In this case report we describe how to recycle the Left Internal Thoracic Artery (LITA) when misused but not damaged. 8 years after a Left Anterior Small Thoracotomy followed by LAD stenting for STEMI in 1st post-operative day, a 67 years old woman had a NSTEMI with angiographic evidence of intra-stent re-stenosis with a perfectly patent LITA, harvested only from the 4th to the 6th intercostal space. During redo surgery, LITA was harvested as a pedicle from the anastomosis to the 4th intercostal space and primarily from the 1st to the 4th intercostal space. Special attention was paid at the level of the 4th intercostal space where the vessel was stuck to the sternum: a 15 blade was used being scissors or cautery too dangerous. At the end of harvesting, the LITA was full-length available for a new coronary anastomosis on LAD, distal to the previous one.
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.
We thank Shixiong Wei et al for their interest in our technical paper on Robotic Septal myectomy for HOCM and their letter to the editor. Their technique of using the Computed Tomography Angiography (CTA) along with 3D Printing technology for the better delineation of the anatomy of HOCM has been an evolving way to approach the problem. As they have mentioned in their letter, we used cardiac magnetic resonance imaging (MRI) predominantly for all our patients who undergo septal myectomy. Using 3D printing technology augmenting CTA or MRI can certainly augment the surgical planning in complex patients. In their case report, Wei et al have shaved off most of the subvalvular tissue along with the mitral valve. Removal of the entire mitral valve definitely would have enhanced the exposure to the mid-ventricular cavity and the apex for their thoracoscopic approach. It will be interesting to know whether they tried to repair the valve before replacement. Our technique of Robotic mitral valve repair, septal myectomy, and particularly papillary muscle re-orientation tries to preserve the sub-valvular apparatus even after completely relieving the mid-cavitary obstruction and this may provide better ventricular re-modeling. We congratulate them on providing a successful surgical option to this complex subset of patients using novel evolving technology and meticulous surgical planning.
Microaxial LVADs are increasingly used for cardiogenic shock treatment. We compared the short-term outcome of patients supported with different microaxial devices for cardiogenic shock. A retrospective propensity score-adjusted analysis was performed in cardiogenic shock patients treated with either the Impella CP (n=64) or the Impella 5.0/5.5 (n=62) at two tertiary cardiac care centers between 1/14 and 12/19. Patients in the Impella CP group were significantly older (69.6±10.7 vs 58.7±11.9 years, p=0.001), more likely in an INTERMACS level 1 (76.6% vs 50%, p=0.003) and post CPR (36% vs 13%, p=0.006). The unadjusted 30-day survival was significantly higher in Impella 5.0/5.5 group (58% vs 36%, p=0.021, odds ratio (OR) for 30-day survival on Impella 5.0/5.5 was 3.68 (95% CI [1.46-9.90], p=0.0072). After adjustment, the 30-day survival was similar for both devices (OR 1.23, 95% CI [0.34-4.18], p=0.744). Lactate levels above 8 mmol/L and preoperative CPR were associated with a significant mortality increase in both cohorts (OR=10.7, 95% CI [3.45-47.34], p<0.001; OR=13.2, 95% CI [4.28-57.89], p<0.001, respectively). Both Impella devices offer a similar effect with regards to survival in cardiogenic shock patients. Preoperative CPR or lactate levels exceeding 8 mmol/L immediately before implantation have a poor prognosis on Impella CP and Impella 5.0/5.5.
Background: Limb ischemia is a major complication of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). Use of ankle-brachial index (ABI) to monitor limb perfusion in VA-ECMO has not been described. We report our experience monitoring femoral VA-ECMO patients with serial ABI and the relationships between ABI and near infrared spectroscopy (NIRS). Methods: This is a retrospective single-center review of consecutive adult patients placed on femoral VA-ECMO between January 2019 and October 2019. Data were collected on patients with paired ABI and NIRS values. Relationships between NIRS and ABI of the cannulated (E-NIRS and E-ABI) and non-cannulated legs (N-NIRS and N-ABI) along with the difference between legs (D-NIRS and D-ABI) were determined using Pearson correlation. Results: Overall, 22 patients (mean age 56.5±14.0 years, 72.7% male) were assessed with 295 E-ABI and E-NIRS measurements, and 273 N-ABI and N-NIRS measurements. Mean duration of ECMO support was 129.8±78.3 hours. ECMO-mortality was 13.6% and in-hospital mortality was 45.5%. N-ABI and N-NIRS were significantly higher than their ECMO counterparts (ABI mean difference 0.16, 95%CI 0.13-0.19, p<0.0001; NIRS mean difference 2.51, 95%CI 1.48-3.54, p<0.0001). There was no correlation between E-ABI vs. E-NIRS (r=0.032, p=0.59), N-ABI vs. N-NIRS (r=0.097, p=0.11), or D-NIRS vs. D-ABI (r=0.11, p=0.069). Conclusions: ABI is a quantitative metric that may be used to monitor limb perfusion and supplement clinical exams to identify limb ischemia in femorally cannulated VA-ECMO patients. More studies are needed to characterize the significance of ABI in femoral VA-ECMO and its value in identifying limb ischemia in this patient population.
