The called burden of cardiac heart failure (CHF) on healthcare systems and economies remains large and a major factor contributing to this burden is the high hospital admission rate for acute decompensated heart failure. These repeated heart failure hospitalizations (HFH) not only exert a high burden on healthcare systems, but also impact patient quality of life and have been associated with impaired prognosis and reduced life expectancy. The need for remote monitoring has become extremely important, mainly based on devices capable of measuring intracardiac filling pressures. If we assume that hemodynamic congestion precedes clinical congestion, the hemodynamic monitoring could be able to detect early signs of congestion and enables clinicians to intervene in a pre-symptomatic phase avoiding hospital admission. Dr. Veenis JF and colleagues present the results of implanting the CardioMEMS device in 10 patients who underwent heartmate 3 implantation. The authors describe the study design based on an earlier publication by the same author. The authors argue that the use of this device will allow the monitoring of patients pre, during hospitalization and after implantation, with a possible reduction in the number of readmissions for allowing the diagnosis and treatment of complications related to ventricular failure and volume overload.
Background: The high incidence of postoperative pulmonary venous obstruction (PVO) is a major mortality-associated concern in patients with right atrial isomerism and extracardiac total anomalous pulmonary venous connection (TAPVC). We evaluated new anatomical risk factors for reducing the space behind the heart after TAPVC repair. Methods: 18 patients who underwent TAPVC repair between 2014 and 2020 were enrolled. Sutureless technique was used in 12 patients and conventional repair in six patients. The angle between the line perpendicular to the vertebral body and that from the vertebral body to the apex was defined as the “vertebral-apex angle (V-A angle).” The ratio of post- and preoperative angles, indicating the apex’s lateral rotation, was compared between patients with and without PVO. Results: The median (interquartile range) age and body weight at repair were 102 (79-176) days and 3.8 (2.6-4.8) kg, respectively. The 1-year survival rate was 83% (median follow-up, 29 [11-36] months). PVO occurred in seven patients (39%), who showed an obstruction of one or two branches in the apex side. The postoperative V-A angle (46° [45°-50°] vs. 36° [29°-38°], P = 0.001) and the ratio of post- and preoperative V-A angles (1.27 [1.24-1.42] vs. 1.03 [0.98-1.07], P = 0.001) were significantly higher in the PVO group than in the non-PVO group. The cut-off values of the postoperative V-A angle and ratio were 41° and 1.17, respectively. Conclusions: A postoperative rotation of the heart apex into the ipsilateral thorax was a risk factor for branch PVO after TAPVC repair.
Abstract Background Subaortic stenosis (SAS) was a rare congenital heart disease of left ventricular outflow tract (LVOT), ranging from “isolated” lesions to “tunnel” or “diffuse” lesions. We conducted a retrospective study to describe the characteristics of patients with different lesions and analyze the risk factors for reoperation. Methods In this study, we examined a single-center retrospective cohort of SAS patients undergoing resection from 2010 to 2019. Patients were classified as simple lesion group (n = 37) or complex lesion group (n = 28). Demographics, perioperative findings, and clinical data were analyzed. Results The surgical effect of the two groups was significantly lower than that before the operation (p <0.05). The median age at operation was 6(3-11.8) years. There was no operative mortality. In complex lesion group, extracorporeal circulation time (CPB time), aortic cross clamp time (ACC time), mechanical ventilation time and ICU stay time were longer. The median follow-up period was 2.8 years (range 1-3.8), with two late death. Six patients (9.2%) required reoperation due to restenosis or severe aortic insufficiency. The freedom from reoperation rates at 5 years was 66.7% for simple lesion but only 52.3% for complex lesion (p = 0.036). Conclusions Although the lesions include many forms, subaortic stenosis resection was still satisfactory. However, the reoperation after initial surgical treatment was not infrequent, especially in patients with complex lesion.
Background: This study aims at better defining the profile of patients with a complicated versus non-complicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favourable/unfavourable hospital outcome. Methods: All patients treated with isolated tricuspid surgery from March 1997-January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit <4 days and/or postoperative length-of-stay <10days. Patients were therefore divided accordingly in two groups. Results: 172 patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p<0.001) and higher in-hospital mortality (13% vs 0%, p<0.001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics’ dose were predictors of complicated postoperative course. Conclusions: In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.
