Background: Transplant patients are known to be at increased risk of developing de novo malignancies (DNM). As heart transplant survival has increased, DNM represent an obstacle to further improving survival. We sought to examine the incidence, risk factors, and prognostic factors of post-transplant DNM. Methods: We studied adult heart transplant recipients from the Organ Procurement and Transplantation Network database (1987-2018). Kaplan-Meier survival analysis was performed to determine annual probabilities of developing DNM, excluding squamous and basal cell carcinoma. Rates were compared to the general population in the Surveillance, Epidemiology, and End Results database. Cox proportional hazards regression was performed to calculate hazard ratios for risk factors of DNM development, all-cause, and cancer-specific mortality. Results: Over median follow-up of 6.9 years, 18% of the 49,361 patients developed DNM, which correlated with an incidence rate 3.8 times that of the general population. The most common malignancies were lung, post-transplant lymphoproliferative disorder, and prostate. Risk was most increased for female genital, tongue/throat, and renal cancers. Male gender, older age, smoking history, and impaired renal function were risk factors for developing DNM, whereas the use of MMF for immunosuppression was protective. Cigarette use, increasing age, the use of ATG for induction and calcineurin inhibitors for maintenance were risk factors for cancer-specific mortality. The development of a DNM increased the risk of death by 40% (p<0.001). Conclusions: Heart transplant patients are at increased risk of malignancy post-transplant, particularly rare cancers. Strict cancer surveillance and attention to immunosuppressive regimens are critical for further prolonging post-transplant survival.
Congestive heart failure is highly prevalent in the elderly population and left ventricular assist device has been increasingly used in this population. LVAD therapy is more costly than medical treatment but it increases the survival and quality of life of the elderly patients with low disease acuity. Therefore careful selection of candidates and implementation of LVAD therapy earlier in the course of the disease is crucial to improve outcomes. With the technical advances and improvement in clinical management, the financial burden of LVAD therapy in the elderly will become less, making this therapy more economically feasible.
The authors in this manuscript have reported an increase in the number of vascular emergencies seen during the early phase of the COVID-19 pandemic in the Lombardy region of Italy. A significant increase in the number of acute limb ischaemia was seen during this phase along with other vascular emergencies. In this review, we have tried to examine this association between increase in vascular emergencies and COVID-19 infection. We have also described the differences in presentations, prognosis and procedural outcomes following operative interventions in these patients compared to the non-COVID patients. An attempt has been made to assess the role of adjunctive measures like intravenous heparin to improve outcomes.
Background and Aim: Interrupted aortic arch (IAA) is defined as a complete interruption of aortic lumen between the ascending and descending aorta. It is an uncommon and complicated congenital heart disease with high mortality in infants. It is rare for patients with isolated IAA to survive to adulthood without operation unless the extensive collateral vessels joining the descending aorta. Here we present three unique cases with isolated IAA together with a review of the literature. Methods: case presentation: We retrospectively searched the hospital patient databases for patients (>14 years) with IAA diagnosed at the Wuhan Union Hospital over the past 10 years and excluded the patients with other cardiac malformations. Three patients were identified. Two were referred to us for hypertension management and were diagnosed with IAA at our hospital. They both declined surgical treatments and underwent conservative therapy including management of their hypertension. One patient was referred to our hospital for further treatment options after the patient was diagnosed with IAA at another hospital. This patient received an extra-anatomic bypass surgery from ascending aorta to descending aorta. His high blood pressure did not resolve and was subsequently managed by anti-hypertensives medications after the surgery. Discussion and conclusions: Adult patients with isolated IAA usually have extensive collateral vessels joining the descending aorta. Surgical intervention may not be necessary for these patients if the patients have no symptoms except hypertension. Anti-hypertensives medical management with long term follow-up appears to be a reasonable treatment option for these patients.