OBJECTIVES: The frozen elephant trunk (FET) technique has become an important tool in the treatment of acute type A aortic dissection. The aim of this study was to evaluate the effect of long FET on spinal cord injury (SCI) and distal aortic remodeling after acute type A aortic dissection based on clinical and radiological outcomes. METHODS: From January 2018 to November 2019, 158 patients [mean age 51.8 years (range 32 - 78 years), 88.6% male] with acute type A aortic dissection were treated by FET with 100 mm (n=113) or 150 mm (n=45) open hybrid stent graft prosthesis. Patients were divided into two groups according to the length of FET. The clinical and radiological outcomes of the patients were reviewed retrospectively. RESULTS: Postoperative outcomes did not differ significantly: in-hospital mortality (9.7% vs 6.7%, P=0.758) and SCI (5.3% vs 2.2%, P=0.674). Aortic remodeling, which was evaluated by aortic diameter, true lumen diameter, false lumen diameter and the rate of false lumen complete thrombosis, was more positive in long FET group in the descending thoracic aorta during the follow-up period. At the abdominal level, there was no statistically significant difference between the two groups. CONCLUSIONS: The long version of FET does not increase the risk of SCI in patients with acute type A aortic dissection. The application of long FET can achieve better results in terms of remodeling of the thoracic aorta in the short- and medium-term follow-up.
Infectious endocarditis (IE) is a rare condition with an estimated yearly incidence of 3 to 10 cases per 100,000 people. Its in-hospital mortality rate hovers around 18%, with one-year mortality reaching up to 40%. Although nearly 50% of IE cases now undergo surgical intervention, it does not appear to elevate the in-hospital mortality risk. Wei et al conducted a study on the relationship between red blood cell distribution width (RDW) value and postoperative death of IE patients. Their most remarkable finding was the in-hospital mortality rate was significantly higher in the High RDW group(55.6%vs.2.7%). Their results suggestted that RDW may become a valuable biomarker for estimating poor postoperative outcome in patients with IE. RDW reflects the variable size of circulating red blood cells and is routinely used to narrow the differential diagnosis of anemia. However, many studies had revealed that RDW maybe a new prognostic marker to predict the cardiovascular event. The increased value have been always linked with inflammatory and oxidative states. Further studies are required to explore the mechanism for the relationship between the RDW and adverse clinical outcomes.
Background: This study evaluated the impact of various sizing metrics on outcomes of female donor to male recipient orthotopic heart transplantation (OHT). Methods: We queried the United Network of Organ Sharing database to analyze all isolated, primary adult OHTs from 1/12010-3/20/2020. Patients were stratified by donor-recipient sex pairing. Logistic regression was used to investigate risk-adjusted effects of current size matching criteria (weight ratio, body mass index (BMI) ratio, predicted heart mass (pHM) ratio) on one-year post-transplant mortality. Kaplan-Meier analysis was used to compare posttransplant survival among cohorts. Results: A total of 22,450 patients were analyzed, of which 3,019 (13.4%) underwent female-to-male transplantation. Of sex-matched pairs, female-to-male donation had the lowest proportion of undersized hearts using weight and BMI ratio metrics (10.5% and 5.2%) but had the highest proportion of undersizing using pHM metrics (48.1%) (all P<0.001). Female-to-male recipients had the lowest rate of unadjusted one-year survival (90.0%, P = 0.0169), and increased hazards of mortality after risk adjustment (OR 1.17, 95% CI 1.01-1.36, P=0.034)). Undersizing using pHM (donor-recipient ratio < 0.85) was the only metric found to be associated in increased mortality after risk adjustment (OR 1.32, 95% CI 1.02 to 1.71, P=0.035). Conclusions: Female-to-male heart transplantation has the worst survival of all sex-matching combinations. Although female donors in this cohort are appropriately sized using traditional metrics, half are under-sized using pHM. This, combined with its strong association with mortality, underscores the importance of routine pHM assessment when evaluating female donors for male recipients.
