The swift advances in interventional cardiology combined with the increasing risk of cardiac surgical procedures resulted in diminishing volume of coronary and valvular surgery and affected the future of cardiac surgery service and training. Application to cardiac surgery training programs have steadily declined. This cross-sectional study aimed at identifying main weakness facing cardiac surgery and advocating some recommendations to improve the status of current and future of cardiac surgery.
Anomalous aortic origin of a coronary artery from the opposite sinus is a rare congenital condition that can cause sudden death in young people. When it is associated with acute aortic dissection, acute myocardial infarction can occur due to enlargement of the sinus of Valsalva. We report the case of a 71-year-old man with anomalous origin of the right coronary artery from the left sinus of Valsalva, who developed right ventricular infarction due to the compression of the right coronary artery between the aorta and pulmonary artery trunk.
The heart transplantation (HT) is undoubtedly the best treatment for end-stage heart failure patients (2). However, the organ shortage remains a major challenge in cardiac surgery. Facing this problem, the medical community starts to extend the donor criteria to select more suitable organs for HT. The use of ECDs is still controversial, since it is associated with a high incidence of primary graft failure (3), and although it guarantees longer survival than without transplantation, there is still some hesitation in accepting this practice.
Background: Thoracic aortic aneurysm is a significant risk factor for aortic dissection and rupture. Guidelines recommend referral of patients to a cardiovascular specialist for periodic surveillance imaging with surgical intervention determined primarily by aneurysm size. We investigated the association between socioeconomic status and surveillance practices in patients with ascending aortic aneurysms. Methods: We retrospectively reviewed records of 465 consecutive patients diagnosed between 2013-2016 with ascending aortic aneurysm ≥4cm on computed tomography scans. Primary outcomes were clinical follow-up with a cardiovascular specialist and aortic surveillance imaging within 2 years following index scan. We stratified patients into quartiles using the area deprivation index (ADI), a validated percentile measure of 17 variables characterizing socioeconomic status at the census block group level. Competing risks analysis was used to determine interquartile differences in risk of death prior to follow up with a cardiovascular specialist. Results: Lower socioeconomic status was associated with significantly lower rates of surveillance imaging and referral to a cardiovascular specialist. On competing risks regression, the ADI quartile with lowest socioeconomic status had lower hazard of follow-up with a cardiologist or cardiac surgeon prior to death (HR 0.46 [0.34, 0.62], p<0.001). Though there were no differences in aneurysm size at time of surgical repair, patients in the lowest socioeconomic quartile were more frequently symptomatic at surgery than other quartiles (92% vs 23-38%, p<0.001). Conclusion: Patients with lower socioeconomic status receive less timely follow-up imaging and specialist referral for thoracic aortic aneurysms, resulting in surgical intervention only when alarming symptoms are already present.
Letter to the Editor: Telemedicine in the era of coronavirus 19: Implications for postoperative care in cardiac surgeryContributing Authors:Anish Verma (Corresponding Author) – Fifth Year Medical StudentRachel Pathimagaraj – Fourth Year Medical StudentDaniel Warrington - Fifth Year Medical StudentJames Whiteway - Fifth Year Medical StudentAll authors are based at the United Kingdom institution, The University of Manchester – Faculty of Biology, Medicine and Health.
ABSTRACT Post infarction ventricular septal rupture (PIVSR) is an infrequent but potentially fatal complication of acute myocardial infarction. • The 30-day mortality rate with the transcatheter approach when performed in the acute phase (less than two weeks) was 25.3% compared to 50% when surgery is performed in the acute phase (within three weeks). • There is no correlation between defect size and mortality. • NYHA class IV and time to VSD closure are risk predictors for transcatheter closure for a 30-day mortality rate of 31.5%.
Background: The radial artery (RA) is often utilized for diagnostic coronary angiography and percutaneous intervention. Recent high-level evidence supports RA use in preference to saphenous vein as a conduit for coronary revascularization. Aim: To demonstrate gross and histologic changes of the RA following transradial access. Methods: We present two patients who had open RA harvest for coronary bypass surgery after transradial catheterization. Results: Examination 8 years after transradial catheterization demonstrated thickened intima and dissection, and examination 12 years following transradial catheterization with percutaneous coronary intervention demonstrated chronic dissection with thickened intima and near occlusion of the lumen. Conclusion: Transradial access via the RA, even after several years, is associated significant injury, making it unusable as a conduit for surgical coronary revascularization. A RA that has been utilized for catheterization should not be considered for coronary revascularization.
