Right superior vena cava draining in the left atrium is a rare anomaly, commonly associated with other cardiac defects. Herein we present the case of a 9 year old patient, asymptomatic but with right heart dilation with sinus venous defect, bilateral superior vena cavas with the right draining into the left atrium.
Background: Computed tomography (CT) is a useful tool for the identification of calcified lesions in the aorta. However, no quantitative evaluation has been established to assess the applicability of simple anastomosis preoperatively. We conducted this retrospective study to establish a reference range of the maximal CT value for application of simple anastomosis. Methods: 122 consecutive patients underwent replacement of the thoracic aorta between 2007-2011, excluding those with acute aortic dissection. The patients were divided into two groups: those who could undergo simple anastomosis (Simple group:n=105), and those who required endarterectomy prior to anastomosis (Manipulation group:n=17). The maximal CT value at the anastomosis site was calculated by an imaging software. Results: The mean maximal CT value (Hounsfield unit: HU) was significantly higher in the Manipulation group (638.1 ± 269.5 [166-1304]) than in the Simple group (94.7 ± 171.5 [0-790]) (p<0.0001). The maximal CT value enabled us to predict the simple anastomosis with the area under the receiver operating characteristic curve of 0.96 (p<0.0001). The cut-off value was 325 HU (sensitivity 94.1%, specificity 81.7%). The 10-year survival rate was significant lower in the Manupilation group (11.8%) than in the Simple group (43.2%). In the multivariate analysis, age (Hazard Ratio [HR]:1.073), Hypertension (HR:2.382) and maximal CT value (HR:1.001) were independently associated with long-term mortality. Conclusions: Preoperative evaluation of the maximal CT value is a useful tool in predicting whether simple anastomosis is applicable or not, in the thoracic aortic surgery. Maximal CT value is a risk factor for long-term mortality.
Minimally Invasive Aortic Valve Replacement is not just a metric of the incision, but rather a holistic approach to minimize the surgical trauma: the technique should reproduce the gold-standard conventional procedure in terms of safety, effectiveness and operative times through a small and different incision. Moreover, the procedure should be simple and reproducible in every Center all over the world. In our experience, we rely more on surgical skills and technique optimization, rather than CT-scan planning: definitely, the pre-operative imaging is helpful in the beginning of the experience to rule out difficult cases.
Background: Minimally invasive mitral valve(MV) surgery(MIVT) is increasingly performed with excellent clinical outcome, despite longer procedural times. This study analyzes clinical outcome and secondary organ function effects in a propensity-matched comparison with conventional MV surgery. Methods and Results: Out of 439 patients undergoing MV surgery from January 2005 to May 2017, 345 patients were included after propensity-matching: 95 sternotomy patients and 250 MIVT patients. Endpoints focused on survival, quality of MV repair and organ function effects through analysis of biomarkers and functional parameters. Despite longer cardiopulmonary bypass(sternotomy: 96.0(IQR34)min – MIVT:134.0(IQR42)min, p<0.001) and cardioplegic arrest times(sternotomy: 61.0(IQR26)min – MIVT:87.0(IQR34)min, p<0.001), no differences in survival nor complication rate were found. Effect on renal function(creatinine, p=0.751 – ureum, p=0.538 - glomerular filtration, p=0.848), myocardial damage by troponine I level (sternotomy:1.8±3.9ng/ml – MIVT:1.2±1.3ng/ml, p=0.438) and ventilatory support > 24 hours(sternotomy:5.5% - MIVT:9.5%, p=0.240) were comparable. Systemic inflammatory reaction by postoperative CRP count was markedly lower for MIVT(p<0.001). Increased rhadomyolysis was found after MIVT surgery, based on significant elevation of creatinine-kinase levels(sternotomy: 431±237U/L – MIVT: 701±595U/L, p<0.001). Conclusion: Despite an inherent learning curve, minimally invasive MV surgery guarantees a clinical outcome and MV repair quality, at least non-inferior to those of MV surgery via sternotomy. Notwithstanding longer cardiopulmonary bypass and cardiac arrest times, the impact on secondary organ function is negligible, excepted for a lower systemic inflammatory response. The postoperative increase of CK-enzymes suggestive for enhanced rhabdomyolysis needs to be accounted when procedural times tend to exceed the critical time threshold for severe limb ischemia.