The safety of transesophageal echocardiography (TEE) probes has been documented in pediatric patients (neonates, infants, and small children even < 2.5 Kg). The overall safety profile of TEE probe is quite favourable with a reported incidence of complications is about 1-3%. However, insertion of the TEE probe can induce vagal and sympathetic reflexes such as hypertension or hypotension, non-sustained ventricular and supraventricular tachyarrhythmias or bradyarrhythmias [3rd degree heart block], and even angina and myocardial infarction. We hereby document a repeated and fatal intraoperative VF precipitated by TEE probe in a 2-year-old, 10 kg paediatric patient diagnosed with ostium secundum atrial septal defect (OS-ASD), supravalvular pulmonary stenosis (PS) and severe right ventricular (RV) dysfunction.
Regional analgesia in Cardiac anesthesia: Welcoming a new era in perioperative pain management.Soojie Yu MD1, Oscar D. Aljure MD21 Mayo Clinic Arizona, Department of Anesthesiology2University of Miami, Department of Anesthesiology, Division of Cardiovascular and Thoracic AnesthesiologyPoorly controlled post-operative pain can delay recovery and may increase the risk of morbidity in patients undergoing cardiac surgery. After surgery, the sternal incision is the most common source of pain. Historically, the mainstay for pain management in this population has been usage of narcotic analgesics but with the recognition that overprescription of opioids may be contributing to the opioid pandemic, an adoption of a multimodal approach for pain management has been gaining more popularity among institutions in the US. Neuraxial analgesia and anesthesia has been used in the past but its impact in hemodynamics added to the risk associated with heparinization and coagulopathy has limited its use in cardiac surgery. Newer regional anesthesia/analgesia methods utilizing ultrasound guidance are associated with lower risk of complications when compared to neuraxial approach. Regional blocks that cover post-sternotomy pain include transverse thoracic muscle plane (TTMP) block, parasternal block, pecto-intercostal fascial blocks (PIFB), and erector spinae plane blocks. Out of all these newer techniques, the number of published prospective double blinded studies are limited. A contributing factor to the difficulty finding literature for these type of blocks is the description of the technique by the authors. A good example is the TTMP block where the local anesthetic is deposited in the TTMP block is similar to the described approach for the parasternal nerve block[3, 4]. Nomenclature aside, Kar and Ramachandran showed there are few prospective randomized control studies published on newer non-neuraxial regional techniques for postoperative pain control after cardiac surgery.In this issue of the Journal of Cardiac Surgery, Zhang et al present a prospective double-blinded study that looks at TTMP blocks placed pre-incision for post-sternotomy pain control after induction of anesthesia. In their study, for their TTMP block, the technique defined by the authors deposits local anesthetic between the costal cartilage and the transversus thoracis muscle as described similarly in other reports .Zhang and collaborators described on their study a significantly lower consumption of intraoperative opioids in the intervention group, that goes in hand with prior studies that have shown similar results when the block is performed after induction of anesthesia[6, 7]. In a study by Padala et al, patients who received blocks pre-incision had decreased fentanyl administration intraoperatively compare to patients who received the block prior to sternotomy closure. In Zhang’s study, the block group had faster extubation times, decreased pain scores up to 24 hours after surgery and decreased post-operative opioid administration. The block group also had improved quality of sleep after extubation which can enhance recovery and decrease risk of delirium.While regional blocks are very effective as shown by Zhang et al, a common issue is the short duration of the analgesic effects. Studies based on patient satisfaction have shown that the majority of patients continue to have mild to moderate sternotomy pain especially with movement and coughing up to post-operative day three or later. Whether the block was placed post-induction or prior to sternal closure, Padala’s study showed timing of placement of regional block did not seem to affect the total opioid requirement nor the pain scores for up to 24 hours postoperatively. Another study by Lee and collaborators, evaluated if the administration of Liposomal Bupivacaine would prolong the analgesic effect of the regional block. This formulation of bupicaine can have analgesic effects up to 72 to 96 hours. In the study, the parasternal intercostal block was placed just before sternotomy closure. Overall pain scores up to 72 hours postoperatively were significantly lower when utilizing a linear mixed effects model at a 5% significance level in the Experal group compare to the placebo group. Opioid administration though was not significantly different overall nor at individual