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.
Abstract The objective of this study was to describe early respiratory outcomes of asymptomatic COVID-19 patients after cardiac surgery. In this retrospective clinical study (case series) we reviewed and analyzed patient clinical data of 25 covid-19 asymptomatic patients that underwent urgent or emergent cardiac surgery between February 29 and April 10, 2020 in Tehran Heart Center Hospital. Median of age was 63 years (IQR, 52-67), Euro SCORE 7.50 (IQR, 6.5-8.5) and body mass index 26.3 (IQR, 22.5-28.6). 68% of patients had one or more comorbidities. Hypertension (56%) was the most common followed by Diabetes type 2 (40%). Off-pump cardiac surgery was done in 4 patients and on-pump on 21 patients with median CPB time of 85 minutes (IQR, 50-147.50). Median anesthesia time was 4.5 hours (IQR, 4-5). Median oxygen index and Fio2 on ventilator were 10 cmH20 (IQR, 9.5-10.5) and 0.64(IQR, 0.60-0.64) respectively. Median pao2/Fio2 was 231(IQR, 184-261). There was one case of extubation failure. The Median intubation time and length of ICU stay were 13 hours (IQR, 9.5-18) and 3 days (IQR, 2-4) respectively. Overall mortality was 16%. Readmission rate to ICU was 16% with. In this group respiratory outcome was worse with median Pao2/Fio2 84.5 (75-122), oxygen index of 4.38(IQR, 3.77-5.1) and morality rate of 75%. Conclusion: Based on the results of this study, very early post-cardiac surgery respiratory outcomes in asymptomatic COVID-19 patients are apparently smooth; nonetheless, readmission to the ICU is high. Overall respiratory outcomes are poor especially for those who readmitted to ICU.
ABSTRACT Background: COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11st, 2020. Responses to this crisis integrated resource allocation for the increased amount of infected patients, while maintaining an adequate response to other severe and life-threatening diseases. Though cardiothoracic patients are at high risk for Covid-19 severe illness, postponing surgeries would translate in increased mortality and morbidity. We reviewed our practice during the initial time of pandemic, with emphasis on safety protocols. Methods: From March 11st to May 15th 2020, 148 patients underwent surgery at the Department of Cardiothoracic Surgery of CHUSJ. The clinical characteristics of the patients were retrospectively registered, along with novel containment and infection prevention measures targeting the new Corona Virus. Results: The majority of adult cardiac patients were operated on an urgent basis. Hospital mortality was 1.9% (n = 2 patients). Most of adult thoracic patients were admitted from home, with a diagnosis of neoplasic disease in 60% patients. Hospital mortality was 3.3% (1). Fifteen children underwent cardiothoracic surgery. There was no mortality. The infection prevention procedures applied, totally excluded the transmission of Covid-19 in the Department. Conclusion: While guaranteeing a prompt response to emergent, urgent and high priority cases, novel safety measures in individual protection, patients circuits and pre-operative diagnose of symptomatic and asymptomatic infection were adopted. The surgical results corroborate that it was safe to undergo cardiothoracic surgery during the initial time of Covid-19 pandemic. The new policies will be maintained while the virus stays in the community.
Unicuspid aortic valves are rare congenital malformations. Surgical repair is feasible in aortic regurgitation, and in some cases of aortic stenosis. The standard surgical approach is a bicuspidization and symmetrization with pericardial patch augmentation of valve cusps. Herein, we are describing our original technique for bicuspidization of a unicuspid aortic valve without cusp patch augmentation. We also address the surgical management of a commissural diastasis.
Background The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardised practice. This single centre retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD. Methods Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into 2 groups: a) ascending aorta (interposition) graft (AAG) without valve replacement; and b) non-valve-sparing aortic root replacement (ARR). Pre-operative covariates were compared, as well as operative characteristics and post-operative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis. Results In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, 9 developed severe aortic regurgitation and 2 patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p=0.004). Conclusions With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.
