The Coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is overwhelming healthcare resources and infrastructure worldwide. Cardiac surgical operating capacity during the COVID-19 pandemic is dramatically lower due to postponement or cancellation of elective or semi-urgent procedures. Earlier reports have demonstrated complicated post-operative courses and high fatality rates in patients undergoing emergent cardiothoracic surgery who were diagnosed post-operatively with COVID-19. These reports raise the possibility that active COVID-19 might precipitate a catastrophic pathophysiogical response to infection in the post-operative period and lead to unfavorable surgical outcomes. Hence, it is imperative to screen patients with SARS-CoV-2 infection prior to surgery and to carefully monitor them in the post-operative period to identify any early signs of active COVID-19. In this report, we present the successful outcome of coronary artery bypass grafting (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection presenting with an acute coronary syndrome and requiring urgent surgical intervention. We employed a meticulous strategy to identify subclinical COVID-19 disease, and after confirming the absence of active disease, proceeded with the CABG operation. The patient outcome was successful with the absence of any overt COVID-19 manifestations in the post-operative period.
The authors share their experience of managing the cardiac surgery services across London during the challenging Covid-19 pandemic. The Pan London Emergency Cardiac Surgery Service model could serve as a blueprint to design policies applicable to other surgical specialities and parts of the UK and worldwide.
Large osteochondroma arising from chest wall and sternum is uncommon and presentation with airway compression is further uncommon. Here we present a case of large chest wall osteochondroma as a part of Hereditary multiple exostoses in a 9 years old boy presented with a history of stridor and shortness of breath. The bony mass of the right chest wall was extending up to a suprasternal notch and compressing the trachea. The case was successfully managed by initial femoro-femoral cardiopulmonary bypass under local anesthesia prior to the induction of anesthesia to prevent respiratory collapse, followed by debulking surgery was done.
Cor triatriatum is a rare congenital heart disease. A 57-years-old woman had cor triatriatum with severe mitral valve regurgitation (MR) and atrial fibrillation (AF). We perfomed mitral valve repair, left atrial appendage resection, and maze procedure by resection of the anomalous septum in the left atrium. At result, MR was controllable and AF disappeared after the operation. Although there is no established maze procedure with cor triatriatum, removing the septum was effective to complete it.
Background: Infective endocarditis (IE) remains an expressive health problem with high morbimortali-ty rates. Despite its importance, epidemiological and microbiological data remain scarce, especially in developing countries. Aim: This study aims to describe IE epidemiological, clinical, and microbiological profile in a tertiary university center in South America, and to identify in-hospital mortality rate and predictors. Methods: Observational, retrospective study of 167 patients, who fulfilled modified Duke’s criteria during a six-year enrollment period, from January 2010 to December 2015. Primary outcome was de-fined as in-hospital mortality analyzed according to treatment received (clinical vs. surgical). Multivari-ate analysis identified mortality predictors. Results: Median age was 60years (Q1-Q3 50-71), and 66% were male. Echocardiogram demonstrated vegetations in 90.4%. An infective agent was identified in 76.6%, being Staphylococcus aureus (19%), Enterococcus (12%), Coagulase-negative staphylococci (10%), and Streptococcus viridans (9.6%) the most prevalent. Overall in-hospital mortality was 41.9%, varying from 49.4% to 34.1%, in clinical and surgical patients, respectively (p=0.047). On multivariate analysis, diabetes mellitus (OR 2.5), previous structural heart disease (OR 3.1), and mitral valve infection (OR 2.1) were all-cause death predictors. Surgical treatment was the only variable related to better outcome (OR 0.45; 95%IC 0.2-0.9). Conclusion: This study presents IE profile and all-cause mortality in a large patient’s cohort, compris-ing a 6-years’ time window, a rare initiative in developing countries. Elderly and male patients predom-inated, while Staphylococcus aureus was the main microbiological agent. Patients conservatively treated presented higher mortality than surgically managed ones. Epidemiological studies from developing countries are essential to increase IE understanding.
Colonoscopy is generally considered a safe procedure, with a low rate of complications. Although rare, the migration of the colonoscope may represents a life-threating events, requiring emergency treatment. We herein describe the case of an elective colonoscopy complicated by an irretrievable colonoscope that migrated, through a previous traumatic diaphragmatic hernia, in the chest cavity. This hernia was likely a chronic complication of a previous abdominal trauma. Several attempts to retrieve the scope were unsuccessful. After further investigations and collegial discussion, a left thoracotomy was performed, with the aim to retrieve the colonoscope and to reduce the hernia.
