OBJECTIVE Postoperative stroke is a serious unsolved complication after acute type A aortic dissection repair. We investigated the incidence and risk factors of stroke and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS Between 2012 and 2019, 202 (56% men, median age 68 years) patients with acute type A aortic dissection underwent surgical repair. Clinical data, image findings, methods of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS Of 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n=25). Brachiocephalic artery dissection was associated with a higher risk of stroke (odds ratio, 3.89, 95%CI 1.104-13.780; P= .035) having no relation with the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION Brachiocephalic artery dissection was an independent risk factor of stroke after acute type A aortic dissection repair.
Here we report the seven-year long-term survival after Aspergillus fumigatus mediastinitis after heart transplantation, an uncommonly described condition. A 66-year-old male developed infection with A. fumigatus covering the entire thoracic cavity with a fungal turf after orthotopic heart transplantation. Repeated surgical removal of infectious and necrotic tissue together with innovative topical treatment using voriconazole and chlorhexidine combined with systemic antifungal treatment lead to control of infection. Definitive wound closure was achieved by standard sternal refixation and latissimus dorsi muscle flap plasty. Survival after A. fumigatus mediastinitis after heart transplantation was achieved with sequential debridement in combination with topical application of antifungal agents.
With new technology comes new complications. We discuss the interesting case presented by Bjelic and colleagues regarding a missplaced TAVR valve into the inflow cannula of an LVAD, leading to hemodynamic collapse. The authors describe the pitfalls of the new technology and interesting surgical maneuvers to address these complications.
The coronavirus disease 19 (COVID-19) pandemic has resulted in widespread economic, health and social disruptions. The delivery of cardiovascular care has been stifled during the pandemic in order to adhere to infection control measures as a way of protecting patients and the workforce at large. This cautious approach has been protective since individuals with COVID-19 and cardiovascular disease are anticipated to have poorer outcomes and an increased risk of death. The combination of postponing elective cardiovascular surgeries, reduced acute care and long-term cardiac damage directly resulting from COVID-19 will likely have increased the demand for cardiac care, particularly from patients presenting with more severe symptoms. The combination of increased demand and inhibited supply will likely result in huge backlog of unmet patients’ needs. The novelty, virulence and infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused substantial morbidity and mortality which have necessitated modifications to the UK government’s healthcare strategy. Without improving cost efficiency, the UK’s ageing population will likely need an increasing spend on cardiac surgery simply to maintain the same level of service. However, the government’s short-term increase in spending is unsustainable especially in the face of ongoing economic uncertainty. This means that the long-term impact of COVID-19 will only increase the need to find innovative ways of delivering equivalent or superior cardiac care at a reduced unit cost.
A 40-year-old male with Becker muscular dystrophy presented with severe mitral regurgitation and underwent mitral valve repair. Following the surgery, the patient became tachycardic, and developed a continuous high grade-fever and hyperbilirubinemia. The patient's condition worsened and we eventually tested his thyroid levels and discovered abnormally high thyroid levels. After diagnosing a severe thyroid storm, the patient was treated with oral administration of Lugol's iodine and thiamazole, as well as an intravenous steroid, which led to an immediate improvement of symptoms. The incidence of thyroid storm after open-heart surgery is extremely rare but highly life-threatening if unrecognized.
Objective: Cardiac tumors are rare conditions. The vast majority of them are benign yet they may lead to serious complications. Complete surgical resection is the gold standard treatment and should be performed as soon as the diagnosis is made. Median sternotomy (MS) is the standard approach and provides excellent early outcomes and durable results at follow-up. However, minimally invasive (MI) is gaining popularity and its role in the treatment of cardiac tumors needs further clarification. Methods: A systematic literature review identified 12 candidate studies; of these, 11 met the meta-analysis criteria. We analyzed outcomes of 653 subjects (294 MI and 359 MS) with random effects modeling. Each study was assessed for heterogeneity. The primary endpoints were mortality at follow-up and tumor relapse. Secondary endpoints included relevant intra- and post-operative outcomes; tumor size was also considered. Results: There were no significant between-group differences in terms of late mortality (incidence rate ratio (IRR): MI vs. MS, 0.98 [95% CI: 0.25¬–3.82], p = 0.98). Few relapses and redo surgery were observed in both groups (IRR: 1.13[0.26-4.88], p=0.87);( IRR: 1.92 [95% CI: 0.39-9.53], p=0.42); MI was associated to prolonged operation time yet with no effects on clinical outcomes. Tumor size did not significantly differ between groups. Conclusions: Both MI and MS are associated with excellent early and late outcomes with acceptable survival rate and low incidence of recurrences. This study confirms that cardiac tumor may be approached safely and radically with a MI approach.
