The impact of the COVID-19 pandemic in New York City (NYC) is dramatic. COVID-19 cases surged, hospitals expanded to meet capacity, and NYC remains the global epicenter of this pandemic. During this unprecedented time, a young woman with known Marfan syndrome presented with an acute complicated type B aortic dissection to our Aortic Center. Using the Provisional Extension to Induce Complete Attachment technique, we treated this patient and quickly discharged her the next day to decrease the risk of COVID-19 infection. Her progress was monitored using frequent phone calls and one office visit at two weeks.
Keeping up with the surgical training might be difficult during the time of COVID-19 pandemic: with most of the health care resources dedicated to face this reality, trainees can improve themselves deep diving in scientific literature, study, Telemedicine and Social Media professional platforms. Moreover, they might be directly involved in COVID patient care, facing a still a still elusive disease with a high lethality rate. Often the frustration of having no valid treatment and a poor incisiveness on the natural course of the COVID19 could lead to a blue mood or a burnout. Eventually, the natural adaptability and the survival instinct prevail and teach us the real meaning of resilience. Every trainee has to be prepared for the second phase, when the new normality will force everyone to cohabit with the virus. Even the obvious teething troubles, this could be the right moment for all the Residents to “grow-up” and develop their own future Character.
A 42-year old man with thrombophilia (prothrombin gene mutation) required the insertion of an inferior vena cava filter because of recurrent gastrointestinal bleeding associated with oral anticoagulation. However, it penetrated through the retro-hepatic vena cava into the liver, being manifested by constant, blunt abdominal pain. Endovascular retrieval was considered of extreme risk, though a surgical approach was performed under cardiopulmonary bypass with deep hypothermic circulatory arrest. The patient has recovered uneventfully with complete symptom relief.
Objectives We aimed to investigate whether uncomplicated type A intramural hematoma (IMHA) patients with type 2 diabetes mellitus (DM) who underwent a “wait-and-watch strategy” and tight glycemic control had similar clinical outcomes as patients without DM who received the same treatment strategy. Methods Between January 2010 and December 2016, uncomplicated IMHA patients with and without diabetes mellitus were included and were propensity score matched to improve balance between the two groups. Cox proportional hazard models were constructed to identify the specific factors associated with aorta-related mortality. The Fine-Gray model for the competing risk analysis was used to estimate the aorta-related and non-aorta-related mortality in different groups during the follow-up period. Results 109 IMHA patients were included in this study, and 66 patients were included after matching. Patients without DM experienced significantly more aorta-related adverse events (51.6% vs 13.3%, P=0.001) and reinterventions than patients in the DM group (29.0% vs 6.7%, P=0.023). Cox regression analysis revealed that a higher matrix metalloproteinase-9 level (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.39-2.09, P<0.001) and larger maximum aortic diameter (HR, 1.41; 95% CI, 1.11-1.80, P=0.005) were associated with higher aorta-related mortality. The competing risk analysis revealed a significantly higher aorta-related mortality during the follow-up period in the no DM group than in the DM group (36.4%; 95% CI, 11.6%-82.3%, P=0.0294). Conclusions Uncomplicated IMHA patients with DM (receiving the “wait-and-watch strategy” and tight glycemic control) may have a lower aorta-related mortality, and rates of aorta-related adverse events and reinterventions than the no DM group.