Abstract Lockdown, quarantine, self-isolation, personal protection equipment, social distancing have become words of daily usage ever since the world health organisation declared COVID-19 as a pandemic. The impact of COVID 19 extends over the medical field, economy, education and politics. Though the knowledge of the virus is evolving, we are yet to find a solution. India, country with the 2nd largest population, went into a phase of lockdown from 25th March 2020 to 31st May 2020. There was phased measure to “Unlock” starting from1st June 2020. This has affected the clinical practise and training of the resident. The challenges faced during this unprecedented time are multi-faceted which includes overcrowding, health care system, educational background. Indian Association of Cardiovascular-Thoracic Surgeons kept continuing the educational program through a series of “Masterclass”.
Cardiopulmonary bypass and extracorporeal membrane oxygenation are commonly used adjuncts to lung transplantation. These techniques are not without associated morbidity and mortality, and the surgeon must be aware of the possibility of aberrant anatomy that could lead to vascular injury during cannulation. In this report, we describe a patient with congenital absence of the inferior vena cava undergoing lung transplantation who required perioperative cardiopulmonary support. A percutaneous dual lumen cannula, Protek Duo, was connected in an Oxy-RVAD configuration to provide right ventricular and oxygenation support both intraoperatively and postoperatively to this patient.
We present a case of coronary artery bypass grafting in a 78-year-old man with triple vessel disease and concomitant cardiac amyloidosis. Postoperatively he developed a profound low cardiac output state and multi-organ failure. He died 3 weeks following surgery. Bypass surgery is rarely performed in patients with cardiac amyloidosis, and there is little in the literature regarding outcomes. The few published cases present a bleak picture, and hence percutaneous coronary intervention should always be preferred.
Objectives: To compare outcomes after the development of early (≤30 days) versus delayed (>30 days) deep sternal wound infection (DSWI) after cardiac surgery. Methods: Between 2005 and 2016, 64 patients were treated surgically for DSWI following cardiac surgery. Thirty-three developed early DSWI, while 31 developed late DSWI. Mean follow up was 34.1 ± 32.3 months. Results: Survival for the entire cohort at 1, 3, and 5 years was 93.9, 85.1, and 80.8%, respectively. DSWI diagnosed early and attempted medical management were strongly associated with overall mortality (hazard ratio (HR), 25.0 and 9.9; 95% confidence intervals (CI), 1.18-528 and 1.28-76.5; p-value 0.04 and 0.04, respectively). Survival was 88.1, 77.0, 70.6 and 100, 94.0 and 94.0% at 1,3, and 5 years in the early and late DSWI groups, respectively (Log-rank = 0.074). Those diagnosed early were more likely to have a positive wound culture (odds ratio (OR), 0.06, 95% CI 0.01-0.69, p=0.024) and diagnosed late were more likely to be female (OR 8.75, 95% CI 2.0-38.4, p=0.004) and require an urgent DSWI procedure (OR 9.25, 95% CI 1.86-45.9, p=0.007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (hazard ratio 7.48, 95% CI 1.38-40.4, p=0.019 and hazard ratio 7.76, 95% CI 1.67-35.9, p=0.009, respectively). Conclusions: Early aggressive surgical therapy for deep sternal wound infection after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and have failed initial medical management have increased mortality.