Spinal cord ischemia remains a dreadful complication after thoracoabdominal aortic aneurysm repair. The role of cerebrospinal fluid drain in such patients needs further clarifications. Tam and colleagues carried out an interesting decision analysis study that supports the routine use of the cerebrospinal fluid drain after thoracoabdominal aneurysm repair. They also demonstrated that the use of the cerebrospinal drain was safe. Here, we firstly discuss the paper's finding and methodology and, secondly, we try to simply explain what a decision analysis study is and, broadly, and how to construct a Markov model.
Determining Prosthesis-Patient Mismatch after TAVR: Which is the Best Method?Authors: Cesar E. Mendoza, MD1 and Diego Celli, MD2Affiliations: 1Division of Cardiovascular Disease, Jackson Memorial Hospital, Miami, Florida;2Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida.Affiliation addresses: 11801 NW 9th Ave, Suite #209 33136 Miami, Florida, United States; 21611 NW 12th Ave 33136, Miami, Florida, United States.Corresponding author: Cesar E. Mendoza, MD; [email protected]; 1611 NW 12th Ave, East Tower 3019, Miami, Florida 33136.Disclosures: Authors have no relationships with the industry. This work is not under consideration in any other journal.Funding: No grants, contracts, and other forms of financial support were used to perform this manuscript.In the last decade, the medical community has witnessed an accelerated development of multiple devices for the transcatheter management of aortic stenosis. Recently, transaortic valve replacement (TAVR) was granted approval for its use in all types of surgical risk patients underscoring its importance in cardiovascular practice. While evidence has shown non-inferiority of TAVR versus surgical aortic valve replacement (SAVR) , it still has inherent intra- and post-procedural complications, prosthesis-patient mismatch (PPM) is one of them.Since the seminal work published by Rahimtoola in 1978 , several studies have investigated PPM. The incidence of PPM after SAVR ranges from 20% to 50% with severe cases having an occurrence rate from 5% to 25%. [3-5]. Severe PPM has been associated with significantly abnormal prosthetic valve echocardiographic parameters and adverse clinical outcomes including a higher risk of mortality [3,5-7]. Although initial studies showed a lower incidence of PPM after TAVR [8, 9], most recent data surprisingly depict an uptrend incidence of PPM with later-generation TAVR prostheses . Regardless of the true global PPM incidence, the number of cases in the severe category remain within robust margins (5% - 36%). Perhaps, more interestingly, the association of TAVR with adverse outcomes is not firm. Indeed, there are conflicting reports, with some studies showing a weak association [11,12], no association [13, 14, 15], or association in particular group of patients .PPM occurs when the effective orifice area (EOA) of a normally functioning prosthesis is too small in relation to the patient’s body size and cardiac output requirements, and this diagnosis must be done after ruling out dysfunction of the prosthesis heart valve. Historically, surgical aortic valve replacement was the method of choice in the management of aortic stenosis; as such, surgeons relied on the manufacturer’s predicted EOA charts to aid in the determination of the minimum valve size for any given valve model. The predicted EOA index (EOAi), which is calculated by dividing the reference value for the prosthesis model and size by the body surface area (BSA) of the patient, has been frequently used to identify PPM in the SAVR studies. Similarly, all contemporary TAVR studies have used the same index for the same purpose; but it nevertheless was measured using Doppler-echocardiography data.In this issue of JOCS, Catalano et al report that the utility of EOAi charts to predict PPM after TAVR for native aortic stenosis may be limited. Indeed, they found in their study that the pre-TAVR prediction of PPM using tables of expected EOA varies significantly from actual PPM measured on intraoperative transesophageal echocardiography using the continuity equation. Although this is a relatively small single-center study, the authors provided information worthy of additional consideration.First, they identified that EOAi charts overestimated the number of patients with PPM for Sapien 3 valves (25.3% predicted versus 13.7% actual) and underestimated the number of patients with PPM for Evolut valves (1.8% predicted versus 11.6% actual), yielding a limited utility for this instrument on pre-operative prediction of PPM in TAVR. Interestingly, a recent publication by Ternacle et al.  provides a different perspective on this topic. It reports that the predicted EOAi was found to be useful to reclassify the majority of patients diagnosed with measured PPM following TAVR to no PPM at all. Furthermore, they found that both methods had a different association with hemodynamic outcomes. In this regard, EOAi and mean transprosthetic gradient had a more powerful correlation when using the predicted EOAi versus the measured EOAi. Based on these findings, the Ternacle’s study suggests that the use of measured EOAi grossly overestimates the incidence of PPM. The discrepancy between both studies may