Background: Prolonged pleural drainage after the Fontan procedure is a common complication. Various protocols have been described, but there is no definitive consensus for the treatment of this complication. Materials and Methods: Our primary aim was to determine the effect of the protocol on the duration of drainage and hospital stay. Our secondary aim was to determine parameters affecting prolonged drainage after the Fontan procedure. Ninety two consecutive patients who underwent the Fontan operation retrospectively analyzed. A protocol-based postoperative management was adopted at July 2018. Patients operated before the protocol were defined as Group 1(n=48), and patients operated after the protocol were defined as Group 2(n=44). Results: The mean age was 5(IQR 4.0-6.9) years the mean body weight was 17.3 (IQR 15.1-21.8) kg.There were statistically significant differences between groups in terms of total drainage, duration of pleural drainage, prolonged drainage and, LOHS(p=0.05,p=0.04, p=0.04,p=0.04,respectively). In the multivariate analysis, the application of the protocol was observed to be the only factor for prolonged drainage (OR:2.46, 95% CI Lower-Upper:1.03-5.86,p=0.04). Conclusion: Standardization and strict application of the medical treatment within a specific protocol without being affected by doctor, nurse or patient-based factors increases the success. After the changes in our medical management strategy, along with the decrease in total drainage and duration of pleural drainage, LOHS was also reduced, of course together with a reduction in the cost. Key Words: Fontan, pleural drainage, hospital stay, protocol
Background and aim of the study: In developed countries, the shortage of viable donors is the main limiting factor of heart transplantation. The aim of this study is to determine whether the same reality applies to Brazil. Methods: Between January 2012 and December 2014, 299 adult heart donor offers were studied in terms of donor profiles, and reasons of refusal. European donor scoring system was calculated, being high-risk donors defined as >17 points. Donor scoring system used to objectively determine the donor profile and correlate with donor acceptance and post-transplant primary graft dysfunction and recipient survival. Cox proportional hazard model was used in determining predictors of long-term mortality. Results: Rate of donor acceptance and heart transplants performed were 45.8% and 19.3%, respectively. Reasons for refusal were mostly non-medical (53.7%). The majority of donors were classified as high-risk (65.5%). Hearts from high-risk donors did not impact on primary graft dysfunction (14.3% vs 10%, P=0.6), neither on long-term survival (P=0.4 by log-rank test). Recipient’s age greater than 50 years (HR 6.02, CI95% 2.41 – 16.08, P<0.0001) was the only predictor of long-term mortality. Conclusions: Shortage of donors is not the main limiting factor of heart transplantation in Mid-West of Brazil. Non-medical issues represent the main reason of organ discard. Most of the donors were classified as high-risk which indicates that an expanded donor pool is a routine practice in our region, and donor scoring does not seem to influence to proceed with the transplant.
Extra Corporeal Membrane Oxygenation (ECMO) is a supportive therapy used to provide cardiac support with or without respiratory support in the event of cardiopulmonary failure. The two main types of ECMO are Veno-arterial ECMO (VA-ECMO) and Veno-venous ECMO (VV-ECMO). The use of ECMO in cardiac surgery has been established in cases of post-cardiotomy cardiogenic shock which is refractory to conventional therapy with inotropes and intra-aortic balloon pulsation support. Survival for this, otherwise, fatal condition has been shown to be improving through the use of ECMO. However, the decision and timing to initiate ECMO therapy remains selective and is dependent on a range of factors such as patient factor, clinician’s judgement, meaning there is no consistent and solid ground regarding the timing of ECMO initiation. This article will provide an extensive review of ECMO indications, contraindications, complications and outcomes to analyse the survival benefit of ECMO following cardiac surgery.
We present the clinical case of a 60-year-old woman complained of dyspnea on exertion. Echocardiogram showed a giant mass in right ventricle (RV) with obstruction to the outflow tract. Thorax CT confirmed a mass of >60 mm infiltrating RV and causing severe stenosis in pulmonary artery, with severe pericardial effusion. Cardiac surgery was performed for tumor resection and pulmonary root replacement with a biological valved conduit. Histological analysis diagnosed a poorly differentiated large-cell neuroendocrine carcinoma. The patient had no immediate postoperative complications and has completed radiotherapy at 6-month follow-up.
Background Displacement of Impella 5.0 secondary to patient movement or transportation is a well known complication. Typically, repositioning of an Impella across the aortic valve is attempted over a guidewire. We present the first case, to our knowledge, of repositioning a dislodged Impella 5.0 without a guidewire under transesophageal echocardiography (TEE) guidance, by inducing rapid ventricular pacing to cross the aortic valve. Case presentation: A 70-year-old man with low left ventricular ejection fraction underwent off-pump coronary artery bypass grafting (OPCABG). On 2nd postoperative day a low cardiac output state developed with increasing lactate levels and consequently the patient was taken to the cardiac catheterization laboratory for insertion of an Impella 5.0. Suddenly the Impella system failed with a rapid hemodynamic deterioration and it was successfully bedside repositioned inducing rapid ventricular pacing. Conclusions: In case of accidental Impella dislodgement and fast deterioration of patient’s hemodynamic status, rapid pacing may be an option to “open” the aortic valve thus aiding quick replacement of Impella 5.0 through the aortic valve into the left ventricle under TEE guidance.
Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by post-operative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.
Abstract Giant right coronary artery aneurysm is a rare coronary artery pathology. We describe a 45-year-old gentleman who presented with unstable angina of recent onset. Diagnostic work up including chest CT angiography and left heart catheterization demonstrated 3-vessel coronary artery disease with giant proximal right coronary artery aneurysm. In the view of the severity of the coronary artery disease and the risk of rupture associated with the giant right coronary artery aneurysm and the clinical presentation, patient was successfully treated by coronary artery bypass surgery. During this procedure, the right coronary artery aneurysm was ligated at both inflow and outflow. Patient recovered well and was discharged home.
