Background. A staged thoracotomy unifocalization approach has not been the dominant option over the past 20 years primarily due to the introduction of midline one-stage complete unifocalization. Methods. In this issue of the Journal of Cardiac Surgery, van de Woestijne and colleagues publish their experience over the past 30 years in 39 consecutive patients with “consistent” staged unifocalization through a lateral thoracotomy in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (PA/VSD/MAPCA). Results. They report definitive repair completion in 76.3% of the patients and an overall survival after definitive repair of 96% at 20 years despite the study period ranging from 1989 to the present. Conclusion. Given the multiple variations one could have with PA/VSD/MPACA, a midline unifocalization approach may not always be possible. Surgeons should be familiar with the lateral thoracotomy unifocalization staged approach to PA/VSD/MAPCA.
Transcatheter aortic valve implantation (TAVI) is rapidly spreading across the world with the endorsement of the cardiological community(1) and the supporting results of randomised controlled trials (2,3). However, TAVI-related complication like aortic dissection, aortic valvular rupture, or left ventricle perforation are still potentially catastrophic (4).
The COVID-19 pandemic has remarkably impacted the hospital management and the profile of patients suffering from acute cardiovascular syndromes. Among them, acute infective endocarditis (AIE) represented a rather frequent part of these urgent/emergent procedures. The paper by Li and colleagues has clearly shown the higher risk features which patients with diagnosis of AIE presented at hospital admission during the first part (first and second waves) of the outbreak, often requiring challenging operations, but fortunately not associated with worse outcome if compared to results obtained prior to the SARS-2 pandemic. The report discussed herein presents several other aspects worth of discussion and comments, particularly in relation to hospital management and post-discharge outcome which certainly deserve to be highlighted, but also further investigations.
We present the case of a middle-aged man who developed an infective endocarditis of the tricuspid valve caused by methicillin-sensitive Staphylococcus aureus and associated with a very large vegetation (nearly 5 cm). Besides the quite unusual size of the vegetation, this report highlights that severe right-sided endocarditis can occur in the absence of classical risk factors (intravenous drug abuse, presence of a cardiac implantable electronic device or other intravascular device, and underlying right-sided cardiac anomaly) and that some cases of severe tricuspid endocarditis can be successfully treated by partial excision and patch repair.
Aortic valve and root replacements require an in-depth understanding of the aortic root and annulus. Both structures can be asymmetric at times, and this needs to be recognized and taken into consideration when peforming valve-sparing operations or other root-replacement procedures. Moreover, the geometry of the aortic annulus can be altered, and when performing an aortic root replacement this can distort the geometry of a neo-aortic valve for instance, and lead to valve dysfunction, which is difficult to reverse. We are describing an altered aortic annulus, which required modification through annulus elevation before proceeding with aortic root replacement with a graft-reinforced pulmonary-autograft.
Hybrid coronary revascularization (HCR) consists of left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and transcatheter revascularization of the non-LAD stenosis in specific settings to achieve complete coronary revascularization. Technique to perform the LITA to LAD graft has ranged from median sternotomy with cardiopulmonary bypass to robotically assisted totally endoscopic coronary bypass surgery using beating heart revascularization.
The gold standard for the treatment of pure aortic insufficiency (PAI) is surgical valve repair or replacement.1 With the newest transcatheter heart valve technologies and the accumulating years of experience of heart teams with the current transcatheter aortic valve replacement (TAVR) prostheses, implanters have push the envelope with off-label use of those valves designed and approved for aortic stenosis, in patients with pure aortic insufficiency especially those at higher risks or for compassionate use.3 However, new prostheses are currently under investigation in clinical use and evidences are provided on the safety and efficacy of those latter. It will be discussed in this commentary, the actual clinical evidences and the use of transcatheter heart valves, in and off label, for the treatment of pure aortic insufficiency.