be explained by the inherent variability in using different Doppler echocardiography imaging modalities to measure EOA. As Catalano et al rightly pointed out, the prosthesis data acquisition and measurements obtained by intraoperative transesophageal echocardiography in their study may not be comparable with its counterpart transthoracic modality, and this particular difference should be taken into account when interpreting the results above mentioned.Second, it is also clear from Catalano’s study that determining the best method to diagnose PPM following TAVR is paramount, but at the same time troublesome due to several factors. First, the pressure recovery phenomenon, a portion of the transprosthetic pressure gradient lost initially at the vena contracta level that recovers later after the prosthetic valve, is not accounted for by Doppler assessment of the maximum transvalvular flow velocities. This may cause overdiagnosis of PPM after TAVR. Second, measured EOA is influenced by the patient’s hemodynamic condition at the time of the evaluation and by the known technical pitfalls on the acquisition of images and measurement performance. Third, the use of the EOA indexed for body surface area may overestimate the severity of PPM in obese patients (body mass index ≥30 kg/m2).Certainly, Catalano’s study allows for a better discussion on the diagnosis and clinical implications of PPM following TAVR. However, the question of what method is a more accurate parameter to determine PPM remains unanswered. Clearly, further research is needed as TAVR is more frequently performed and new TAVR prostheses become available. Accurate prediction of PPM in this setting will help guide the operator’s decision on proper prosthesis size and type.
It has been long believed that ischemic mitral regurgitation is secondary to left ventricular remodelling and the mitral per se remains unaffected. This proviso has recently been challenged and the mitral valve has been described as a structure that responds and adapts to challenges and attempts to correct the mitral regurgitation. The response of mitral valves in this setting can be incomplete or can even be mal-adapted. The ability of the mitral valve to respond in this manner has been described as “mitral plasticity”. Endothelial to Mesenchymal transition and Valvular Interstitial Cells are key to this mitral plasticity and function through a complex array of signalling pathways. Identification and manipulation of these pathways may provide a possibility to correct the incomplete or mal-adapted mitral valve responses. Surgical treatment can also be tailored based on whether the valve has maladapted or has undergone incomplete adaptation.
Objectives:Surgical management of aortic arch hypoplasia with associated intra-cardiac anomalies is a challenge in newborns.We reviewed the characteristics and outcomes of neonates and infants who underwent pulmonary artery banding concomitant to arch repair and single-stage total repair at our institution. Methods:Medical records of 60 patients undergoing aortic arch reconstruction for aortic arch hypoplasia between 2014 to 2019 were retrospectively reviewed.Twenty-five patients were female (41.6%), and the age of the patients ranged from 4 to 120 days (median 19.5 days).The patients were divided into two groups;Group 1 (23 patients) underwent pulmonary artery banding concomitant to arch repair, Group 2 (37 patients) underwent single-stage total repair in addition to arch repair.All arch repair procedures consisted of an extended (to the midportion of the ascending aorta)patch aortoplasty. Results:Postoperative early mortality occurred in 12 patients, 8 in Group 1(34.8%), and 4 in Group 2 (10.8%).There was an early survival advantage in group 2 (p=0.019).Recoarctation was occurred in 13 cases (21.6%), and 11 (18.3%) of them required reintervention (balloon angioplasty:7, re-operation:4).On univariate analysis, risk factors associated with death were pulmonary artery banding (HR,0.44;CI,0.09-2;p=0.019),prematurity (HR,4,67;CI,1.34-16.18;p=<0.001),preoperative mechanical ventilation support requirement (HR,0.048;CI, 0.52-6.39;p=0.048),and functional single ventricle (HR,0.43;CI,0.1-1.86;p=0.006).The mean duration of follow-up was 21.9±15.1 months, and there was no late death in each group. Conclusion:Single-stage repair of aortic arch hypoplasia with intracardiac pathologies has better results than palliation, according to survival rates and postoperative results.The use of patch augmentation technique in aortic arch hypoplasia is valid and associated with an acceptable incidence of recurrent arch obstruction.
Primary cardiac lymphoma is rare, with a frequency of 1.0% to 1.6% among cardiac malignant tumors. Chemotherapy is often selected as first-line treatment for primary cardiac lymphoma. However, when the tumor causes heart failure or life-threatening hemodynamic collapse, antecedent urgent surgery is required. We herein report a successful case of complete tumor resection and reconstruction of the right atrium and right ventricle using a bovine pericardial patch combined with tricuspid valve replacement in a patient with a huge primary cardiac lymphoma filling the right heart that manifested as tricuspid valve stenosis and subsequent heart failure.