Background Porcine aortic roots (PAR) have been reported in the literature with acceptable short and long-term outcomes for the treatment of aortic root aneurysms. However, their efficacy in type A aortic dissection (TAAD) is yet to be defined. Methods Using data from a locally collated aortic dissection registry, we compared the outcomes in patients undergoing aortic root replacement for TAAD using either of two surgical options: i) PAR or ii) composite valve grafts (CVG). A retrospective analysis was conducted for all procedures in the period 2005-2018. Results A total of 252 patients underwent procedures for TAAD in the time period. Sixty-five patients had aortic root replacements (PAR n=30, CVG n=35). Between group comparisons identified a younger CVG group (50.5 vs 64.5, p<0.05) although all other covariates were comparable. Operative parameters were comparable between the two groups. The use of PAR did not significantly impact operative mortality (OR 0.93, 95% CI 0.22-3.61, p=0.992), stroke (OR 2.91, 0.25 – 34.09, p=0.395), re-operation (OR 0.91, 95% CI 0.22 – 3.62, p=0.882) or length of stay (coef 2.33, -8.23 – 12.90, p=0.659) compared to CVG. Five-year survival was similar between both groups (PAR 59% vs CVG 69%, p=0.153) and re-operation was negligible. Echocardiography revealed significantly lower aortic valve gradients in the PAR group (8.69 vs 15.45 mmHg, p<0.0001), and smaller left ventricular dimensions both at 6 weeks and 1 year follow up (p<0.05). Conclusions This study highlights the comparable short and mid-term outcomes of PAR in cases of TAAD, in comparison to established therapy.
Background Post-Cardiotomy ECMO (PC-ECMO) represents a unique subset of critically ill patients, with a paucity of data regarding long-term survival, and characteristics correlated with short and long-term outcomes. We present a retrospective cohort PC patients supported with ECMO at a single institution, with outcomes at 1 and 3-year follow-up. Methods Data was collected retrospectively for all patients requiring ECMO within 72 hours of index cardiac operation, excluding assist devices and heart transplantation. Operative data, frozen mediastinum status, cannulation site, postoperative hemorrhage, and timing of cannulation (immediate versus delayed) were all collected and examined. Primary outcomes were ability to wean from ECMO, hospital survival, and long-term survival. Results 33 patients required PC ECMO, representing a total of 179 days of ECMO support. Overall survival data were: ability to wean 61%, hospital survival 55%, one month survival 45%. The estimated 12 and 36 month survival for all PC ECMO patients was 40% and 33% respectively. Twelve and 36 month survival for all hospital survivors was 66% and 60% respectively. Operative times, type of operation performed, open chest status, reoperation for hemorrhage and cannulation location (central/peripheral) were all compared. There were no statistically significant relationships of these variables short or long-term survival. Conclusions Overall 12 month survival for PC-ECMO patients was 40%, and was 33% at 36 months. For hospital survivors, 1 year survival was 66%, and was 60% at 36 months. These data support PC-ECMO as a reasonable salvage strategy, with mid-term survival comparable to other surgically treated diseases.
Abstract: The objective of this study was to identify patient and hospitalization characteristics associated with in-hospital mortality in infants with truncus arteriosus. We conducted a retrospective analysis of a large administrative database, the National Inpatient Sample dataset of the Healthcare Cost and Utilization Project for the years 2002–2017. We also sought to evaluate the resource utilization in the subgroup of subjects with truncus arteriosus and 22q11.2 deletion syndrome. Neonates with truncus arteriosus were identified by ICD-9 and ICD-10 codes. Hospital and patient factors associated with inpatient mortality were analyzed. Overall, 3009 neonates met inclusion criteria; a total of 326 patients died during the hospitalization (10.8%). Extracorporeal membrane oxygenation utilization was 7.1 %. Univariate and multivariate logistic regression analyses were used to identify risk factors for in-hospital mortality. Independent risk factors for mortality were prematurity (aOR = 2.43, 95% CI: 1.40–4.22, p = 0.002), diagnosis of stroke (aOR = 26.2, 95% CI: 10.1–68.1, p < 0.001), necrotizing enterocolitis (aOR = 3.10, 95% CI: 1.24–7.74, p = 0.015) and presence of venous thrombosis (aOR = 13.5, 95% CI: 6.7–27.2, p < 0.001). Patients who received ECMO support or had cardiac catheterization procedure during the hospitalization had increased odds of mortality (aOR = 82.0, 95% CI: 44.5–151.4, p < 0.001, and aOR = 1.65, 95% CI: 0.98–2.77, p = 0.060, respectively). 22q11.2 deletion syndrome was associated with an inverse risk of death despite having more non-cardiac comorbidities; this patient subpopulation also had a higher length of stay and increased cost of hospitalization.
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.