Dear Editor,With great interest, I read the article by Yim and associates1 and congratulate them for the quality of the review carried out on the internal mammary artery harvesting techniques. However, I would like to help clarify some aspects specifically related to the history of this procedure.The skeletonized IMA harvesting technique is usually considered to be newer than pedicle dissection. Actually, when Arthur Vineberg first implanted an IMA in a human heart in 1950, he only separated the arterial vessel from the chest wall. For more than a decade, only arteries were implanted according to Vineberg’s proposed method, and it wasn’t until the early 1960s that William Sewel proposed implanting a pedicle into the myocardium, that also contained the internal mammary vein and other tissues (”pedicle operation”) with the intention of draining excess blood and avoiding the formation of myocardial hematomas.2It is also incorrect to claim that skeletonized IMA harvesting was introduced due to concerns offered by reduced sternal blood flow and potential mediastinitis. In January 1972, David Galbut and his group introduced systematic skeletonized harvesting into their series of patients revascularized with bilateral internal mamary arteries, some time before that procedure began to be linked with deep sternal wound infections. Galbut probably only took advantage of obtaining longer arteries and easier construction of sequential anastomoses.2Furthermore, when Cunningham first described the IMA’s skeletonized harvesting technique in 1992 he specified that to avoid thermal injury to the artery, it was extremely important to keep the cautery setting on low throughout the dissection.3 After this advice, smoke never seems to have been a concern for surgeons, so it was hardly the reason for the introduction of harmonic technology in IMA dissection, which was also initially used in the “open harvesting” technique.4Finally, I consider it curious that this review does not include the semiskeletonization technique, introduced in 19975 and currently used by various groups.References1. Yim D, Wong WYE, Fan KS, Harky A. Internal mammary harvesting: Techniques and evidence from the literature. J Card Surg. 2020;35(4):860-7.2. López de la Cruz Y, Nafeh Abi-Rezk M, Betancourt Cervantes J. Internal mammary artery harvesting in cardiac surgery: an often mistold story. CorSalud. 2020;12(1):64-76.3. Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection. Ann Thorac Surg. 1992;54(5):947-50.4. Higami T, Kozawa S, Asada T, Shida T, Ogawa K. Skeletonization and harvest of the internal thoracic artery with an ultrasonic scalpel. Ann Thorac Surg. 2000;70:307-8.5. Horii T, Suma H. Semiskeletonization of Internal Thoracic Artery: Alternative Harvest Technique. Ann Thorac Surg. 1997;63:867-8.Note: The author of this manuscript is not an employee of any agency of the Cuban government; he is only a cardiovascular surgeon in a public hospital. The author of this manuscript also does not represent the Cuban government in relation to this “letter to the editor”.
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.
Background: In severe cases, the COVID-19 viral pathogen produces hypoxic respiratory failure unable to be adequately supported by mechanical ventilation. The role of extracorporeal membrane oxygenation (ECMO) remains unknown, with the few publications to date lacking detailed patient information or management algorithms all while reporting excessive mortality. Methods: Case report from a prospectively maintained institutional ECMO database for COVID-19. Results: We describe veno-venous (VV) ECMO in a COVID-19 positive woman with hypoxic respiratory dysfunction failing mechanical ventilation support while prone and receiving inhaled pulmonary vasodilator therapy. After nine days of complex management secondary to her hyperdynamic circulation, ECMO support was successfully weaned to supine mechanical ventilation and the patient was ultimately discharged from the hospital. Conclusions: With proper patient selection and careful attention to hemodynamic management, ECMO remains a reasonable treatment option for COVID-19 patients.
Title: Pasteurella Multiocida Infection Resulting in a Descending Thoracic Aorta Mycotic Pseudoaneurysm Objective: Highlight our management of a P. Multiocida infected descending thoracic aorta mycotic pseudoaneurysm Methods: Report a case of canine bite resulting in a P. Multiocida descending thoracic aorta mycotic pseudoaneurysm Results: We present a 61-year-old gentleman who was initially seen in an Emergency Department after a canine bite. He was admitted and treated with a course of IV antibiotics for P. Multiocida bacteremia and discharged. Three weeks post discharge, he continued to feel generalized malaise and work-up was significant for a descending thoracic aorta mycotic pseudoaneurysm. The patient underwent a low left posterior lateral thoracotomy and femoral-femoral cardiopulmonary bypass for complete resection and replacement with a 24 mm GelweaveTM graft (Terumo Cardiovascular Group, Ann Arbor, Michigan). Given purulence and gross infection we planned for a staged approach, with a secondary washout and omental flap for biologic coverage of the graft. The patient did well clinically and was discharged at 14 days to rehabilitation with six-week intravenous course of antibiotics. Conclusions: The patient’s clinical course with subsequent follow-up suggest that complete resection of the mycotic pseudoaneurysm, followed by omental flap coverage is a viable strategy to manage mycotic aortic infections with virulent organisms.