Background: The advent of Frozen elephant trunk (FET) for reconstruction of elective and non-elective aortic arch surgery has augmented the treatment of complex aortic pathologies in a single-stage operation. To date, no studies have been focused on the prevalence and predictors of coagulopathy potentiated by FET procedure. Methods: In a systematic review, we searched databases up to June 2020 for studies reporting coagulopathy complications after FET procedure. A proportional meta-analysis was carried out using STATA software (StataCorp, TX, USA). Results: In total, 46 studies including 6313 patients were eligible. The pooled estimation of reoperation for postoperative bleeding was 7% (95% confidence interval [CI] 5 to 8; I2 = 84.73%; reported by 39 studies including 4796 patients). The mean volume of transfused packed blood cells and fresh frozen plasma was 1677 ml (95% CI 1066.4-2287.6) and 1016.5 ml (95% CI 450.7-1582.3). The subgroup by stent type showed a decrease in the heterogeneity (I2 = 0.01%, I2 = 53.95%, I2 = 0.01%, and I2 = 54.41% for Thoraflex® Hybrid, E-vita®, Frozenix®, and Cronus®, respectively). The subgroup by chronicity of operation resulted in less heterogeneity among patients undergoing elective compared to non-elective operation (I2 = 29.22% versus I2 = 80.56% in non-elective). Meta-regression analysis showed that age and male gender significantly impacted on the reoperation for postoperative bleeding. Conclusions: The FET procedure for arch replacement is associated with coagulopathy and the transfusion of blood products. Male, age, and selective choice of FET use were identified as heterogeneity sources of reoperation for postoperative bleeding.
Much has changed since the introduction of surgical valve repair in the 1950s, from the introduction bioprosthetic valves to percutaneous approaches to valve repair. Yet, despite substantial advancements in bioprosthetic valve technology, there has been a lack of direct, independent comparison between bioprosthetic mitral valve devices, accompanied by a marked heterogeneity in approaches to the sizing and selection thereof. Wang et al. have hence endeavoured to evaluate, head-to-head, the technical successes and biomechanical outcomes associated with three different bioprosthetic mitral valves (Epic, Abbott, IL; Mosaic, Medtronic, MN; Mitris Resilia, Edwards Lifesciences, CA) in a porcine model, under standardised haemodynamic and anatomical conditions. With a robust experimental technique, they have made clear the heterogeneity in both sizing and biomechanical properties between bioprosthetic mitral valves, and have further emphasised the need for a uniform approach to the manufacturing and sizing of bioprosthetic valves.
Background: Minimally invasive heart valve surgery has previously been shown to be safe and feasible in obese patients. Within this population, we investigated the effect of obesity class on the patient outcomes of minimally invasive aortic valve replacement (mini-AVR). Methods: A single center retrospective cohort study of consecutive patients with obese body mass indices (BMIs) who underwent mini-AVR between 2012 and 2018. Patients were stratified into 3 groups according to Centers for Disease Control and Prevention adult obesity classifications: Class I (BMI 30.0 to < 35.0), Class II (BMI 35.0 to < 40.0), and Class III (BMI ≥ 40.0). The primary outcomes were postoperative length of stay (LOS), 30-day mortality within, and cost. Results: Amongst 182 obese patients who underwent mini-AVR, LOS (Class I 4 [3-6] vs. Class II 4 [3-6] vs. Class III 5 [4-6] days; p=0.098) and costs (Class I $24,487 [$20,199-$27.480] vs. Class II $22,921 [$20,433-$27,740] vs. Class III $23,886 [$20,063-$33,800] USD; p=0.860) did not differ between obesity class cohorts. Postoperative 30-day mortality (Class I 2.83% [n=2] vs. Class II 0% [n=0] vs. Class III 0% [n=0]; p=0.763) was limited by an insufficient sample size relative to a low event rate but did not differ between patient cohorts. Conclusions: Mini-AVR is safe and feasible to perform for obese patients regardless of their obesity class. Patients with obesity should be afforded the option of minimally invasive aortic valve surgery regardless of their obesity class.