Background: The treatment of complex thoracic aorta pathologies remains a challenge for cardiovascular surgeons. After introducing Frozen Elephant Trunk (FET), a significant evolution of surgical techniques has been achieved. The present meta-analysis aimed to assess the efficacy of FET in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on post-operative neurologic outcomes. Methods: A standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was conducted for all observational studies of patients diagnosed with ATAAD undergoing total arch replacement with FET reporting in-hospital mortality, bleeding, and neurological outcomes. A random-effect meta-analysis was performed using STATA software (StataCorp, TX, USA). Results: Thirty-five studies were eligible for the present meta-analysis, including 3211 patients with ATAAD who underwent total arch replacement with FET. The pooled estimate for in-hospital mortality, postoperative stroke, and spinal cord injury were 7% (95% CI 5 – 9; I2 = 68.65%), 5% (95% CI 4 – 7; I2 = 63.93%), and 3% (95% CI 2 – 4; I2 = 19.56%), respectively. Univariate meta-regression revealed that with increasing the duration of hypothermic circulatory arrest time, the effect sizes for postoperative stroke and SCI enhances. Conclusions: It seems that employing the FET procedure for acute type A dissection is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET.
Background and aim of the study: Several studies reported safety and potential benefits of single dose Del Nido cardioplegia (DNC) in selected Adult Cardiac Surgery (ACS) procedures. However, studies are scarce on routine use of DNC in more complex procedures and patients with high risk profile. We sought to compare DNC with cold blood cardioplegia (BC) in all types of ACS including complex procedures. Methods: Data for 305 consecutive unselected patients who underwent ACS procedures (July/2017 to Nov/2019) were included. DNC was routinely used whenever is available (n=231) and if not available, cold BC is used (n=74). All categories of ACS procedures (primary or redo) were included. Repeated measures analysis was performed to compare baseline, peak and trough Troponins levels in both groups. Linear regression analysis was used to identify independent predictors of peak Troponins level. Results: The two groups were comparable in baseline characteristics including euro score (ES II), risk profile and surgical complexity. DNC was associated with lower cardiopulmonary bypass (CPB) and cross clamp times, cardioplegia volume and number of cardioplegia doses (P<.001). Importantly, DNC was associated with lower postoperative Troponin level (P=.001), shorter duration of inotropic support (P=.02) and shorter intensive care unit stay (P=.04). On linear regression analysis, DNC was an independent predictor of lower postoperative peak Troponin (t = -3.5, P<.001). Conclusions: Routine use of DNC in all types of ACS procedures compared to BC was associated with significantly shorter CPB and clamp times, significantly lower post-operative troponin release and shorter duration of inotropic support.
Aims：This study aimed to investigate the safety, feasibility and availability of perimembranous ventricular septal defect (PmVSD) closure via a left parasternal ultra-minimal trans intercostal incision in children. Methods and results：From January 2015 to January 2019, 131 children with restrictive PmVSDs were enrolled in this study and successfully done in 126 patients (96.18%). PmVSDs were occluded via an ultra-minimal trans intercostal incision (≤1 cm), and the entire occlusive process was guided and monitored by TEE. A pericardium hanging technique was employed without sternal incision. PmVSDs were closed through a short delivery sheath assembled using a concentric occluder device. All patients were followed up for a perid ranging from18 months to 24 months. Thirteen patients with PmVSD had aneurysm of membranous septum (AMS). Multistream (more than or equal to 2) PmVSDs with AMS were found in eleven cases. After the operation, mild residual shunt beside the amplatzer occluder in one patient was found and had self-healing result during the 5-month follow-up period. Five patients transferred to ventricular septal defect repair operation under direct visualization with a cardiopulmonary bypass. One reason was ventricular fibrillation when guide wire passed the PmVSD, another was device dislocation, and others were the guide wire cannot pass through the PmVSD. Conclusions：PmVSDs closure using a concentric occluder via a left parasternal ultra-minimal trans intercostal incision under TEE guidance is feasible, safe, and effective in children. This approach can be considered as an alternative treatment to open-heart surgery for restrictive PmVSDs.
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.
Background Use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (e.g. acute Type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favour of improved surgical access and outcomes. This review seeks to elucidate whether proximalisation of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes. Methods We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. Results Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. Conclusion Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review therefore recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalisation of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.