To the Editor: The interesting and timely paper by Cain et al.1, in press in the Journal of Cardiac Surgery , provides important details concerning the devastating consequences of Mycobacterium chimaera (MC ) infection. In their patient extreme fragility of the mediastinal tissues was observed after repair of an acute aortic dissection; during follow-up multiple reoperations were required to treat recurrent dehiscence of the aortic grafts. Despite repeat explantation of foreign materials infection persisted with mediastinitis and eventual systemic diffusion with fatal outcome.MC infection after open cardiac surgery using cardiopulmonary bypass has been recently reported as a clinical outbreak worldwide and identified as originating by contaminated water in heater-cooler units2. Current experience shows that MC causes a slow-growing and extremely difficult to treat infection with an incubation period which has been recently demonstrated to be as long as >12 years3.We have recently treated a patient, quite similar to that reported by Cain et al.1, who presented with a pseudoaneurysm of the distal suture line twelve years after repair of type A aortic dissection4. At first operation replacement of the ascending aorta and hemiarch using of a Djumbodis®dissection system (Saint Come-Chirurgie, Marseille, France) was performed. At reoperation extremely fragile tissues were noted and, after removing the metallic stent, the aortic arch was replaced with a frozen elephant trunk technique. Cultures of the excised material grewMC . In this case we hypothesized that the stent played an important role in the onset of infection for at least 2 reasons: presence of foreign material in the blood stream and injury to the aortic wall by the edges of the stent. The case described by Cain et al.1 also supports our belief that extreme fragility of the aortic tissues caused by MB was a further important factor in the occurrence of this complication.Interestingly, a delayed diagnosis occurred in both cases; this most likely played a critical role in favouring development of extra‐cardiac manifestations of the disease, in reducing the effectiveness of antibiotic therapy due to immunologic impairment and causing a negative outcome in both patients.MB infection may have different locations ranging from single-organ to systemic manifestations5. When it involves the mediastinum and particularly the major vascular structures often results in life-threatening complications despite proper antimycobacterial treatment. An early diagnosis, even with significantly extended surveillance, appears extremely difficult due to slow-growing and long incubation period of MB .Although no specific guidelines are so far available, intra-operative prevention with improvement of setting and development of heater-cooler units is mandatory and should be based on specific recommendations5.
Background: Although minimally invasive mitral valve surgery (MIMVS) has become the first choice for primary mitral regurgitation (MR) in recent years, clinical evidence in this field is yet limited. The main focus of this study was the analysis of preoperative (Pre), postoperative (Post) and 1-year follow-up (Fu) data in our series of MIMVS in order to identify factors that have an impact on the left ventricular ejection fraction (LVEF) evolution after MIMVS. Methods: We reviewed the perioperative and 1-year follow-up data from 436 patients with primary MR (338 isolated MIMVS und 98 MIMVS combined with tricuspid valve repair) to analyzed patients baseline characteristics, the change of LV size, the postoperative evolution of LVEF and its factors, and the clinical outcomes. Results: The overall mean value of EF slightly decreased at 1-year follow-up (mean change of LVEF: -2.63±9.00%). A significant correlation was observed for PreEF und EF evolution, the higher PreEF the more pronounced decreased EF evolution (in all 436 patients; r= -0.54, p<0.001, in isolated MIMVS; r= -0.54, p<0.001, in combined MIMVS; r= -0.53, p<0.001). Statistically significant differences for negative EF evolution were evident in patients with mild or greater tricuspid valve regurgitation (TR) (in all patients; p<0.05, OR=1.64, in isolated MIMVS; p<0.01, OR=1.93, respectively). Overall clinical outcome in NYHA classification at 1 year was remarkably improved. Conclusions: Our results suggest an excellent clinical outcome at 1 year, although mean LVEF slightly declined over time. TR could be a predictor of worsened FuEF in patients undergoing MIMVS.
The literature describes multiple approaches for the repair of stenosed branch pulmonary arteries. Regardless of the technique, restenosis is undesirably and notoriously common. We describe a case of severe left pulmonary artery stenosis repaired with a novel technique in consideration of factors leading to restenosis. The native main pulmonary artery was transected and turned down to create a direct anastomosis with the left pulmonary artery. The child had a normal sized main pulmonary artery with tricuspid atresia and pulmonary atresia with ductus arteriosus feeding the severely stenosed left pulmonary artery. Our novel technique resulted in hemodynamically gratifying results with a tension free tissue-tissue anastomosis with potential for growth.
Left ventricular assist devices (LVADs) have become integral to the treatment of advanced heart failure. Surgical bleeding is a known complication of LVAD placement but is most associated with intraperitoneal pump locations. Here we describe a case of massive postoperative hemorrhage secondary to erosion of an intrapericardial LVAD into an intercostal artery with an associated rib fracture.
