Background:The advent of TAVR changed the practice for treating patients with severe aortic stenosis. Heart-Teams improved their decision-making process to refer patients to the best and safest treatment. Evidence allowed centers to increase funding and TAVR volume and extend indications to different risk category of patients. This study evaluates the outcomes of intermediate-risk patients treated for severe aortic stenosis in an academic center. Methods:Between 2012 and 2019, 812 patients with aortic stenosis underwent TAVR or SAVR. A propensity score-matching analytic strategy was used to balance groups and adjust for time periods. Outcomes were recorded according to the Society of Thoracic Surgeons Guidelines; primary outcome being 30-day mortality and secondary outcomes being perioperative course and complications. Results:No difference in mortality was seen but complications differed: more postoperative transient ischemic attacks, permanent pacemaker implantations and perivalvular leaks in the transcatheter group, while more acute kidney injuries, atrial fibrillation, delirium, postoperative infections and bleeding, tamponade and need for reoperation in the surgical group as well as longer hospital length-of-stay. However, over the years, morbidities/mortality decreased for all patients treated for aortic stenosis. Conclusions:Data showed an improvement in morbidities/mortality for intermediate risk patients treated with SAVR or TAVR. Increased funding allowed for higher TAVR volume by increasing access to this technology. Also, the difference in complications could impact healthcare cost. By incorporating important metrics such as length-of-stay, readmission rates and complications into decision-making, the Heart-Team can improve clinical outcomes, healthcare economics and resource utilization.
OBJECTIVE. For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches in order to establish the possible gold standard. METHODS A systematic search was performed to identify all publications reporting the outcomes of four approach for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis. RESULTS There were 31 included studies with 9,663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA and 6.4% RRA; Early TR moderate-or-more was 9.6%, 4.8%, 4.6% and 3.8%; Late mortality was 22.5%, 18.2%, 11.9% and 11.9%; Late TR moderate-or-more was 27.9%, 18.3%, 14.3% and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (–85% vs. no TA; –64% vs. SA; –32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches, however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes. CONCLUSIONS. Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provides more stable FTR across time.
During the COVID-19 pandemic, ER visits have drastically decreased for non-COVID conditions such as appendicitis, heart attack and stroke. Patients may be avoiding seeking medical attention for fear of catching the deadly condition or as an unintended consequence of stay-at-home orders. This delay in seeking care can lead to increased morbidity and mortality, which has not been figured in the assessment of the extent of damage caused by this pandemic. This case illustrates an example of “collateral damage” caused by COVID-19 pandemic. What would have been a standard STEMI treated with timely and successful stenting of a dominant right coronary artery occlusion, became a much more dangerous post-infarction VSD; all because of a 2-day delay in seeking medical attention by an unsuspecting patient.
COVID-19 hit hard worldwide. There has been an impact on global activity of cardiac surgery. Spain has been one of the hardest hit countries with one of the highest per population incidences and death. Cardiac surgical activity has suffered a negative impact all over the country. The following is an overview of the epidemiology and impact on resources, the caseload and surgical societal implemented recommendations, the description of the ECMO activity and nosocomial transmission among healthcare workers.
We report a case of intravenous drug use-associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-weeks gestation. Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement one week later. Both the patient and her infant were successfully managed through the perioperative period.
The morphology variations of the so-called scimitar vein are many and varied. We present a synthesis of 92 published investigations of the overall scimitar syndrome. We reviewed the clinical presentations, diagnostic modalities, surgical approaches, and outcomes. Diagnostic information was provided by clinical presentations, radiographic findings, transthoracic and transesophageal echocardiography, computed-tomographic angiography, magnetic resonance imaging, angiocardiography, and ventilation/perfusion scans. These investigations served to elucidate the origin, course, and termination of the scimitar vein, the intracardiac anatomy, the presence of associated defects, and the patterns of any accompanying pulmonary lesions. In short, they defined the disease prior to surgical intervention. Of the patients described, up to four-fifths presented during infancy, with cardiac failure, increased pulmonary flow, and pulmonary hypertension. Associated cardiac and extracardiac defects, particularly hypoplasia of the right lung, are present in up to three-quarters of cases. Overall operative mortality has been cited between 4.8% and 5.9%. Mortality was highest in patients with preoperative pulmonary hypertension, and those undergoing surgery in infancy. Despite timely surgical intervention, post-repair obstruction of the scimitar vein, intra-atrial baffle obstruction, or stenosis of the inferior caval vein were reported in up to two-thirds of cases. The venous obstruction could not be related to any particular surgical technique. On long term follow-up, one sixth of patients reported persistent dyspnoea and recurrent respiratory infections. Any infants presenting with heart failure, right-sided heart, and hypoplastic right lung should be evaluated to exclude the syndrome. An increased appreciation of variables will contribute to improved surgical management.