Left ventricular surgical remodeling (LVSR) has been, for long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, manly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes an hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the Authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario
In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with an intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating bio-humoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendinae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor β (TGF-β), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-β activation facilitates leaflet growth, excessive TGF-β activation, as after a myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity and to explain why the equation “large heart=moderate/severe mitral regurgitation” and “small heart=no/mild mitral regurgitation” does not work into the clinical practice.
Objective.As aneurysm related events and rupture is not eliminated, postoperative lifelong surveillance is mandatory after endovascular aneurysm repair(EVAR).For surveillance colored Doppler ultrasound(CDUS) is a standard method of noninvasive evaluation having the advantages of availability, cost-effectiveness and lack of nephrotoxicity and radiation.We evaluated CDUS for primary surveillance tool after elective EVAR by comparing with computerized tomography. Methods.Between 2018-2020, 84 consecutive post-EVAR patients were evaluated.Firstly, CDUS was performed by two Doppler operators from the Radiology and computed tomographic angiography (CTA) was performed.A reporting protocol was organized for endoleak detection and largest aneurysm diameter. Results.Among 84 patients, there were 11 detected endoleaks(13,1%) with CTA and 7 of them was detected with CDUS (r=0,884,p<0.001).There is an insufficiency in detecting low flow by CDUS.Eliminating this frailty, there was a strong correlation of aneurysm sac diameter measurement between CTA and CDUS (r=0,777,p<0,001).The sensitivity and specificity of CDUS was 63,6% and 100% respectively.The accuracy was 95,2%.Positive and negative predictive values were 100% and 94,8%.Bland-Altman analysis and linear regression analysis showed no proportional bias (mean difference of 1.5±2.2mm,p=0.233). Conclusions.CDUS promises accurate results without missing any potential complication requiring intervention as Type I or III endoleak.Lack of detecting type II endoleaks may be negligible as sac enlargement was the key for reintervention in this situation and CDUS has a remarkably high correlation with CTA in sac diameter measurement. CDUS may be a primary surveillance tool for EVAR and CTA will be reserved in case of aneurysm sac enlargement,detection of an endoleak,inadequate CDUS or in case of unexplained abdominal symptomatology
Hemolytic anaemia often challenges congenital heart surgery. Hereditary spherocytosis is a rare familial hemolytic anaemia. When associated with congenital heart disease, the safe performance of cardiopulmonary bypass becomes a priority. The increased risk of hemolysis during cardiopulmonary bypass could potentially lead to significant secondary organ damage. Till now, only very few reports of successful repair of a congenital heart defect in patients with hereditary spherocytosis have been reported. We report the only case of successful repair of a congenital heart defect in an infant with hereditary spherocytosis.
Background: Myocardial bridging (MB) is commonly treated in patients with hypertrophic cardiomyopathy (HCM). However, whether and how MB should be treated in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent septal myectomy remain unclear. Methods: A total of 823 adults with HOCM who underwent septal myectomy at the Fuwai Hospital from 2011 to 2017 were retrospectively studied. Results: Overall, 31 events occurred: 24 patients died and 7 had nonfatal myocardial infarction (MI). The 3-year cumulative event-free survival of all-cause death (97.9% vs 100% vs 100% vs 98.4%, p=0.89) and cardiovascular death (98.3% vs 100% vs 100% vs 98.4%, p=0.63) were similar among the four groups (non-MB, CABG, unroofing, untreated, respectively). The 3-year cumulative event-free survival of nonfatal MI (100% vs 97.5% vs 98.0% vs 89.9%, p<0.001) and combined endpoints (97.9% vs 97.5% vs 98.0% vs 88.4%, p=0.02) were significantly lowest in untreated MB. Cox regression analysis indicated that untreated MB was a significant independent predictor of combined endpoints (hazard ratio [HR]: 4.06, 95% confidence interval [CI]: 1.60–10.32, p<0.001). Moreover, 49 patients underwent coronary artery computed tomography after surgery. The patency rate of the saphenous vein graft (SVG) was significantly higher than that of the left internal mammary artery (LIMA) (13.3% vs 84.2%, p<0.001). No MB was detected in the unroofing group. Conclusions: Surgical MB treatment could be beneficial and performed safely during septal myectomy. Myocardial unroofing is the recommended treatment for MB, and unroofing when technically possible may be preferable for long-term outcomes.