Proximilisation of Frozen Elephant Trunk (FET) necessitates the ligation and reimplantation of the left subclavian artery (LSA), the origin of which is distal and posterior, make rerouting difficult and cumbersome. We describe a rather simple technique for subclavian artery exposure and effective anatomical reconstruction in the mediastinum coupled with hybrid FET utilisation for aortic aneurysm in elective and non-elective settings. The division of the sternocleidomastoid coupled with the sandbag behind the left shoulder brings the LSA superficial enabling anastomosis without any difficulty.
Title: The Time May Soon Be At HandRunning Head: Time May Soon Be At HandAuthors: Saqib Masroor, MD1 and Donald B. Glower MD21. University of Toledo College of Medicine and Life Sciences, Department of Surgery, Division of Cardiothoracic Surgery2. Duke University Medical Center, Department of Surgery, Division of Cardiothoracic SurgeryMeeting Presentation: NoneDisclosure: NoneWord Count: 1213
Background and Aim: Clinical education has been disrupted by the COVID-19 pandemic. We present a standardized remote alternative online cardiothoracic surgery primer to accommodate a shortened clinical calendar. Methods: A week-long cardiothoracic surgery course consisting of virtual case-based lectures and small groups as well as surgical operation walkthroughs was conducted iteratively through April and May 2020 at Emory University School of Medicine, Atlanta, GA for new clinical third-year medical students. Results: Remote learning platforms helped maintain medical student clinical education. Cardiothoracic procedure video walkthroughs were highly demanded for remote learning. Virtual small group discussions were felt to be invaluable in facilitating active problem solving and clinical decision making of cardiothoracic surgery. Conclusion: Our online cardiothoracic surgery curriculum can be a framework for alternative medical student clinical education. Student feedback is necessary as we adapt to teaching during the COVID-19 pandemic and future global disruptions.
Currently available evidence supports the safety and efficacy of rapid deployment and sutureless prostheses for aortic valve replacement (AVR) in aortic stenosis as suggested by the International Expert Consensus in 2016. Following the increasing experience and the good results obtained in AVR, the use of sutureless and rapid deployment prostheses in peculiar situations, at times as an ‘off-label’ indication, has been reported demonstrating to represent an effective solution to challenging surgical problems, such as described by Piperata et al. in a recent issue of the Journal of Cardiac Surgery for the treatment of active infective endocarditis complicated by an extensive aortic annulus abscess. The considerable experience acquired so far with rapid deployment and sutureless valves has stimulated many surgeons to use such devices in patients in whom limiting the overall ischemic time is felt to be of paramount importance, but also in different surgical scenarios. Therefore, we believe the time has come to strongly support the unusual or even ‘off label’ employment of these devices by including them in future recommendations.
Background: Acute type A aortic dissection (ATAAD), is a surgical emergency often requiring intervention on the aortic root. There is much controversy regarding root management; aggressively pursuing a root replacement, versus more conservative approaches to preserve native structures. Methods: Electronic database search we performed through PubMed, Embase, SCOPUS, google scholar and Cochrane identifying studies that reported on outcomes of surgical repair of ATAAD through either root preservation or replacement. The identified articles focused on short- and long-term mortalities, and rates of re-operation on the aortic root. Results: There remains controversy on replacing or preserving aortic root in ATAAD. Current evidence supports practice of both trends following an extensive decision-making framework, with conflicting series suggesting favourable results with both procedures as the approach that best defines higher survival rates and lower perioperative complications. Yet, the decision to perform either approach remains surgeon decision and bound to the extent of the dissection and tear entries in strong correlation with status of the aortic valve and involvement of coronaries in the dissection. Conclusions: There exists much controversy regarding fate of the aortic root in ATAAD. There are conflicting studies for impact of root replacement on mortality, whilst some study’s report no significant results at all. There is strong evidence regarding risk of re-operation being greater when root is not replaced. Majority of these studies are limited by the single centred, retrospective nature of these small sample sized cohorts, further hindered by potential of treatment bias.