Objective: This study aimed to establish a risk assessment model to predict postoperative severe acute lung injury (ALI) risk in patients with acute type A aortic dissection (ATAAD). Methods: Consecutive patients with ATAAD admitted to our hospital were included in this retrospective assessment and placed in the postoperative severe ALI and non-severe ALI groups based on the presence or absence of ALI within 72 h postoperatively (oxygen index (OI) ≤100 mmHg). Patients were then randomly divided into training and validation groups in a ratio of 8:2. Logistic regression analyses were used to statistically assess data and establish the prediction model. The prediction model’s effectiveness was evaluated via tenfold cross-validation of the validation group to facilitate construction of a nomogram. Results: After screening, 479 patients were included in the study: 132 (27.5%) in the postoperative severe ALI group and 347 (72.5%) in the postoperative non-severe ALI group. Based on logistics regression analyses, the following variables were included in the model: coronary heart disease (CHD), cardiopulmonary bypass (CPB) ≥257.5 min, left atrium (LA) diameter ≥35.5 mm, hemoglobin ≤139.5 g/L, preCPB OI ≤100 mmHg, intensive care unit (ICU) OI ≤100 mmHg, left ventricular posterior wall thickness (LVPWT) ≥10.5 mm, and neutrophilic granulocyte percentage (NEUT) ≥0.824. The area under the receiver operating characteristic (ROC) curve of the modeling group was 0.805, and differences between observed and predicted values were not deemed statistically significant via the Hosmer–Lemeshow test (χ2=6.037, df=8, P=0.643). For the validation group, the area under the ROC curve was 0.778, and observed and predicted value differences were insignificant when assessed using the Hosmer–Lemeshow test (χ 2=3.3782, df=7; P=0.848). The average tenfold cross-validation score was 0.756. Conclusions: This study established a prediction model and developed a nomogram to determine the risk of postoperative severe ALI after ATAAD. Variables used in the model were easy to obtain clinically and the effectiveness of the model was good.
Background: We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types. Methods: We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observedto-expected (O/E) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio >2 in one operation type with O/E ratio ≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures. Results: Among 37 NY centers, annual center volumes were 220±120 cases for CABG and 190±178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R2 = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio > 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase. Conclusions: In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.
Under the unprecedented pressures of the global coronavirus disease 2019 (COVID-19) pandemic, there is an urgent requisite for successful strategies to safely deliver cardiac surgery. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first described in early December 2019, and the rapid spread and emergence of this virus has caused significant disruptions in the delivery of healthcare services worldwide.1,2 In particular, provision of cardiac surgery has been disproportionally affected due to reallocation of intensive care resources, such as ventilators.2Additionally, patients with pre-existing cardiovascular disease are likely to have comorbidities which are associated with poorer clinical outcomes in confirmed SARS-CoV-2 cases.3,4 Despite this, Yandrapalli and colleagues have reported the first case of a successful coronary artery bypass graft (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection, which offers insights into how cardiac surgery could be adapted to solve the challenges of this pandemic.5In response to the burden of COVID-19 on healthcare systems in the United Kingdom (UK), elective cardiac surgeries have been delayed owing to the redistribution of intensive care resources and the unquantifiable risk of acquiring COVID-19.2 Likewise, cardiac surgery services have undergone structural remodelling into a centralised system in an attempt to continue provisions of emergency surgery alongside hospital management of COVID-19 patients.2Unsurprisingly, most cardiac surgery units across the globe have seen a sharp decline in surgeries as a result, and one unit reported an 83% reduction in cardiac index cases between 23rd March to 4th May 2020.2 Similar models have been used in Europe to manage healthcare services and increase intensive care capacity. For example in the Lombardy region of Italy, 16 out of 20 cardiac surgical units discontinued services and all urgent cases have been consequently diverted to the remaining four units for centralised services.6 Whilst these measures have been beneficial for supporting the focused management of COVID-19 patients, it is important to reflect upon the future consequences of delayed elective cardiac surgery. Indeed, such patients are likely to have progressive conditions and further work is needed to investigate the long-term impact of COVID-19 on mortality and morbidity in this cohort.The case report by Yandrapalli and colleagues highlight the importance of routine SARS-CoV-2 testing for all patients requiring cardiac surgery, especially for detecting asymptomatic or subclinical infections.5 Active SARS-CoV-2 infection may precipitate an overproduction of early response proinflammatory cytokines in post-operative period, leading to unfavourable surgical outcomes.7,8 Moreover, preliminary studies have shown that patients with established cardiovascular diseases may have a greater risk of increased SARS-CoV-2 infection severity and prognosis.9 Taken together, assessment for active infection is crucial for risk stratification. In addition, clinicians should consider the threshold for surgery when selecting patients for cardiac surgery. An international, multi-centre