Background The use of thoracic endovascular aortic repair (TEVAR) for the management of uncomplicated type B aortic dissection (un-TBAD) remains controversial. There is a lack of consensus over whether pre-emptive TEVAR should be carried out in patients with un-TBAD at risk of progression to complicated TBAD. We present a review of current evidence and seek to suggest criteria where endovascular intervention in un-TBAD may prove beneficial relative to pharmacotherapy alone. Methods and Materials PubMed and Cochrane databases were searched using terms including: type B aortic dissection, risk factors, medical therapy, TEVAR, false lumen expansion, and mortality. Papers were selected based on title and abstract. Results Optimal medical therapy remains the mainstay treatment for patients with un-TBAD, however patients with un-TBAD present with varying degrees of disease progression risk. Factors such as age, aortic morphology, history of connective tissue disorders, false lumen thrombosis, and aortic branch involvement may potentiate progression from un-TBAD to complicated TBAD. Short- and long-term outcomes associated with TEVAR for TBAD remain promising. Conclusion Pre-emptive TEVAR may be beneficial in patients with un-TBAD presenting with the above factors, however further prospective research into the optimal timing for TEVAR in un-TBAD is required.
Bilateral lung transplant for pulmonary hypertension with pulmonary artery aneurysmBerhane Worku MD1,2, Charles Mack MD1,3, Ivancarmine Gambardella MD1,2New York Presbyterian Weill Cornell Medical Center, New York NY 10021New York Presbyterian Brooklyn Methodist Hospital, Brooklyn NY 11215New York Presbyterian Queens Hospital, Queens NY 11335Corresponding AuthorBerhane Worku MD Brooklyn Methodist HospitalDepartment of Cardiothoracic Surgery506 6th StreetBrooklyn, NY 11215718-780-7700Bmw2002@med.cornell.eduPulmonary artery aneurysms (PAA) may be secondary to congenital cardiac defects such as a patent ductus arteriousus (PDA), atrial septal defect, or ventricular septal defect. They may also occur secondary to infection or connective tissue disease or they may be idiopathic in nature. Repair is undertaken to prevent the sequelae of rupture or dissection, although the specific size criteria at which repair is recommended remains controversial. Pulmonary hypertension (PH) may also lead to PAA, in which case isolated repair is not recommended. Heart-lung transplant has classically been the treatment of choice for PH with PAA, especially when associated with congenital heart defects, right ventricular dysfunction, and pulmonic valve regurgitation.In the setting of PH with PAA and correctable cardiac defects, bilateral lung transplant (BLT) has been described. Concurrent PAA repair is required, and several techniques exist to allow for this. In the current issue of the Journal of Cardiac Surgery, Doi et. al. offer a review of PH with PAA, with a focus on strategies to allow for BLT and PAA repair, hence avoiding the need for HLT. They describe a case of a patient with PH secondary to a PDA and a 9cm PAA who underwent BLT and PAA repair. The donor descending aorta and a bovine pericardial tube was used to reconstruct the recipient main and right PA, respectively. The patient suffered from persistently elevated PA pressures postoperatively due to a kink in the anastomosis between the neo-main PA (donor descending aorta) and the neo-right PA (bovine pericardial tube) requiring surgical revision, but the patient otherwise made an excellent recovery1.The benefit with BLT (rather than HLT) stems from limitations in donor supply which may result in unacceptably long wait times and reduced waitlist survival in patients awaiting HLT. As right ventricular function typically improves after BLT for PH, the donor heart from a HLT bloc may be better served to another patient with terminal cardiac failure. A variety of techniques have been described to allow for repair of massive PAAs at the time of BLT. Harvesting of the entire donor PA to allow replacement of the PAA has been described and is feasible when the donor heart is unsuitable for transplantation2,3. When the donor main PA is unavailable for harvesting, pulmonary arterioplasty and replacement with donor descending aorta have been described at the time of BLT4-7. After resection of the PAA, the proximal donor aorta is anastamosed to the proximal PA with the distal aorta oriented towards the