Abstract The first clinical implantation of the “Essen I prosthesis” took place in 2005, which was then followed by E-Vita open plus. With further advancements E-Vita Neo and E-Novia was introduced. These devices enable the surgeons to perform FET in zone 0/1 which eventually reduce the incidence of paraplegia, recurrent laryngeal nerve palsy and proximalization of supraaortic arch vessels. E-vita open plus and successors alleviate frozen elephant trunk operations rendering more stable results in promoting positive remodelling of the distal aorta.
Background: This study compared outcomes of patients bridged with extracorporeal membrane oxygenation (ECMO) to orthotopic heart transplantation (OHT) following the recent heart allocation policy change. Methods: The United Network of Organ Sharing Registry (UNOS) database was queried to examine OHT patients between 2010-2020 that were bridged with ECMO. Waitlist outcomes and one-year posttransplant survival were compared between patients waitlisted and/or transplanted before and after the heart allocation policy change. Secondary outcomes included posttransplant stroke, renal failure, and one-year rejection. Results: 285 waitlisted patients were included, 173 (60.7%) waitlisted under the old policy and 112 (39.3%) under the new policy. New policy patients were more likely to receive OHT (82.2% vs 40.6%), and less likely to be removed from the waitlist due to death or clinical deterioration (15.0% vs 41.3%) (both P<0.001). 165 patients bridged from ECMO to OHT were analyzed, 72 (43.6%) transplanted during the old policy and 93 (56.3%) under the new. Median waitlist time was reduced under the new policy (4 days [IQR 2-6] vs 47 days [IQR 10-228]). Postoperative renal failure was higher in the new policy group (23% vs 6%; P=0.002), but rates of stroke and one-year acute rejection were equivalent. One-year survival was lower the new policy but was not significant (79.8% vs 90.3%; P=0.3917). Conclusions: The UNOS heart allocation policy change has resulted in decreased waitlist times and higher likelihood of transplant in patients supported with ECMO. Posttransplant one-year survival has remained comparable although absolute rates are lower.
The recognition of fibrinolysis phenotypes in trauma patients has led to a reevaluation of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, however the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this study was to fill that gap. Methods: Data were retrospectively reviewed from 78 cardiac surgery patients. Phenotypes were defined as hypofibrinolytic (LY30 <0.8%), physiologic (LY30 0.8-3.0%) and hyperfibrinolytic (LY30 >3%). Continuous variables were expressed as M ± SD or median (interquartile range). Results: The study population was 65±10 yrs old, 74% male, average body mass index of 29±5 kg/m2. Fibrinolytic phenotypes were distributed as physiologic=45%, hypo=32% and hyper = 23%. There was no obvious effect of age, gender, race, or ethnicity on the distribution of fibrinolysis phenotypes; 47% received AF. The time with chest tube during post-operative recovery was longer in those who received AF (4[3,5] days) vs no AF (3[2,4] days), P=0.037). All cause morbidity occurred in 51% of patients who received AF vs 25% with no AF (p=0.017). However, with AF vs no AF, apparent differences in median chest tube output (1379 vs 820ml, p=0.075), hospital LOS (13 vs 10 days, P=0.873), estimated blood loss (1100 vs 775 ml, P=0.127), units of transfused RBCs (4 vs 2], P=0.152) or all-cause mortality (5.4% [2/37] vs 10% [4/41], P=0.518) were not statistically significant. Conclusion: This is the first description of three distinctly different fibrinolytic phenotypes in cardiac surgery patients. In this population, the use of AF was associated with increased morbidity.
Background: Subxiphoid incisional hernias are one of the complications following a median sternotomy, a surgical procedure to provide access to the mediastinum. Incidence has been reported between 1-4%, although the true incidence is not well known due to its asymptomatic nature. Method: A comprehensive search was performed on multiple sites. Keywords included “incisional hernia OR Subxiphoid hernia” AND “Median sternotomy OR Cardiac Surgery OR Coronary artery bypass graft OR Transplant OR Valve replacement”. Articles up to 1st of August 2020 were included in this study. Results: 8 articles were included in the study, with a total number of 132 patient identified. The incidence ranged from 0.81% to 3.44%. There was a mixture of repair method and follow up period reported. Recurrence post-repair ranged from 10% to 43%. Conclusion: Subxiphoid incisional hernias remains challenging to manage. We have discussed the incidence, risk factors, preventions, and management of subxiphoid incisional hernias including both the open and laparoscopic technique.