Aim Cardiogenic shock (CS) withholds a significantly high mortality rate between 40-60% despite advances in diagnosis and medical/surgical intervention. To-date, machine learning(ML) is being implemented to integrate numerous data to optimize early diagnostic predictions and suggest clinical courses. This systematic review summarizes the area under the curve (AUC) receiver operating characteristics (ROC) accuracy for the early prediction of CS. Methods A systematic review was conducted within databases of PubMed, ScienceDirect, Clinical Key/MEDLINE, Embase, GoogleScholar, and Cochrane. Cohort studies that assessed accuracy of early detection of CS using ML software were included. Data extraction was focused on AUC-ROC values directed towards early detection of CS. Results A total of 943 studies were included for systematic review. From the reviewed studies, 2.2% (N=21) evaluated patient outcomes, of which 14.3% (N=3) were assessed. The collective patient cohort (N=698) consisted of 314(45.0%) females, with an average age and body mass index (BMI) of 64.1years and 28.1kg/m2, respectively. Collectively, 159 (22.8%) mortalities were reported following early CS detection. Altogether, the AUC-ROC value was 0.82 (alfa=0.05), deeming it of superb sensitivity and specificity. Conclusions From the present comprehensively gathered data, this study accounts the use of ML software for the early detection of CS in a clinical setting as a valid tool to predict patients at risk of CS. The complexity of ML and its parallel lack of clinical evidence implies that further prospective randomized control trials are needed to draw definitive conclusions prior to standardizing use of these technologies.
The present perspective is a synthesis of 80 published investigations in the setting of a retroaortic left brachiocephalic vein, described in 250 patients. Clinical presentation, radiographic findings, ultrasonographic findings, saline contrast echocardiography, computed-tomographic angiocardiography, magnetic resonance imaging, and angiocardiography provided the diagnostic information used to define the disease entity prior to considering the surgical approach to the associated cardiac anomalies. We have also addressed several issues concerning the influence of isomerism, the establishment of diagnosis, and its importance in various surgical and interventional procedures. Although the retroaortic left brachiocephalic vein is asymptomatic, its recognition during clinical investigation should raise the possibility of an association with other malformations, especially right aortic arch, ventricular septal defect, and anomalies of the outflow tracts. We submit that an increased appreciation of this venous anomaly may facilitate surgical planning, endovascular procedures, placement of central venous lines, and transvenous pacemakers.
Background: Acute type A aortic dissection(ATAAD) is life-threatening and requires immediate surgery. Sudden chest pain may lead to a risk of misdiagnosis as acute coronary syndrome and may lead to subsequent antiplatelet therapy. We used the Chinese Acute Aortic Syndrome Collaboration Database (AAS) to study the effects of antiplatelet therapy (APT) on clinical outcomes. Methods: The AAS database is a retrospective multicentre database where 31 of 3092 had APT with aspirin or clopidogrel or both before surgery. Before and after propensity score matching, the incidence of complications and mortality was compared between APT and non-APT patients by using a logistic regression model. The sample remaining after PSM was 30 in the APT group and 80 in the non-APT group. Results: The sample remaining after matching was 30 in the APT group and 80 in the non-APT group. We found 10 cases with percutaneous coronary intervention in the APT group(33.3%). The APT group received more volume of packed red blood cell (RBC), 8.4±6.05 units; plasma, 401.67±727 ml, and platelet transfusion(14.07±8.92 units). The drainage volume was much more in the APT group( 5009.37±2131.44ml, P=0.004). Mortality was higher in APT group(26% vs 10%, P=0.027). The preoperative APT was independent predictor of mortality(OR 6.808, 95% CI1.554-29.828, P = 0.011). Conclusion: APT prior to ATAAD repair was associated with more transfusions and higher early mortality. The timing of surgery should be carefully considered based on the patient’s status and the surgeon’s experience.