right lung. The distal donor aorta is anastamosed to the donor right PA. The innominate and left carotid orifices can be used for anastomoses to the donor left PA5,6. Extension of a short donor left PA with an autologous pericardial tube has been described5. Similarly, extension of a short donor right PA with a bovine pericardial tube is described in the current report1.Pulmonary valve (PV) regurgitation may occur secondary to annular dilation from the PAA. PV replacement has been described, including sutureless valve implantation with valves intended for percutaneous deployment4. Durability remains a concern, and valve sparing repair techniques (commisuroplasty) have also been described3. When the donor heart is not being harvested, BLT with procurement of the donor right ventricular outflow graft has been described8. HLT always remains a reasonable option in the setting of extremely massive PAA associated with severe PV regurgitation and right ventricular dysfunction, assuming adequate donor availability and ability of the recipient to tolerate the longer wait time9.Recovery of right ventricular function and tricuspid regurgitation after BLT for PH has been documented, supporting the shift from HLT to BLT for this entity. In the setting of left ventricular diastolic dysfunction, severe pulmonary edema and hypoxia can be seen after BLT for PH as the LV is suddenly loaded, and in such a scenario ECMO has been utilized to allow time for LV remodeling. Various centers may prefer HLT over BLT for these cardiac consequences of prolonged PH10. In the absence of these complicating factors, BLT should be considered for PH in otherwise appropriate candidates. BLT for PH with PAA is likely best managed with harvesting the donor main PA when the donor heart is not being considered for harvest. When the donor PA is not available, the decision to attempt the abovementioned strategies for PAA repair such as neo-PA creation with donor aorta and the associated prolongation of donor ischemic time must be weighed against exposing the patient to elevated waitlist mortality while waiting for an acceptable heart-lung bloc to become available. Transplant center expertise and regional differences in heart and lung donor utilization rates will likely a relevant factor to consider when selecting the optimal strategy for each patient.REFERENCESDoi A, Gajera J, Niewodowski D, Gangahanumaiah S, Whitford H, Snell G, Kaye D, Joseph T, McGriffin D. Surgical management of giant pulmonary artery aneurysms in patients with severe pulmonary arterial hypertension. J Card Surg; in press]Schwarz S, Benazzo A, Prosch H, Jaksch P, Klepetko W, Hoetzenecker K. Lung transplantation for pulmonary hypertension with giant pulmonary artery aneurysm. J Thorac Cardiovasc Surg 2020;159:2543-50Shayan H, Sareyyupoglu B, Shigemura N, Thacker J, Bermudez C, Toyoda Y. Lung transplant, double valve repair, and pulmonary artery aneurysm resection. Ann Thorac Surg 2012;93:e3-5Pelenghi S, Primiceri C, Belliato M, Ghio S, Scelsi L, Totaro P. Is it time for a paradigm shift: Should double-lung transplant be considered the treatment of choice for idiopathic pulmonary arterial hypertension and giant pulmonary aneurysm? J Card Surg 2021;36:2996-2999Noda M, Okada Y, Saiki Y, Sado T, Hoshikawa Y, Endo C, Sakurada A, Maeda S, Oishi H, Kondo T. Reconstruction of pulmonary artery with donor aorta and autopericardium in lung transplantation. Ann Thorac Surg 2013;96:e17-9Force SD, Lau CL, Moazami N, Trulock EP, Patterson GA. Bilateral lung transplantation and pulmonary artery reconstruction in a patient with chronic obstructive pulmonary disease and a giant pulmonary artery aneurysm. J Thorac Cardiovasc Surg 2003;126:864-6.Oda H, Hamaji M, Motoyama H, Ikeda T, Minatoya K, Nakajima D, Chen-Yoshikawa TF, Date H. Use of a three-dimensional model in lung transplantation for a patient with giant pulmonary aneurysm. Ann Thorac Surg 2020;109:e183-5Zanotti G, Hartwig MG, Davis RD. A simplified technique for pulmonary artery aneurysm repair in a lung transplant recipient with right ventricular outflow tract obstruction. J Thorac Cardiovasc Surg 2013;145: 295-6Eadington T, Santhanakrishnan K, Venkateswaran. Heart-lung transplantation for idiopathic pulmonary arterial hypertension and giant pulmonary artery aneurysm – case report. J Cardiothorac Surg 2020;15:169Budev MM, Yun JJ. Advanced circulatory support and lung transplantation in pulmonary hypertension.