time points up to 72 hours post-operatively.In this article, Zheng discusses the placement of a continuous infusion catheter as compared to a single shot block as an option to prolong the analgesic effects of the TTMP block. On a similar study, Ueshima, et al placed bilateral catheters after performing a TTMP block in two patients undergoing a median sternotomy. These catheters were administering intermittent and on demand boluses of levobupivacine for two days postoperatively. Both patients did not require any additional analgesics. A limitation for this technique is that the catheters were placed after induction of general anesthesia and this could not be feasible in all cardiac surgeries with median sternotomy. The internal mammary artery (IMA) and vein courses through the TTMP therefore administration of local anesthetic or placement of a catheter could be an issue in patients undergoing coronary artery bypass grafting with IMA harvesting.TTMP blocks are relatively quick and easy to place but complications which include pneumothorax, local anesthetic allergy, infection  and injury to the internal mammary artery and vein can occur. One particular study showed tissue plane separation after the TTMP block that did not affect directly the ability to harvest the IMA nor did it have any obvious effect on the IMA. In this study, Zheng had a very low incidence of complications adding to the safety profile of this block in cardiac surgery.Another popular technique that has been recently described that also targets the anterior intercostal nerves is the pecto-intercostal fascial block (PIFB) also called parasternal intercostal nerve block (PINB). For PIFB, local anesthetic is deposited between the pectoralis major and intercostal muscles making the location more superficial to TTMP block. The more superficial location potentially decreases the risk of pneumothorax while still providing post-sternotomy pain control. Similar to TTMP blocks, patients who received PIFB had decreased pain scores but the amount of opioid consumption was not significant decreased compared to placebo control. There has not yet been a study published comparing TTMP to PIFB for post-sternotomy pain control and risk of complications.In this issue of the Journal of Cardiac surgery, Zheng adds supporting evidence to the use of the newer non-neuraxial regional techniques as a feasible, practical option for the management of postoperative pain control in patients undergoing open cardiac surgery. This study adds to the growing evidence that TTMP blocks cover median sternotomy pain which is the main source of pain in post-cardiac surgery patients. The TTMP blocks are safe, easy to perform in the operating room after anesthesia and the incidence of complications is very low as reported in other studies. Limitations exist with TTMP blocks which include the relative short duration of analgesia. More studies will be needed to evaluate the continuous infusion of local anesthetic or other supplemental regional techniques to prolong the beneficial effects of this block.1. Mueller, X.M., et al., Pain location, distribution, and intensity after cardiac surgery. Chest, 2000. 118(2): p. 391-6.2. Kar, P. and G. Ramachandran, Pain relief following sternotomy in conventional cardiac surgery: A review of non neuraxial regional nerve blocks. Ann Card Anaesth, 2020. 23(2): p. 200-208.3. Del Buono, R., F. Costa, and F.E. Agro, Parasternal, Pecto-intercostal, Pecs, and Transverse Thoracic Muscle Plane Blocks: A Rose by Any Other Name Would Smell as Sweet. Reg Anesth Pain Med, 2016. 41(6): p. 791-792.4. Fujii, S., Transversus thoracis muscle plane block and parasternal block. Reg Anesth Pain Med, 2020. 45(4): p. 317.5. Ueshima, H. and H. Otake, Where is an appropriate injection point for an ultrasound-guided transversus thoracic muscle plane block?J Clin Anesth, 2016. 33: p. 190-1.6. Cardinale, J.P., et al., Incorporation of the Transverse Thoracic Plane Block Into a Multimodal Early Extubation Protocol for Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth, 2020: p. 1089253220957484.7. Padala, S., et al., Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg, 2020. 35(7): p. 1525-1530.8. Ranjbaran, S., et al., Poor Sleep Quality in Patients after Coronary Artery Bypass Graft Surgery: An Intervention Study Using the PRECEDE-PROCEED Model. J Tehran Heart Cent, 2015. 10(1): p. 1-8.9. Lahtinen, P., H. Kokki, and M. Hynynen, Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity.Anesthesiology, 2006. 105(4): p. 794-800.10. Lee, C.Y., et al., A Randomized Controlled Trial of Liposomal Bupivacaine Parasternal Intercostal Block for Sternotomy. Ann Thorac Surg, 2019. 107(1): p. 128-134.11. Ueshima, H. and H. Otake, Continuous transversus thoracic muscle plane block is effective for the median sternotomy. J Clin Anesth, 2017. 37: p. 174.12. Ueshima, H. and H. Otake, Ultrasound-guided transversus thoracic muscle plane block: Complication in 299 consecutive cases. J Clin Anesth, 2017. 41: p. 60.13. Khera, T., et al., Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled Trial. J Cardiothorac Vasc Anesth, 2021. 35(3): p. 896-903.