Objective Affecting 1 in 500 individuals; Hypertrophic cardiomyopathy (HCM) is an autosomal dominant cardiovascular disorder which is prevalent throughout the world. Surgical myectomy and alcohol septal ablation (ASA) are two methods currently used for the management of drug refractory Hypertrophic obstructive cardiomyopathy (HOCM). ASA may prove to be a useful, less invasive tool when confronting patients with HOCM especially those who are more elderly or deemed to be a higher surgical risk. Methods Electronic literature search was conducted to identify relevant articles that discussed invasive methods to treat drug refractory HOCM. No limits were placed on timing of the publication or the type of article. Key words and MeSH terms were used to conduct the search and the results were summarized in the relevant section. Results Current evidence suggests that alcohol septal ablation is a safe and effective procedure in treating patients with HOCM with similar short- and long-term outcomes when compared with surgical myectomy. Selection of patient with appropriate assessment is the key for satisfactory outcomes. Conclusion ASA has been shown to be a safe and reliable procedure; advanced imaging techniques and dedicated multi-disciplinary teams can be used to carefully select patients with HOCM. Though surgical myectomy is recommended as gold standard treatment for drug refractory HOCM, however, ASA may play an increasing role in the near future due an ageing population; both ASA and SM can have a synergistic effect in treating those who are affected by HOCM.
Double-outlet left ventricle (DOLV) is a rare congenital cardiac anomaly. The aorta and the main pulmonary arterial trunk arises predominantly from the left ventricle(LV) and is associated with a malaligned ventricular septal defect(VSD), various degrees of hypoplasia of the right ventricle, and presence or absence of pulmonary stenosis. Bi-ventricular repair is the preferred treatment option whenever possible. Various techniques for bi-ventricular repair have been described. The best option for DOLV correction is by translocating the pulmonary root to the right ventricle(RV). In this series, we report four patients who underwent biventricular repair of DOLV in our institute with excellent outcomes. All patient details were collected from the institute patient record system. Echocardiographic data were obtained from the records. Intraoperative charts were reviewed for further information on the surgical procedure and cardiopulmonary bypass. Postoperative data included survival, functional status and followup echocardiography. Of the four children, three underwent pulmonary root translocation and one child underwent Reparation al etage Ventriculaire(REV) procedure. There was no mortality and all children are in stable clinical condition in the recent follow-up and no re-operations or interventions were required following primary surgical correction. Thus DOLV is anatomically and surgically a challenging subset. Pulmonary root translocation in this anatomy is technically challenging but safe and superior option when compared to other alternative surgical procedures and it can be performed with excellent results, even in infants.
Background: With the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short- and long-term mechanical circulatory support devices, including the implantation of total artificial hearts (TAH) are modalities that are increasingly being used as treatment options for patients with end-stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH. Case Presentation: A 65 years old man with a history of non-ischemic cardiomyopathy had received a left ventricular assist device, and then two years later underwent orthotopic heart transplantation using the bicaval anastomosis technique. The post procedural course was complicated by primary graft failure, resulting in the need for the implantation of a TAH. About 5 months after the TAH implantation he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal and liver function. Conclusion: Potential fatal complications caused by catheter or wire entrapment in the right sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH.
Severe recurrent mitral regurgitation (MR) within 1 year of mitral valve repair is usually attributed to a technical issue with the original repair procedure. However, when artificial chordae are employed to correct mitral valve prolapse, ventricular remodeling (i.e. decreased ventricular size) can lead to recurrent prolapse and valve dysfunction. To highlight this phenomena, we present 2 patients who experienced early failure after undergoing mitral valve repair with artificial chordae.
Less invasive techniques for cardiothoracic surgical procedures are designed to limit surgical trauma, but technical requirements and preoperative planning are more demanding than those for conventional sternotomy. Patient selection, interdisciplinary collaboration, and surgical skills are key factors for procedural success. Aortic valve replacement is frequently performed through an upper hemisternotomy, but the right anterior minithoracotomy represents an even less traumatic, technical advancement. Preoperative assessment of the ascending aorta in relation to the sternum is mandatory to select patients and the intercostal access site. This description of the surgical technique focuses on the specific procedural details including the obligatory planning with computed tomography, and our cannulation strategy. We also sought to define the anatomical ascending aorto-sternal relationship, as it is of utmost importance in preoperative computed tomographic planning.