A 63-year-old male, with a history of coronary artery bypass grafting using bilateral internal thoracic artery grafts, underwent surgical aortic valve replacement. Avoiding the graft injury, we selected the right anterior mini-thoracotomy approach under cardiac arrest with systemic hyperkalemia with remaining bilateral internal thoracic artery grafts open. Deep hypothermia was induced to obtain more reliable myocardial protection. We believe this strategy can be considered as a therapeutic option in patients requiring aortic valve replacement but unsuitable for transcatheter aortic valve replacement.
Objective: There is paucity of data on outcomes after isolated tricuspid valve surgery. This meta-analysis aims to compile available data on isolated tricuspid valve surgery and compare isolated tricuspid valve repair (iTVr) with isolated tricuspid valve replacement (iTVR) to elucidate outcomes after tricuspid valve surgery. Methods: A literature search of 6 databases was performed. The primary outcomes was 30-day mortality. Secondary outcomes were early stroke, post-op pacemaker placement, and tricuspid reoperation within 5 years. Publication bias was explored using the funnel plot. Results: Ten retrospective studies involving 1407 patients (iTVr group = 779 patients and iTVR group = 628 patients) were included. A cumulative analysis demonstrated a significant difference favoring iTVr for 30-day mortality [odds ratio – 10 studies (95% confidence interval) 0.34 (0.18-0.66)]; 4.7% versus 12.6%, for iTVr and iTVR, respectively. Post-op pacemaker placement favored iTVr [odds ratio – 6 studies (95% confidence interval) 0.37 (0.18-0.77)]. Although stroke rates and TV reoperation favored iTVr, they did not reach statistical significance. No publication bias was identified. Conclusions: This meta-analysis demonstrates that iTVr has better 30-day mortality and fewer permanent pacemaker placements. Etiology and severity of TR, as well as careful patient selection remain the most important factors for optimal outcomes.
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.
Abstract: Background: Fluid overload (FO) and acute kidney injury (AKI) after CABG surgery are due to multiple perioperative etiologies associated with high failure to rescue rates (FTR) and associated with poor outcomes 1-,3. Diuretics, fluid restriction, ultrafiltration (UF) and renal replacement therapies are the treatment modalities implemented as monotherapy or in combination to address this severe complication. There is limited data on the use of simplified UF therapy as a fluid management strategy in post-operative cardiac surgery patients. Methods: A retrospective review of our post operative isolated CABG patients was done from Jan 1 st, 2020 to July 31 st, 2021. Those subjected to a simplified UF protocol incorporating Goal Directed Therapy (GDT) to treat fluid overload and/or acute kidney injury were evaluated for 30-day survival and readmission rates. Results: A total of 254 isolated CABG procedures were performed during this period. Ultrafiltration was used in 17 (6.7%) patients. The 30-day mortality for the entire CABG cohort was 5/254 (2.0%) patients and in the UF group 0/17 (0%). The mean age of UF therapy patients was 65.8 years (Range 41-89). The mean Society of Thoracic Surgeons STS mortality score of UF patients was 5.7% (Range 0.6-50.0). The 30-day survival for the 17 patients placed on UF therapy was 100% and their readmission rate was 2/17 (11.7%). Conclusions: The use of ultrafiltration in this patient population with relatively high STS scores provided a safe and effective modality to manage fluid balance but further studies are needed.
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. Right ventricular failure (RVF) is a severe event that increases perioperative mortality after Left Ventricle Assist Device (LVAD) implantation. RV function is particularly affected by the LVAD speed by changing RV preload and afterload as well as the position of the interventricular septum. However, there are no studies focusing on the relationship between pump speed optimization and risk factors for development of lateRVF. Methods. Between 2015 and 2019,50 consecutive patients received LVAD implantation at San Camillo Hospital in Rome. Of these, 38 who underwent pump speed optimization were included. Post optimization hemodynamic data were collected. We assessed: a new Hemodynamic Index (HI), calculated as follows HI=MAP x PCWP/CVP x RPM set/RPM max; risk factors for late RVF, which was defined as the requirement for 7 days or more of inotropic support. Results 10 patients had late RVF after LVAD implantation. 5 patients required diuretic therapy and speed optimization. In 3 patients inotropic support with adrenaline 0.05 g/kg/min was started. 2 patients required prolonged continuous veno-venous hemofiltration and high dosage inotropic support. Multivariate analysis revealed that a low HI (odds ratio 11.5, 95 % confidence interval,1.85-65.5,p[.003] was an independent risk factor for late RVF after LVAD implantation. Conclusion A low HI, according to our study, is a significant risk factor for the development of RVF after LVAD implantation. We suggest adopting this index during the follow-up to stratify the different hemodynamic profiles and modify the therapeutic strategies according to the different HI levels obtained for every single patient.