Cardiac wounds have been described for centuries and still remain often fatal. For a long period of time suture of a myocardial laceration was thought to be absolutely impossible if not sacrilege. It is only at the end of the 19th century that pioneers decided to defy such dogma in desperate cases. Nowadays it seems obvious that a cardiac stab wound require emergent surgery whenever possible. The story of cardiac wounds highlights nicely the change of mind that is required to accept progress and new procedures in medicine.
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.
Anomalous origin of the left circumflex artery (LCA) arising from the right coronary sinus was observed in a 45 year-old man with aortic root aneurysm. Valve-sparing aortic root replacement (VSARR) was decided despite the subannular course of the LCA. A modified Tirone David procedure was performed with specific consideration for distribution of the proximal suture line due to the peri-aortic and subannular course of the LCA. Due to the risk of LCA injury, a coronary artery bypass grafting was performed using the left internal thoracic artery to secure the perfusion of the LCA. The challenging association of aortic root aneurysm and anomalous origin and course of the LCA was managed successfully during VSARR.
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
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.
Heart-Lung transplant (HLT) is a widely accepted modality for certain patients with advanced and refractory cardiopulmonary disease. Some of these patients are critically ill on the transplant waiting list, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be used as a bridge to transplantation. Although the experience with ECMO as a bridge to lung transplant is promising, there is limited evidence to use ECMO as a bridge to HLT. Femoral cannulation remains a concern for ambulation given the risk of bleeding and cannula complications despite studies reporting its safety. We present a case of a 56-year-old male with interstitial lung disease (ILD) and severe secondary pulmonary hypertension, who was successfully bridged to HLT with ambulatory femoral VA-ECMO.
Objectives: Though guidelines are set by the American Board of Thoracic Surgery for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multi-disciplinary developed course designed to standardize common high-risk bedside procedures and credential our residents. The aim of this study was to survey the attitudes of residents to and query the efficacy of such a course. Methods: The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands on simulation session. Knowledge based pre and post evaluations were administered as well as Likert based survey regarding multiple aspects of the residents’ perceptions of the course and the procedures. Results: Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail and thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pre and post-test knowledge-based evaluations. ConclusionCardiothoracic residents have favorable attitudes towards standardization and credentialing for high risk bedside procedures and utilizing such courses may help standardize procedural techniques.
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.
Rupture of a congenital left ventricular diverticulum (CLVD), a rare anatomical anomaly, is a catastrophic event, with potential fatal consequences. Repair techniques documented in the literature include primary closure and single patch closure. We describe a case of a 57-year-old woman with symptomatic anterolateral CLVD. Our approach involves a linear incision through the epicardial surface of the diverticulum with exclusion of the cavity, and restoration of normal ventricular geometry via a two patch technique.
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.
A flail chest can occur when cardiopulmonary resuscitation causes extensive rib fractures. Despite successful cardiopulmonary resuscitation, if the flail chest is not treated, the patient may not survive regardless of the correction of the primary condition that caused the cardiac arrest. Therefore, if flail chest persists despite proper conservative management to correct the flail chest, active surgical management is essential. We present a successful surgical treatment with pectus bar for a patient with flail chest, caused by extensive segmental rib fractures sustained during cardiopulmonary resuscitation for a massive pulmonary thromboembolism.
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.
Iatrogenic aortocoronary dissection is a rare but potentially fatal complication of coronary catheterizations. Although the incidence is comparatively low, dissection often leads to procedure failure with increased risk of myocardial infarction and death. Iatrogenic aortocoronary dissection is principally caused by disruption of intima at the ostia of the right or left coronary artery during interventional procedures and appears as luminal filling defects, the persistence of contrast or intimal tear outside the coronary lumen. Dissection could propagate in the anterograde direction causing subtotal or total occlusion of the coronary lumen or extend in the retrograde direction into the sinus of Valsalva, ascending aorta, aortic arch or descending aorta resulting in hemodynamic instability. We present a case of Right Coronary Artery dissection leading to Type-A aortic dissection suffered during diagnostic coronary catheterization. This required emergency supracoronary replacement of the ascending aorta with an aortic interposition tube graft and venous grafts to coronary arteries
We read with great interest the article by Khashkhusha TR et al “ACE inhibitors and COVID-19: We don’t know yet”. The authors discuss whether the use of angiotensin-converting enzyme (ACE) inhibitors (ACEIs) in novel coronavirus disease‐19 (COVID‐19) patients is beneficial or harmful. ACEIs and angiotensin receptor antagonists (ARBs) both upregulate ACE2 levels. We believe that ARBs should be preferred since, unlike ARBs, ACEIs may increase angiotensin II through the chymase pathway. We would like to discuss potential harms ACEI may cause through secondary bradykinin-chymase pathways.