Background: Recent reports have revealed better clinical outcomes for extracorporeal cardiopulmonary resuscitation (ECPR) than conventional cardiopulmonary resuscitation (CPR).In this retrospective study, we attempted to identify predictors associated with successful weaning off extracorporeal membrane oxygenation (ECMO) support after ECPR. Methods: The demographic and clinical data of 30 ECPR patients aged over 18 years treated between August 2016 and January 2019 were analyzed. All clinical data were retrospectively collected. The primary endpoint was successful weaning from ECMO support after ECPR. Patients were divided into two groups based on successful or unsuccessful weaning off ECMO support (Weaned (n=14) vs. Failed (n=16)). Results: Univariate logistic regression analysis showed that age, CPR duration, ECMO complications, and loss of pulse pressure significantly predicted the results of weaning off ECMO support. However, multivariate logistic regression analysis showed that only CPR duration and loss of pulse pressure independently predicted unsuccessful weaning from ECMO support. Conclusion: We conclude that long CPR duration and loss of pulse pressure after ECPR predict unsuccessful weaning from ECMO. However, unlike CPR duration, loss of pulse pressure during post-ECPR was related to subsequent management. In patients with reduced pulse pressure after ECPR, careful management is warranted because this reduction is closely associated with unsuccessful weaning off ECMO support after ECPR.
On March 11, 2020, the World Health Organization (WHO) declared the SARS-CoV-2 outbreak a pandemic: it took a toll of more than 300.000 deaths and more than 4.5 million cases, worldwide. The initial data pointed out the tight bond between cardiovascular diseases and worse outcomes in COVID19-patients. Epidemiologically speaking, there is an overlap between the age-groups more affected by COVID-related death and the age-groups in which Cardiac Surgery has its usual base of patients. The Cardiac Surgery Departments have to think to a new normal: since the virus will remain endemic in the society, dedicated pathways or even dedicated Teams are pivotal to treat safely the patients, in respect of the safety of the health care workers. Moreover, we need a keen eye on deciding which pathologies have to be treated with priority: Coronary Artery Disease (CAD) showed a higher mortality rate in patients affected by COVID19, but it’s however reasonable to think that all the cardiac pathologies affecting the lung circulation - such as symptomatic severe mitral diseases or aortic stenosis - might deserve a priority access to treatment, in order to increase the survival rate in case of an acquired-Coronavirus infection later on.
Redo multiple valve replacement is known to carry additional risk of morbidity and mortality. Currently, a transcatheter-based valve-in-valve approach could be useful in reducing potential serious consequences. On the other hand, this approach poses several technical challenges regarding the device and procedural aspects of the procedure. We present the case of a 78-year-old man who presented with symptoms of heart failure due to mitro-aortic bioprosthesis degenerations who was deemed to be at extremely high risk for conventional redo surgery. A two-steps single admission transcatheter-based approach was planned with a transfemoral aortic valve-in-valve procedure followed by a trans-apical mitral valve-in-valve implantation. The outcome was good and the recovery was fast.
Background and aim: The incidence of symptomatic cerebral infarction after minimally invasive cardiac surgery (MICS) with retrograde perfusion has been increasing. However, there is no report about silent brain infarction (SBI) after MICS with retrograde perfusion. Because SBI may cause delirium and decline of cognitive function, this condition is important clinically. Thus, the current study aimed to investigate the occurrence of SBI after MICS via magnetic resonance imaging (MRI). Methods: Between July 2014 and July 2018, 174 patients underwent MICS with retrograde perfusion and postoperative MRI in this study. Univariate and multivariate analyses were performed to examine the occurrence of SBI and to identify its risk factors. Results: Of 174 patients, 26 (14.9%) presented with SBI. The univariate analysis revealed that age and aortic valve stenosis (AS) are the risk factors of SBI. Meanwhile, multivariate analysis revealed AS as the only risk factor of SBI. Conclusions: At our institution, the incidence of SBI after MICS with retrograde perfusion was acceptable.