Objectives: To elucidate the impact of regulation of tricuspid regurgitation (TR) using tricuspid annuloplasty on postoperative changes in right ventricular (RV) systolic and diastolic functions. Methods: We enrolled 69 patients who underwent aortic or mitral valve surgery between July 2016 to March 2018 without recurrence. Patients with concomitant coronary artery bypass grafting or a history of previous cardiovascular surgery were excluded, remaining 45 patients enrolled. Patients were divided into 2 groups according to concomitant tricuspid annuloplasty (T: n=12 vs non-T: n=33). RV global longitudinal strain (RVGLS), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) and early tricuspid inflow velocity/early diastolic tricuspid annular velocity ratio (tricuspid E/e’) were assessed as functional indices at preoperative, postoperative and 1-year follow-up periods. Results: RVFAC deteriorated postoperatively but recovered at follow-up in group T, whereas that in group non-T showed gradual deterioration overtime. RVGLS and TAPSE showed similar temporary deterioration and recovery between groups. Tricuspid E in group T increased postoperatively and showed significant difference, which was kept until follow-up period. Tricuspid e’ decreased postoperatively, and recovered slightly in both groups. As a result, postoperative RV diastolic function (tricuspid E/e’) showed significant difference between groups. This difference was maintained until follow-up. Conclusions: RV systolic function deteriorated postoperatively, but there was a tendency to improve at follow-up regardless of tricuspid annuloplasty. RV diastolic function may potentially be impaired when TR was regulated by tricuspid annuloplasty.
Title: Cardiac surgery and healthcare quality: Is the right question being asked?Authors : Abdullah Nasif, MD1/ Saqib Masroor, MD1 1Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo Medical Center Toledo, OH USAManuscript: Minimally Invasive Mitral Valve Surgery After Previous Sternotomy: A Propensity-Matched Analysis.Disclosure : NoneWord Count : 1381Even though by 2003, Casselman (and many others) had concluded that totally endoscopic mitral valve repair can be performed safely with excellent results and a high degree of patient satisfaction1, less than a quarter of all isolated mitral valve procedures were performed using minimally invasive approach (MIS) by 20162. Conventional sternotomy (ST) remains the approach of choice in the majority of cardiac surgery centers. Since 2011, partial sternotomy has fallen out of favor and right mini thoracotomy (RMT) approach has been the major MIS approach (with or without robotics) for both primary as well as re-operative mitral valve surgery. At experienced centers, the indications for MIS surgery have been expanded to include complex pathologies, reoperative surgery, endocarditis, as well as a hybrid open approach for severely calcified mitral annuli using an open deployment of transcatheter aortic valve3-5.One reason for the slow adoption of MIS has been the lack of randomized prospective trials comparing the conventional sternotomy approach with MIS. Most literature supporting the use of MIS has consisted of retrospective review of series of individual surgeons or centers, which have shown a shorter length of stay, reduced need for transfusions and a quicker recovery2,3. Since these reports came from centers with extensive experience and the fact that initial cohorts of patients undergoing MIS were relatively lower risk patients, these retrospective observational studies were not as convincing in their conclusions, because the two groups of patients were not similar. Only a few propensity-matched analyses comparing MIS vs sternotomy have so far been reported in patients undergoing primary surgery4-6.For re-operative mitral valve surgery, there has been one propensity-matched comparison of 42 pairs of patients undergoing right mini-thoracotomy MIS vs sternotomy from China7. MIS patients had lower transfusions, shorter length of stay and lower costs, while having similar mortality. However, the study had a mean length of stay of 22 days vs 16 days and mortality of 11% vs 7 % for sternotomy and MIS patients, respectively and thus the results cannot be reliably generalized.In this issue of the Journal , Hamandi et al8, reviewed 305 isolated MV reoperations that were performed in a single institution between 2007-2018. Patients who underwent MIS MV reoperation totaled 199, while sternotomy operations were 106. The primary endpoints were operative mortality and 1-year survival with operative complications and length of stay being secondary endpoints. Median age of patients was 69 years with an equal gender distribution. The team performed propensity-matched analysis to compare the two groups.There were 88 well-balanced matched pairs. There was no statistically significant difference in mortality among the matched groups at 30 days (3.4% vs 8.0%, p=0.19) or at 1-year (15.9% vs. 16.5%, p=0.9). Comparing long-term survival rates, no statistically significant difference was found up to 5 years postoperatively. Also, the incidence of post-operative complications such as atrial fibrillation, valve dysfunction or renal failure didn’t show any statistically significant difference. However, intraoperative blood utilization was significantly lower among the MIS cohort (p<0.01). Patient satisfaction was not evaluated as is not possible in a retrospective analysis. Neither was readmission rates and other similar measures which would be important in a value-based care system.The 30-day mortality difference (3.4% vs 8%), while not statistically significant, tended to be lower in MIS patients. 