Over the last two decades, the medical community witnessed an outstanding and accelerated development on minimally invasive therapies. With the dorsal spine of supportive data from large randomized control trials, transcatheter aortic valve replacement (TAVR), aortic and mitral valve-in-valve, mechanical circulatory support and peripheral endovascular interventions all share the need of accessing a vascular bed with a large bore catheter. Nevertheless, to date, there has yet to be a universal consensus on defining large-bore vascular access (LBVA) in the world of transcatheter therapies. We explore the evolution, characteristics and vascular compatibility of the current commercially available devices, analyze the devices along with access site-specific complications rates and finally review the present methods for percutaneous vascular closure.
Background: Patent ductus arteriosus is an important cause of morbidity and mortality especially in very low birth weight infants.The aim of the present study was to evaluate outcomes of bedside surgical ligation of patent ductus arteriosus via limited upper ministernotomy as an alternative approach to thoracotomy. Material and Method: A total of 23 low birth weight premature infants who underwent bedside ligation of PDA in the neonatal intensive care unit January 2017 to April 2020, were enrolled. The patients were divided into two groups: those with thoracotomy(n=13) and those with limited upper ministernotomy(n=10).These patients were evaluated retrospectively in terms of clinical and preoperative,intraoperative,postoperative parameters between the groups. Results: Mean birth weight was 1059±275 grams in the thoracotomy group and 1035±285 grams in the ministernotomy group. There was no statistically significant difference in the age at surgery,weight at surgery,preoperative MV support,inotropic score onset of surgery and total procedure time between the groups.There was a statistically significant difference in the hospital length of stay,postoperative MV time and complications in the intensive care unit in favor of the ministernotomy group(p=0.04,p=0.03,p=0.034 respectively).The study showed no statistically significant difference in the mortality rate between the two groups (2 patients in the thoracotomy group and 1 patient in the ministernotomy group). Conclusion:The limited upper ministernotomy is anatomically and technically feasible alternative to classical left posterolateral thoracotomy for bedside surgical PDA ligation.
ABSTRACT: Objective To investigate the Aneurysmal of the left sinus of Valsalva, and to improve the understanding of the disease and the level of diagnosis and treatment. Methods This article mainly reports a case of huge Aneurysmal of the left sinus of Valsalva patients treated with surgical treatment. Results After surgery, the prognosis of the case was good. Conclusion Aneurysmal of the left sinus of Valsalva has low incidence，which is rare in clinical with no clinical specific symptoms leading to difficulty in early detection. The appropriate surgical method should be considered to the patient condition, to prevent the tumor rupture and the death of patients.
Objectives: Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via left small thoracotomy. Methods: We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency and completeness of revascularization. Clinical variables during hospitalization and follow-up were collected and analyzed. Results: All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2–5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3/186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491/510) [98.3% (171/174) for left internal thoracic artery grafts and 95.2% (318/334) for saphenous vein grafts]. The rate of complete revascularization was 98.8% (510/516) of the total grafts in 180 of 186 (96.8%) patients. Conclusions: Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for patients with multivessel disease.
High volume ECMO centers have developed mobile ECMO programs in recent years to facilitate implementation of ECMO support at hospitals with lower capabilities, and transfer these patients for further care. We report a case of mobile ECMO on patient with COVID-19 related ARDS, and discuss the potential application in current SARS-CoV-2 pandemic.