cohort study by COVIDSurg Collaborative which included 1128 confirmed SARS-CoV-2 patients undergoing a broad range of surgeries revealed that 30-day mortality risk was significantly associated with the patient demographics of male sex, an age of 70 years or older, and poor preoperative physical health status.10 Collectively, the risks and benefits of cardiac surgery should be carefully considered in such patients due to higher mortality risk.10Alternative therapeutic procedures with rapid discharge, such as percutaneous intervention or medical therapy, may be more appropriate to reduce SARS-CoV-2 related mortality and nosocomial infection risk.11Current evidence is limited for postoperative outcomes in cardiac surgery cases. In the aforementioned cohort study by COVIDSurg Collaborative, the 30-day mortality rate was 23.8%.10In addition, the study reported that 51.2% of patients had postoperative pulmonary complications, which was associated with a higher mortality rate of 38.0%.10 In another case report describing an emergency CABG operation, the asymptomatic patient succumbed to pulmonary complications arising from a SARS-CoV-2 infection confirmed postoperatively.12 The authors acknowledge that the undiagnosed infection may have triggered a refractory pathological response after cardiac surgery. Indeed, recent literature has suggested that patients with SARS-CoV-2 are at higher risk of developing thromboembolisms, possibly mediated by the interaction with angiotensin-converting enzyme 2 (ACE2) receptors.13Similarly, there is a consensus that SARS-CoV-2 has direct adverse effects on the myocardium due to high expression of ACE2.14 As such, SARS-CoV-2 can potentially trigger multisystem complications which require vigilant monitoring, especially in patients requiring cardiopulmonary bypass and at high risk of developing thromboembolisms. Cardiac surgery patients represent a vulnerable patient population, and this cohort may experience worse outcomes with SARS-CoV-2 infection based on the current available evidence. In the latest recommendation, UK currently advises all patients who are listed for elective cardiac surgery to self-isolate for 14 days prior to surgery date, in a measure to limit and contain the exposure of such cohort to the smallest possibilities of acquiring COVID-19.Currently, the future of cardiac surgery after the pandemic is unclear as the evidence is still emerging. However, the lessons learnt from these unprecedented times can be taken forward to inform future service planning. Moving forwards, routine screening of patients for SARS-CoV-2 infection will undoubtedly play a key role in identifying asymptomatic or subclinical infections. The preoperative UK National Health Service testing recommendations should be broadened so that all patients undergoing cardiac surgery are screened, given the higher risk of postoperative complications in this population. Similarly, repeat testing is important for monitoring patients for concomitant infections. Alongside changes to hospital protocol, service delivery will inevitably shift. The successful application of telemedicine during the pandemic has already been reported in the delivery of oncology services.15 Moreover, the benefits of telecardiology outside of the COVID-19 era have been previously reported, and cardiology services will likely embrace the utilisation of telemedicine for managing outpatient consultations.16 Units will also have to address the vast backlog of surgeries caused by cancellation of elective cardiac operations in a sustainable manner, with adequate hospital space and personal protective equipment availability.17 In order to resume success services, planning for this eventuality should begin now and patients at significant mortality risk due to delayed surgery need to be prioritised.Ultimately, clear guidelines should be implemented to ensure safe resumption of surgical services, whilst also reassuring patients concerned about safety.3 Whilst the future trajectory of this pandemic is uncertain, the insights from the impact of COVID-19 on cardiac surgery will undoubtedly shape the future delivery of cardiac surgery.
Background: This study investigates the use of modern machine learning (ML) techniques to improve prediction of survival after orthotopic heart transplantation (OHT). Methods: Retrospective study of adult patients undergoing primary, isolated OHT between 2000-2019 as identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was one-year post-transplant survival. Patients were randomly divided into training (80%) and validation (20%) sets. Dimensionality reduction and data re-sampling were employed during training. Multiple machine learning algorithms were combined into a final ensemble ML model. Discriminatory capability was assessed using area under receiver-operating-characteristic curve (AUROC), net reclassification index (NRI), and decision curve analysis (DCA). Results: A total of 33,657 OHT patients were evaluated. One-year mortality was 11% (n=3,738). In the validation cohort, the AUROC of singular logistic regression was 0.649 (95% CI 0.628-0.670) compared to 0.691 (95% CI 0.671-0.711) with random forest, 0.691 (95% CI 0.671-0.712) with deep neural network, and 0.653 (95% CI 0.632-0.674) with Adaboost. A final ensemble ML model was created that demonstrated the greatest improvement in AUROC: 0.764 (95% CI 0.745-0.782) (p<0.001). The ensemble ML model improved predictive performance by 72.9% ±3.8% (p<0.001) as assessed by NRI compared to logistic regression. DCA showed the final ensemble method improved risk prediction across the entire spectrum of predicted risk as compared to all other models (p<0.001). Conclusions: Modern ML techniques can improve risk prediction in OHT compared to traditional approaches. This may have important implications in patient selection, programmatic evaluation, allocation policy, and patient counseling and prognostication.