Thin, metallic wires can easily penetrate the gastrointestinal system if ingested and cause serious cardiac issues in children. We report a pediatric case of such an object that caused cardiac tamponade after lodging in the left ventricle. The wire was extracted without cardiopulmonary bypass and a full recovery was made. Cardiac issues after ingestion of foreign objects are rare but immediate surgery is required for resolution.
Background and aim: On the basis of previously published accounts, coupled with our own experience, we have assessed the surgical approaches to patients with isomeric atrial appendages. Methods: We reviewed pertinent published studies on surgical treatment of individuals with isomeric atrial appendages, with the pertinent surgical details provided by most of the manuscripts. Results: Half of patients with right isomerism, and two-thirds of those with left isomerism have bilateral superior caval veins. Azygos extension of the inferior caval vein is reported in three-quarters of those with left isomerism. The coronary sinus is universally absent in right isomerism, along with totally anomalous pulmonary venous connection, and is absent in two-fifths of those with left isomerism.. Univentricular atrioventricular connections are expected in up to three-quarters of those with right isomerism. Atrioventricular septal defect is reported in up to four-fifths, more frequently in right isomerism, with such patients typically having discordant ventriculoatrial connections or double outlet right ventricle. Reported mortalities extend to 85% for those with right, and 50% for those with left isomerism. In right isomerism, mortality is up to 54% for systemic-to-pulmonary arterial shunting, up to 75% for univentricular repair, and up to 95% for repair of totally anomalous pulmonary venous connection itself. No more than one-quarter had undergone Fontan completion, with reported mortalities of 21%. Conclusion: Early surgical results are satisfactory in patients with left isomerism, but disappointing for those with right. Recent advances in cardiac and liver transplantation may offer improved survival.
Technical details for complex cardiac tumor resection are sparse. We describe the operative technique of modified autotransplantation for resection of a complex pericardial synovial sarcoma in a 63-year-old, Caucasian female. Surgical exposure demonstrated tumor origin at the superior cavoatrial junction and invasion of the aorta, main pulmonary artery, superior pulmonary veins, and left atrial roof. Full macroscopic surgical resection was achieved. The patient received adjuvant radiation for microscopic positive margins and remains alive and with no tumor progression at one year postoperatively. We conclude that modified autotransplantation is a challenging but effective surgical technique when performed with careful patient selection and availability of skilled, cardiothoracic surgeons at a cardiac center of excellence.
The meta-analysis by He and collaborators [has the worth to cover, as much as possible, a gap of scientific evidence where conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provide better pooled results, both early and late, with respect to mitral valve replacement (MVR). However, the superiority of MVP is driven by some single large cohort-studies where surgeons had wide experience in the field of MVP for IE. This finding is also confirmed by other studies. But if mitral repair produces such a better short- and long-term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder but to repair or not to repair, is that really the question? The AATS consensus suggests to repair “whenever possible” but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP as to perform in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with very large volume of valve repairing. This decision cannot therefore be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam.
Background and aim of the study. Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few mm. Material and Methods. From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69±7 years and ESII 3.5±1.7. Four patients had moderately impaired ejection fraction (35-49%). Results. There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow up of 53±14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2±2.0 to 42.5±4.1 mm, p=0.03. The diameter of the proximal arch remained unchanged, from 37.1±1.6 to 36.3±2.9 mm, p=0.20. Conclusions. In presence of moderately dilated AA wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure.
This case report describes the management of a large iatrogenic ventricular septal defect (VSD) created by the coring device during systemic ventricular assist device (RVAD) insertion in a 16 year-old patient with congenitally corrected transposition of the great arteries. The VSD was closed by bovine pericardial patch and the ventriculotomy was extended laterally to relocate the VAD sewing ring. After RVAD implantation, patient initially remained cyanotic, potentially due to a tiny VSD patch leak with right to left shunting. Hypoxia was successfully corrected by rescue nitric oxide infusion and patient was bridged to transplant after 91 days.