Objective: The arterial switch operation is the standard treatment for the transposition of the great arteries. The timely variation in the residual pressure gradient across the pulmonary arteries is ill-defined. This work is aimed to study the progressive changes in the pressure gradient across the pulmonary valve and pulmonary arteries after arterial switch operation (ASO). Methods: All eligible patients for this study who underwent arterial switch operation between 2000 and 2019 were reviewed. Transthoracic echocardiography (TTE), was used to estimate the peak pressure gradient across the pulmonary artery and its branches. The primary outcome was the total peak pressure gradient (TPG) which is the sum of peak pressure gradients across the main pulmonary artery and pulmonary artery branches. Furthermore, a longitudinal data analyses with mixed effect modeling were used to determine the independent predictors for the changes in pressure gradient. Results: 309 patients were included in the study. Over 17-year follow up, the freedom from pulmonary stenosis reintervention was 95% (16 out of the 309 patients underwent reintervention = 5%). the Longitudinal data analyses of serial 1844 echocardiographic studies for the included patients revealed that the TPG recorded in the first postoperative echocardiogram across pulmonary valve, right and left pulmonary artery branches was the most significant predictor for reintervention. Conclusion: The total peak gradient measured in the first postoperative echocardiogram is the most important predictor for reintervention. We propose that a total peak gradient in the first postoperative echocardiography of 55 mmHg or more is a predictor for reintervention
The Revivent TC™ TransCatheter Ventricular Enhancement System (BioVentrix Inc, San Ramon, CA, USA) is intended for use in heart failure with cardiac dysfunction a previous myocardial infarction. The resultant increased left ventricular systolic volume and discrete, contiguous, non-contractile (akinetic and/or dyskinetic) scar located in the antero-septal, apical (may extend laterally) region of the left ventricle (LV) lends itself to Revivent. The procedure, called Less Invasive Ventricular Enhancement (LIVE), consists of the implantation of a series of micro-anchors pairs in order to exclude the scarred myocardium, in order to reduce and reshape the LV. We present the procedure step-by-step, as team coordination between the cardiac surgeon and the interventional cardiologist is essential to ensure good procedural outcomes. This is a novel and new technique to address Heart Failure secondary to Myocardial Infarction.
Background Stroke remains a devastating complication of cardiac surgery. The aim of this study was to characterise the incidence of stroke and analyse the impact of stroke on patient outcomes and survival. Methods A retrospective analysis was performed of patients with a CT-confirmed stroke diagnosis between 01/01/2015 and 31/03/2019 at a single centre. 2:1 propensity matching was performed to identify a control population. Results Over the period 165 patients suffered a stroke (1.99%), with an incidence ranging 0.85% for CABG to 8.14% for aortic surgery. The mean age was 70.3 years and 58.8% were male. 18% had experienced a previous stroke or TIA. Compared to the comparison group, patients experiencing post-operative stroke had a significantly prolonged period of ICU admission (8.0 vs 1.1 days p<0.001) and hospital length of stay (12.94 vs 8.0 days p<0.001). Patient survival was also inferior. In-hospital mortality was almost 3 times as high (17.0% vs 5.9%; p<0.001). Longer-term survival was also inferior on Kaplan-Meier estimation (p<0.001). The 1-year and 3-year survival were 61.5% and 53.8% respectively compared to 89.4% and 86.1% for the comparison group. Conclusion Perioperative stroke is a devastating complication following cardiac surgery. Perioperative stroke is associated with significantly inferior outcomes in terms of both morbidity and mortality. Notably a 28% reduction in 1-year survival. The potential to reduce morbidity and mortality with the emergence of mechanical thrombectomy, demonstrates the need for clear links between cardiothoracic and stroke teams to support individuals affected by perioperative stroke.
The authors of “Outcomes of truncus arteriosus repair and predictors of mortality” carried out a retrospective analysis of more than 3000 infants with truncus arteriosus using the National Inpatient Sample dataset of the Healthcare Cost and Utilization Project database. Logistic regression was used to identify factors associated with in-hospital mortality. The authors also identified a seemingly protective effect of 22q11.2 deletion. But do these findings offer a complete understanding of surgical risk factors for patients with truncus arteriosus?
Individuals with single-ventricle congenital heart disease who are palliated to a Fontan circulation are at risk for heart failure and liver disease, with recurrent ascites being one potentially debilitating cause of late morbidity. Although ascites associated with heart failure or liver failure is usually characterized by a high serum-ascites albumin gradient (SAAG), we have observed multiple instances of ascites in Fontan patients with low SAAG, suggesting an inflammatory process. We present three cases in which recalcitrant ascites severely and adversely impacted quality of life, and describe our initial experience with intraperitoneal corticosteroids in this setting.