Background: This study evaluated the utilization and outcomes of postcardiotomy mechanical circulatory support (MCS). Methods: This was a retrospective, single institution analysis of adult cardiac surgery cases that required de novo MCS following surgery from 2011-2018. Patients that were bridged with MCS to surgery were excluded. The primary outcomes were early operative mortality and longitudinal survival. Secondary outcomes included postoperative complications, and five-year all-cause readmission. Results: 533 patients required de novo postcardiotomy MCS, with the most commonly performed procedure being isolated coronary artery bypass grafting (29.8%). Median cardiopulmonary bypass and cross clamp times were 185 (IQR 123-260) minutes and 122 (IQR 81-179) minutes, respectively. A total of 442 (82.9%) of patients were supported with intra-aortic balloon pump counterpulsation, 23 (4.3%) with an Impella device, and 115 (21.6%) with extracorporeal membrane oxygenation. Three (0.6%) patients had an unplanned ventricular assist device placed. Operative mortality was 29.8%. Longitudinal survival was 56.1% and 43.0% at 1- and 5-years, respectively. Survival was lowest in those supported with ECMO and highest with those supported with an Impella (P<0.001). Freedom from readmission was 61.4% at 5-years. Postoperative ECMO was an independent predictor of mortality (HR 5.1, 95% CI 2.0-12.9, P<0.001), but none of the MCS types predicted long-term hospital readmission after risk adjustment. Conclusions: Postcardiotomy MCS is associated with high operative mortality. Even patients that survive to discharge have compromised longitudinal survival, with nearly only half surviving to 1-year. Close follow-up and early referral to advanced heart failure specialists may be prudent in improving these outcomes.
Key Points : • Interventional therapies directed at fenestration closure in the Fontan patient must rely on good hemodynamic data • The Large Optimus-CVSTM stent is an additional armamentarium for fenestration closure however, longer term follow up is needed • Multi institutional studies defining the long-term benefits of fenestration closure and outlining fenestration management guidelines may help improve the long-term morbidity and mortality in this group of patients.
The case report by Sicim et al. is the placement of extra-anatomical bypasses in bilateral common carotid arteries. The similar previous reports of the extra-anatomical bypass usually indicate unilateral bypass. Whether or not the Willis' circle is incomplete is difficult to judge during emergency surgery, and the authors' judgment seems to have been correct in the sense that it could maintain cerebral perfusion reliably and quickly. The direct perfusion and extraanatomical bypass of carotid artery is a reasonable strategy in patients with cerebral malperfusion.
The morphology variations of the so-called scimitar vein are many and varied. We present a synthesis of 92 published investigations of the overall scimitar syndrome. We reviewed the clinical presentations, diagnostic modalities, surgical approaches, and outcomes. Diagnostic information was provided by clinical presentations, radiographic findings, transthoracic and transesophageal echocardiography, computed-tomographic angiography, magnetic resonance imaging, angiocardiography, and ventilation/perfusion scans. These investigations served to elucidate the origin, course, and termination of the scimitar vein, the intracardiac anatomy, the presence of associated defects, and the patterns of any accompanying pulmonary lesions. In short, they defined the disease prior to surgical intervention. Of the patients described, up to four-fifths presented during infancy, with cardiac failure, increased pulmonary flow, and pulmonary hypertension. Associated cardiac and extracardiac defects, particularly hypoplasia of the right lung, are present in up to three-quarters of cases. Overall operative mortality has been cited between 4.8% and 5.9%. Mortality was highest in patients with preoperative pulmonary hypertension, and those undergoing surgery in infancy. Despite timely surgical intervention, post-repair obstruction of the scimitar vein, intra-atrial baffle obstruction, or stenosis of the inferior caval vein were reported in up to two-thirds of cases. The venous obstruction could not be related to any particular surgical technique. On long term follow-up, one sixth of patients reported persistent dyspnoea and recurrent respiratory infections. Any infants presenting with heart failure, right-sided heart, and hypoplastic right lung should be evaluated to exclude the syndrome. An increased appreciation of variables will contribute to improved surgical management.
WeChat and access to wireless communication may offer a continuum of care following medical and surgical intervention. This cardiac surgery research study evaluates the process of parental education and social support following pediatric cardiac surgery utilizing standard of care compared to telehealth.