A 75 years old man with previous aortic abdominal aneurysm surgery through a transverse laparotomy underwent bilateral internal mammary artery (BIMA) to coronary artery bypass grafting (CABG). He immediately thereafter developed a severe chest and upper abdominal walls ischemia with metabolic acidosis, and finally deep sternum wound infection and upper abdominal wall necrosis. He benefitted from sternal reconstruction and vaccum assisted treatment, with delayed pectus major flap reconstruction. Chest and abdominal wall infarction following BIMA harvesting is a very rare but life-threatening complication. Caution use of BIMA should be in order in patients with inferior epigastric artery flow impairment.
Background and aim of the study: Patients with severe coronavirus disease 2019 (COVID-19) develop a profound cytokine-mediated pro-inflammatory response. This study reports outcomes in 10 patients with COVID-19 supported on veno-venous extracorporeal membrane oxygenation (VV-ECMO) who were selected for the emergency use of a hemoadsorption column integrated in the ECMO circuit. Materials and Methods: Pre and post treatment, clinical data and inflammatory markers were assessed to determine the safety and feasibility of using this system, and to evaluate the clinical effect. Results: During hemoadsorption, median levels of interleukin (IL)-2R, IL-6, and IL-10 decreased by 54%, 86%, and 64% respectively. Reductions in other markers were observed for LDH (-49%), ferritin (-46%), D-dimer (-7%), C-reactive protein (-55%), procalcitonin (-76%) and lactate (-44%). Vasoactive-inotrope scores decreased significantly over the treatment interval (-80%). The median hospital length of stay was 53 days (36-85) and at 90-days post cannulation, survival was 90% which was similar to a group of patients without the use of hemoadsorption. Conclusions: Addition of hemoadsorption to VV-ECMO in patients with severe COVID-19 is feasible and reduces measured cytokine levels. However, in this small series, the precise impact on the overall clinical course and survival benefit still remains unknown.
Background: Left pulmonary vein (PV) obstruction can occur due to compression between the left atrium (LA) and the descending aorta (DA). One of the effective solutions for this problem is posterior aortopexy. In this study, we have reported five cases of posterior aortopexy to relieve left PV obstruction between the LA and the DA. Methods: Since August 2012, five patients have undergone posterior aortopexy for compression of the left PV between the LA and the DA. The median age and weight of the patients at the time of operation were 5.5 months (range, 1-131 months) and 5.2 kg (range, 4.2-29.5 kg), respectively. The left PV obstruction was initially diagnosed on echocardiography in four patients and computed tomography angiography in one patient. The median peak pressure gradient across the obstructed left PV was 7.3 mmHg (range, 4-20 mmHg). Concomitant procedures were ventricular septal defect closure in one patient and patent ductus arteriosus ligation in one patient. Results: There was no PV obstruction on echocardiography in any of the patients after the operation except in the case of one patient who had diffuse pulmonary vein stenosis. The median follow-up duration was 34 months (range, 14-89 months), and during follow-up no incidence of the left PV obstruction was observed in any of the surviving patients. Conclusions: The posterior aortopexy technique could be a good surgical option for the left PV obstruction caused by compression between the LA and the anteriorly positioned DA.
Heart allotransplantation has become one of the methods of choice in the treatment of severe heart failure. In the face of its difficulties, such as the unmet balance between organ supply and demand, the use of xenotransplantation might be an attractive option in the near future, even more with the ongoing progress achieved regarding the avoidance of hyperacute rejection and primary organ disfunction, maintenance of xenograft function and control of xenograft growth. To make possible this translational challenge, some points must be taken into account indeed, and they are the equipoise of human benefit and animal suffering, the risk of unknown infections, a well prepared informed consent, ethical and religious beliefs, and the role of cardiac xenotransplantation in a ventricular assistance device era.