Intimal sarcomas simultaneously involving the right atrium and the inferior vena cava are rare. We report an advanced cardiac intimal sarcoma in the right atrium of a 19-year-old man that was complicated by tumor-related inferior vena cava thrombosis. We initially performed partial tumor resection and vena cava thrombectomy to resolve the circulatory obstruction, because complete resection was difficult due to the invading malignancy and an unclear margin. The patient received adjuvant chemo- and radiotherapy along with anticoagulant therapy. After 3 months, the border of the residual sarcoma was clear, and the patient underwent a secondary complete sarcoma excision (including that of the right atrium) and a suprahepatic vena cava reconstruction. At the 2-year follow-up, there was no tumor recurrence. We conclude that aggressive treatment and a staged complete resection can lead to improved outcomes for advanced cardiac intimal sarcoma with poor prognosis.
Objective: The study aimed to evaluate the indications and describe the aortic valve reconstruction techniques by Ozaki’s procedure in Vietnam and report mid-term outcomes of this technique in Vietnam. Methods: Between June 2017 and December 2019, 72 patients diagnosed with isolated aortic valve disease, with a mean age of 52.9 (19 – 79 years old), and a male:female ratio of 3:1 underwent aortic valve reconstruction surgery by Ozaki’s technique at Cardiovascular Center, E Hospital, Vietnam. Results: The aortic valve diseases consisted of aortic stenosis (42%), aortic regurgitation (28%), and a combination of both (30%). In addition, the proportion of aortic valves with bicuspid morphology and small annulus (≤ 21 mm) was 28% and 38.9%, respectively. The mean aortic cross-clamp time was 106 ± 13.8 minutes, mean cardiopulmonary bypass time was 136.7 ± 18.5 minutes, and 2.8% of all patients required conversion to prosthetic valve replacement surgery. The mean follow-up time was 26.4 months (12- 42 months), the survival rate was 95.8%, the reoperation rate was 2.8%, and rate of postoperative moderate or higher aortic valve regurgitation was 4.2%. Postoperative valvular hemodynamics was favorable, with a peak pressure gradient of 16.1 mmHg and an effective orifice area index of 2.3 cm 2. Conclusions: This procedure was safe and effective, with favorable valvular hemodynamics and a low rate of valvular degeneration. However, more long-term follow-up data are needed.
Emergency surgery, blood transfusion, and reoperation for bleeding have been associated with increased operative morbidity and mortality. The recent increased use of direct oral anticoagulants and antiplatelet medications have made the above more challenging. In addition, cardiopulmonary bypass (CPB) with its associated hemodilution, fibrinolysis and platelet consumption may exacerbate the pre-existing coagulopathy and increase the risk of bleeding. Management decisions are typically made on a case-by-case basis. Surgery is delayed when possible and less invasive percutaneous options should be considered if feasible. Attention is paid to exercising meticulous techniques, avoiding excessive hypothermia and treating coexisting issues such as sepsis. Ensuring a dry operative field upon entry by correcting the coagulopathy with reversal agents is offset by the concern of potentially hindering efforts to anticoagulate the patient (heparin resistance) in preparation for CPB, in addition to possibly increasing the risk of thromboembolism. Proper knowledge of the anticoagulants, their reversal agents, and the usefulness of laboratory testing are all essential. Platelet transfusion remains mainstay for antiplatelet medications. Four-factor prothrombin complex concentrate is considered in patients on oral anticoagulants if CPB needs to be instituted quickly. Specific reversal agents such as idarucizumab and andexanet alfa can be considered if significant tissue dissection is anticipated such as redo sternotomy, but are costly and may lead to heparin resistance and anticoagulant rebound.