Background and aim of the study. To report early clinical outcomes of the frozen elephant trunk technique (FET) for the treatment of complex aortic diseases after transition from conventional elephant trunk. Methods. A single-center, retrospective study of patients who underwent hybrid aortic arch and FET repair for aortic arch and/or proximal descending aortic aneurysms, acute and chronic Stanford type A aortic dissection with arch and/or proximal descending involvement, Stanford type B acute and chronic aortic dissections with retrograde aortic arch involvement. Results. Between December 2017 and May 2020, 70 consecutive patients (62.7±10.6 years, 59 male) were treated: 41 (58.6%) for acute conditions and 29 (41.4%) for chronic. Technical success was 100%. In-hospital mortality was 14.2% (n=12, 17.1% emergency vs. 10.3% chronic, P=NS); 2 (2.9%) major strokes; 1 (1.4%) spinal cord injury. Follow-up was 12.5 months (IQR 3.7—22.3. Overall survival at 3, 6, 12 and 24 months was 90% (95% CI, 83.2—97.3), 85.6% (95% CI, 77.7—94.3), 79.1% (95% CI, 69.9—89.5), 75.6% (95% CI, 65.8—86.9) and 73.5 (95% CI, 63.3—85.3). There were no aortic re-interventions and no dSINE; 5 patients with residual type B dissection underwent TEVAR completion. Conclusions. In a real-world setting, FET demonstrated a rapid learning curve and good clinical outcomes, even in acute type A aortic dissections. Techniques to perfect the procedure and to reduce remaining risks, and consensus on considerations such as standardized cerebral protection need to be reported.
Background: Strokes are a known complication of acute type A aortic dissection (ATAAD) repair. Understanding the neuroanatomy, mechanism, and severity of stroke will facilitate efforts to improve prediction, prevention, and treatment strategies. Methods: Retrospective review of patients who sustained stroke from a consecutive series of patients undergoing ATAAD repair. Neuroimaging was interpreted by two stroke neurologists blinded to clinical results. Severity of stroke was assessed by National Institutes of Health Stroke Scale (NIHSS). Residual disability at thirty days was assessed using the modified Rankin Scale (mRS). Results: Twenty percent (38/189) of patients undergoing repair for ATAAD had stroke [unilateral 58%, bi-hemispheric 42% (p=0.33)]. All strokes were ischemic. No significant lateralization (right vs. left) was noted with unilateral strokes (26% vs 32%, p=0.67). Etiology of stroke was embolic (58%), hypoperfusion (26%), mixed (11%) and unknown (5%). There were no intraoperative variables that correlated with the neuroanatomy or mechanism of stroke. Pre-operative carotid dissection was seen in 40% (n=15), while postoperatively 10% (n=4) sustained intracranial large vessel occlusion (LVO). Strokes were moderate or severe (NIHSS ≥ 9) in 97% of cases, with 66% incidence of moderate residual disability (mRS ≥ 3) at one month postoperatively. Conclusions: Stroke associated with ATAAD is heterogeneous in etiology and location. Most strokes are severe on detection and result in significant residual disability. One in 10 strokes are due to LVO amenable to endovascular treatment. Future trials may evaluate the role for early neuroimaging and treatment of incident stroke given modern advancements in endovascular stroke therapy.
The morphological variations when one, or both, of the atrial chambers is subdivided, are many and varied. We present a synthesis of 198 published investigations of this “family” of uncommon lesions. Almost three-quarters of patients with divided atrial chambers present during infancy with severe pulmonary hypertension and cardiac failure. Associated cardiac and extra-cardiac defects are present in between half and nine-tenths of cases. Acquired division of the left atrium has been reported after the Fontan operation, orthotopic cardiac transplantation, and complicated aortic valvar infective endocarditis. Surgery under cardiopulmonary bypass remains the definitive treatment. Balloon dilation may be considered in anatomically compatible variants in the setting of cardiac failure and pregnancy as a bridge to definitive treatment. Overall, mortality has been cited between nil to 29%. Presentation during infancy, associated congenital anomalies, pulmonary hypertension, and surgery in the previous era, have been the reported causes of death. The operative survivors have long-term favourable outcomes, with near normal cardiac dimensions and low risk of recurrence. While asymptomatic patients with division of the right atrium do not need treatment, surgical resection of the dividing partition under cardiopulmonary bypass is recommended in symptomatic patients with complex anatomy, the spinnaker malformation, or associated cardiac anomalies. Balloon dilation may be considered in uncomplicated patients with less obstructive lesions. Hybrid intervention and endoscopic robotic correction also have been performed. We submit that an increased appreciation of the anatomic background to division of the atrial chambers will contribute to improved surgical management.