Background Despite significant advancements in operative techniques and myocardial protection, triple valve surgery (TVS) remains a formidable operation with a relatively high in-hospital mortality. We evaluated the prognostic value of Model for End-stage Liver Disease score including sodium (MELD-Na) for mortality after TVS and its predictive value when incorporated in the EuroSCORE risk model. Methods We performed a retrospective cohort study of 61 consecutive patients who underwent TVS from November 2005 to June 2016. Demographics, clinical, biochemical, and operative data were collected and analysed. Results Median follow-up duration was 8.0 years. 70.5% of patients suffered from rheumatic heart disease. 86.9% underwent mechanical double valve replacement with tricuspid valve repair. There were six operative deaths (9.84%), with the most common cause of death being multiorgan failure (83.3%). 26.2% had a moderately elevated MELD-Na score of 9 to 15, and 4.9% had a severely elevated score of >15. Patients with a MELD-Na >9 had a higher unadjusted rate of operative mortality, prolonged ventilation, need for dialysis and acute liver failure after TVS. Hierarchical logistic regression was performed using logistic EuroSCORE as the base model. After risk adjustment, each point of MELD-Na score increase was associated with 1.405 times increase in odds of operative mortality. The regression analysis was repeated by incorporating individual components of the MELD-Na score, including bilirubin, sodium, and albumin. All three biochemical parameters were significantly associated with operative mortality Conclusion MELD-Na score as a quantifier of hepatorenal dysfunction is sensitive and specific for mortality after triple valve surgery.
A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supraannular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. As current data is limited, a literature review concerning subtle aortic dissection is provided.
The outcome of coronary artery bypass surgery depends on complete revascularization. In our paper, we attempt to demonstrate that Off-pump coronary artery bypass (OPCAB) is applicable to coronary heart disease patients with low LVEF. Low LVEF does not affect cardiac revascularization. Low LVEF is an independent risk factor for the outcome of CABG patients, but it does not mean that the OPCAB procedure leads to poor outcomes. In our hospital, we used on-pump CABG or conventional bypass surgery for coronary heart disease patients with low LVEF before 2010.With the accumulation of cases, OPCAB is now used in more than 95% of coronary artery bypass grafts in our center. Our data suggest that OPCAB is safe and reliable for patients with low LVEF.
Background: This study investigated the impact of transplanting center donor acceptance patterns on usage of extended-criteria donors (ECDs) and posttransplant outcomes following orthotopic heart transplantation (OHT). Methods: The Scientific Registry of Transplant Recipients was queried to identify heart donor offers and adult, isolated OHT recipients in the United States from 1/1/2013-10/17/2018. Centers were stratified into 3 equal-size terciles based on donor heart acceptance rates (<13.7%, 13.7%-20.2%, >20.2%). Overall survival was compared between recipients of ECDs (≥40 years, left ventricular ejection fraction <60%, distance ≥500 miles, hepatitis B, hepatitis C or human immunodeficiency virus, or ≥50 offers) and recipients of traditional-criteria donors, and among transplanting terciles. Results: A total of 85,505 donor heart offers were made to 133 centers with 15,264 (17.9%) accepted for OHT. High-acceptance programs (>20.2%) more frequently accepted donors with LVEF <60%, HIV, HCV, and/or HBV, ≥50 offers, or distance >500 miles from the transplanting center (each p<0.001). Posttransplant survival was comparable across all three terciles (p=0.11). One- and five-year survival were also similar across terciles when examining recipients of all five ECD factors. Acceptance tier and increasing acceptance rate were not found to have any impact on mortality in multivariable modeling. Of ECD factors, only age ≥40 years was found to have increased hazards for mortality (HR 1.33, 95% CI 1.22-1.46, p<0.001). Conclusions: Of recipients of ECD hearts, outcomes are similar across center-acceptance terciles. Educating less aggressive programs to increase donor acceptance and ECD utilization may yield higher national rates of OHT without major impact on outcomes.
We report a case of acute right ventricular failure in a patient with cardiogenic shock on left-sided mechanical circulatory support with Impella 5.0. The patient was successfully bridged to heart transplantation using additional right-sided support with ProtekDuo. Key learning points of the case include prompt recognition of right ventricular failure in patients on left-sided support, early consideration of right-ventricular mechanical support platforms, and timely deployment of right-sided mechanical support.