Background and aim: Ischemic heart disease is the leading cause of death around the world. Coronary artery bypass grafting offers efficient surgical revascularization for ischemic disease. Both on- or off-pump coronary artery bypass methods provide promising results to octogenarians, once complete vascularization is achieved. However, off-pump bypass requires a certain level of experience to achieve sufficient results. We have applied an off-pump coronary artery bypass-first strategy to all generations since 2008. This study investigated early and long-term results of surgical revascularization for octogenarians by a team with an off-pump-first strategy. Methods: All cases of isolated coronary artery bypass grafting performed since 2008 were identified and divided into a young group (age <80 years) and an old group (age >=80 years). Peri-operative results were investigated retrospectively in both groups and long-term results for the old group were assessed. Results: Among the 707 patients, 97% underwent off-pump bypass, and 94 cases were classified to the old group. Distal anastomoses and ventilator time were identical between groups (young vs. old: 3.3 vs. 3.2; 3.7 h vs. 3.7 h). In-hospital death rates were 0.5% and 0% in the young and old groups, respectively. With a mean follow-up of 1318 days, actual 1-, 3-, and 5-year survival rates for octogenarians were 92.1%, 81.2% and 68.3%, respectively. Nearly half of the patients reached their nineties, which was close to the life expectancy of the national general octogenarian. Conclusions: An experienced team with an off-pump-first strategy could provide valid therapeutic options for octogenarians.
BACKGROUND: Postoperative pericardial adhesions have been associated with increased morbidity, mortality, and surgical difficulty. Barriers exist to limit adhesion formation, yet little is known about their use in cardiac surgery. The study presented here provides the first major systematic review of adhesion barriers in cardiac surgery. METHODS: Scopus and PubMed were assessed on November 20, 2020. Inclusion criteria were clinical studies on human subjects, and exclusion criteria were studies not published in English and case reports. Risk of bias was evaluated with the Cochrane Risk of Bias Tool. Barrier safety and efficacy data were assessed with Excel and GraphPad Prism 5. RESULTS: 25 studies were identified with a total of 13 barriers and 2,928 patients. Polytetrafluoroethylene (PTFE) was the most frequently evaluated barrier (13 studies, 67% of patients) with an infection rate of 1.14%, bleeding event rate of 0.75%, mortality rate of 1.22%, adhesion formation rate of 37.31%, and standardized tenacity score of 26.50. Several barriers had improved safety and efficacy. In particular, Cova CARD had an infection rate of 0.00%, a bleeding event rate of 0.00%, and a tenacity score of 15.00. CONCLUSIONS: Overall, the data varied considerably in terms of study design and reporting bias. The amount of data was also limited for the non-PTFE studies. PTFE has historically been effective in preventing adhesions. More recent barriers may be superior, yet the current data is non-confirmatory. No ideal adhesion barrier currently exists, and future barriers must focus on the requirements unique to operating in and around the heart.
Ever since the adoption of the newest heart allocation system in the Fall of 2018, clinicians have grappled with the safest method of utilizing temporary mechanical circulatory support to get patients successfully to transplantation. In unique patients that do not have a durable left ventricular assist device as a therapeutic option and have not had a full work-up for transplantation consideration, the establishment of ambulatory extracorporeal membrane oxygenation is an attractive solution.
ABSTRACT The involvement of Medical Technology (MedTech) corporations in the provision of surgical care remains a topic of debate. This relationship is especially relevant in cardiac and aortic surgery as the use of grafts, stents, prostheses, and other devices is an integral component of most procedures. Many argue that the involvement of device representatives in cardiac surgical cases is valuable – they are often experts on their product and are able to contribute their expertise in challenging cases. Yet, the potential for MedTech corporations to influence surgeons’ clinical decision-making introduces a conflict-of-interest and calls into question what the ‘best practice’ for sales reps should be. The influence of MedTech corporations over policymaking bodies in the US, UK, and Europe also represents a major issue for transparency and is equally deserving of evaluation.
Surgical left ventricle restoration (SVR) was firstly by Cooley in 1958 with the “linear suture technique”, and three decades later, Dor used a circular patch to reconstruct the left ventricle excluding the scarred parts of the septum and ventricular wall. It gained popularity and eventually almost abandoned after the contrasting literature evidences. Hassanabad et al. presented a comprehensive review of current literature on surgical ventricle restoration (SVR) techniques and clinical outcomes, trying to understand if SVR has still a substantial role in the modern medicine.