4 patients in the MIS group converted to sternotomy due to adhesions. It is not clear from the manuscript, if the mortality in the MIS group was in some way related to the conversions or not. But based on our experience over the years and from the analysis of this manuscript, we recommend an early conversion to sternotomy if one is dealing with difficult adhesions, rather than risking a long tedious operation and possibly emergently converting to sternotomy. It is also important to note that 75% of patients were discharged home, however readmission rate is unknown. With the advent of value-based purchasing, readmission rates should also be looked at. Overall, the authors should be congratulated on their excellent management of this subset of patients and for taking the time share their experience with us.Propensity score matching is commonly used in evaluation research to estimate average treatment effects.9 The main benefit in using this statistical method is to remove confounding bias from observational cohorts. It attempts to reduce the effects of confounders by matching already treated subjects with control subjects who exhibit a similar propensity for treatment based on preexisting covariates that influence treatment selection. However, it is limited in that it requires the removal of data and works primarily on binary treatments. In this study, by including standardized mean difference (SMD), the authors were able to balance the covariates in this propensity-matched analysis.Other than being a single-center retrospective study, this study suffered from other short-comings of a propensity match study, such as the loss of study power due to the decreased sample size after performing propensity matching. Also, “the surgeon effect” was noted. Since the MIS MV reoperative surgeries were performed by the same surgeons who performed the sternotomy cases, the results may not be generalizable.The question being addressed by this manuscript (and by most other similar comparisons of one therapy vs another) is, “Is MIS better than sternotomy?”Unfortunately, that question cannot be satisfactorily addressed with this or similar studies. Healthcare quality has evolved since its inception in 1999 with the Institute of Medicine report, titled “To Err is human”. In the subsequent report “Crossing the Quality Chasm”11, a high-quality care is defined as beingsafe, effective, patient-centered, timely, efficient and equitable. Our healthcare delivery system is changing, and so should our research methodologies. Our analyses should go deeper than scratching the surface with mortality and morbidity data. Most studies, including this one by Hamandi et al, do not even address “effectiveness” adequately in the context of healthcare quality. Having similar mortality and morbidity means that both approaches are equally ‘safe ’. We have little information about other measures of safety, such as readmissions, central line associated blood borne infections. We have not evaluated whether the two approaches were patient centered (Did the patient participate in choosing the approach?), efficient (Cost of care) or equitable.As cardiac surgeons dealing with life and death from up close, we are not used to viewing healthcare from the rather distant 6-pronged quality viewpoint mentioned above. But this is important for a very important reason which I explain below.Individual surgeons and patients may not have the power to bring about a meaningful change in the way we do business everyday. But just like state pension funds pressured oil companies into facing climate change10, big stakeholders like insurance companies and other payers may be able to convince the cardiac surgeons to face the future. For that to happen, quality metrics such as readmission rates, cost of care and patient satisfaction must be looked at and reported, because that is how these stakeholders assess quality. According to some studies7 MIS approach is better in terms of cost and patient satisfaction. Such comprehensive analyses of quality will go a long way in answering a slightly different question than the one posed earlier; “Does MIS offer better quality than sternotomy?”If we want to influence healthcare delivery and have a passion for quality, then our research methodology must reflect the high standards, that we have set for our clinical work. We should also develop new measures of quality besides morbidity and mortality. We have to look at those metrics that have traditionally been ignored by surgeons, but are important for the payers and the hospitals that rely on these payers for their success. As far a minimally invasive vs sternotomy approach is concerned, that question is not going to last for long. Not because one side would have won or the other lost, but because for those that have not yet boarded the train of minimally invasive mitral valve surgery, that train may have already left the station, moving at full speed ahead towards the “percutaneous station”. It is not a matter of if , but when , sternotomy would not be the standard of care for mitral valve surgery. Today’s vascular surgeons save open repair of abdominal aortic aneurysm for a very small subset of patients. There is no reason to believe that tomorrow’s mitral valve surgeons will consider open sternotomy any differently for mitral valve surgery.
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.
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.
Scimitar syndrome is rare malformation defined as partial or total anomalous pulmonary venous return of the right lung veins to the inferior vena cava just above or below the diaphragm. Severe forms of the disease are diagnosed in infancy and childhood . However, because of the mild form of the syndrome in adult patients, they remain asymptomatic and few cases are reported in the literature. We report an unusual presentation of this syndrome mimicking unstable angina in one of the two described cases.