It is an elegant albeit limited study reporting effects of pre op LVEF on long term results in patients with RHD undergoing DVR. Study includes146 pqtients out of 201 who underwent DVR in the study period. Although all had some improvement immediate post op, those with preserved EF and smaller left ventricles regardless of type of prostheses used, surgical techniques ( partial or full Sub-valvular Apparatus Preservation), had more sustained improvement after 3-4 years than those with lower EF and more dilation . It can be partially explained by more prevalence of aortic insufficiency in patients with pre op lower EF <50 and dilation ( average LVESD 49 mm vs 32 mm in EF >50). There are myocardial factors which also play a part , those with abnormal LV function have more extensive loss of myofibrils either due to disproportion of mitochondria-to-myofibril ratio or myofibrillar degeneration exhibiting the extent RHD involves myocardium. Structural adaptation may not all be just a result of hemodynamic abnormalities in these patients (1). The recommendation that surgical intervention should occur before the LV starts to dilate or EF drops is well founded and would be impactful in the developing world, an estimated 250,000 deaths occur annually worldwide and 10.5 million disability adjusted life years due to RHD, mostly in young people.
The surgical treatment of pulmonary hypertension (PH), with or without pulmonary artery aneurysm, has evolved during the last 40 years from heart-lung transplants to bilateral lung transplants as the treatment of choice for PH patients with preserved right and left ventricular function and without complex cardiac abnomalies.
Ravitch technique of chest correction has been considered, although invasive, as safe and efficacious surgical method. We describe a case of 35-year-old woman with cardiac tamponade and in cardiogenic shock due to exceptional late complication after pectus excavatum reconstruction by means of classic Ravitch technique 19 years earlier. This very late adverse event was caused by broken metal sternal wire that injured the wall of the ascending aorta. Patient underwent salvage repair of this segment of aorta in cardiopulmonary bypass. Postoperative course and post-discharge 3-year follow-up have been uneventful.
Cardiac ochronosis is a rare disease, estimated to affect 1 in 250,000 persons. While there is extensive evidence of the musculoskeletal alterations of the disease, cardiac involvement has not been widely studied and most information we currently have derives from case reports and case series. We report the case of a 64-year old patient with a known history of alkaptonuria who presented with dyspnea and weight loss. On evaluation, he was found to have severe aortic stenosis, coronary artery disease, and interventricular septal hypertrophy. Surgery revealed extensive ochronotic pigment deposition affecting the cardiac septum, both internal thoracic arteries, the native coronary arteries, and the aortic valve. Ochronotic heart disease is an often disregarded presentation of alkaptonuria. More information is needed on the course of the disease, as well as long-term outcomes after valve replacement surgery and/or CABG in patients with alkaptonuria.
Infectious complications after percutaneous transluminal coronary angioplasty are uncommon and can occur at any point of time leading to high morbidity and mortality. We report a case of delayed coronary artery stent infection and rupture, with epicardial infected false aneurysm formation, and right coronary artery to right atrium fistula formation, presenting after one month of pyrexia.
Cerebrovascular Accidents represent a dangerous complication of cyanotic children with tetralogy of fallot with incidence of 8.6%.Tetralogy of Fallot has been associated with raised haematocrit with low arterial Saturation. Here we describe an 18 months old female child of Tetralogy of Fallot with Cyanotic spells acute onset right sided hemiplegia with Right Atrial thrombus who underwent emergency surgery with intraoperative predicament.
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.