Objectives: To compare outcomes after the development of early (≤30 days) versus delayed (>30 days) deep sternal wound infection (DSWI) after cardiac surgery. Methods: Between 2005 and 2016, 64 patients were treated surgically for DSWI following cardiac surgery. Thirty-three developed early DSWI, while 31 developed late DSWI. Mean follow up was 34.1 ± 32.3 months. Results: Survival for the entire cohort at 1, 3, and 5 years was 93.9, 85.1, and 80.8%, respectively. DSWI diagnosed early and attempted medical management were strongly associated with overall mortality (hazard ratio (HR), 25.0 and 9.9; 95% confidence intervals (CI), 1.18-528 and 1.28-76.5; p-value 0.04 and 0.04, respectively). Survival was 88.1, 77.0, 70.6 and 100, 94.0 and 94.0% at 1,3, and 5 years in the early and late DSWI groups, respectively (Log-rank = 0.074). Those diagnosed early were more likely to have a positive wound culture (odds ratio (OR), 0.06, 95% CI 0.01-0.69, p=0.024) and diagnosed late were more likely to be female (OR 8.75, 95% CI 2.0-38.4, p=0.004) and require an urgent DSWI procedure (OR 9.25, 95% CI 1.86-45.9, p=0.007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (hazard ratio 7.48, 95% CI 1.38-40.4, p=0.019 and hazard ratio 7.76, 95% CI 1.67-35.9, p=0.009, respectively). Conclusions: Early aggressive surgical therapy for deep sternal wound infection after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and have failed initial medical management have increased mortality.
Since publication of our initial experience with non-sternotomy minimally invasive pulmonary embolectomy (MIPE) via a left mini thoracotomy, we have expanded our experience, refined the operation and streamlined the post-operative management of patients. Our initial publication described three patients who underwent MIPE.1 We described our technique which included peripheral cardiopulmonary bypass (CPB) via femoral arterial and venous cannulation, left sided 5cm anterior thoracotomy in the 3rd intercostal space, identification and incision of the main pulmonary artery distal to the pulmonic valve, extraction of clot with subsequent primary closure of the pulmonary artery, and use of a 5mm, 30 degree laparoscope as an adjunct to assess clearance of the pulmonary artery.2 The patients included in this series had no post-operative complications, had a mean hospital length of stay of three days with mid-term follow-up up to 8-months revealing no untoward complications of the procedure. With early success of the MIPE at our institution, we began employing it preferentially over sternotomy with central CPB and pulmonary embolectomy. Since initial publication of our results, we have performed the MIPE in two additional patients with excellent outcomes. We herein present augmentations we’ve made to the procedure with a case-presentation which highlights these adaptations.
Over the last two decades, the medical community witnessed an outstanding and accelerated development on minimally invasive therapies. With the dorsal spine of supportive data from large randomized control trials, transcatheter aortic valve replacement (TAVR), aortic and mitral valve-in-valve, mechanical circulatory support and peripheral endovascular interventions all share the need of accessing a vascular bed with a large bore catheter. Nevertheless, to date, there has yet to be a universal consensus on defining large-bore vascular access (LBVA) in the world of transcatheter therapies. We explore the evolution, characteristics and vascular compatibility of the current commercially available devices, analyze the devices along with access site-specific complications rates and finally review the present methods for percutaneous vascular closure.
Background: Patent ductus arteriosus is an important cause of morbidity and mortality especially in very low birth weight infants.The aim of the present study was to evaluate outcomes of bedside surgical ligation of patent ductus arteriosus via limited upper ministernotomy as an alternative approach to thoracotomy. Material and Method: A total of 23 low birth weight premature infants who underwent bedside ligation of PDA in the neonatal intensive care unit January 2017 to April 2020, were enrolled. The patients were divided into two groups: those with thoracotomy(n=13) and those with limited upper ministernotomy(n=10).These patients were evaluated retrospectively in terms of clinical and preoperative,intraoperative,postoperative parameters between the groups. Results: Mean birth weight was 1059±275 grams in the thoracotomy group and 1035±285 grams in the ministernotomy group. There was no statistically significant difference in the age at surgery,weight at surgery,preoperative MV support,inotropic score onset of surgery and total procedure time between the groups.There was a statistically significant difference in the hospital length of stay,postoperative MV time and complications in the intensive care unit in favor of the ministernotomy group(p=0.04,p=0.03,p=0.034 respectively).The study showed no statistically significant difference in the mortality rate between the two groups (2 patients in the thoracotomy group and 1 patient in the ministernotomy group). Conclusion:The limited upper ministernotomy is anatomically and technically feasible alternative to classical left posterolateral thoracotomy for bedside surgical PDA ligation.
Background: We developed an integrated triple-branched stent to treat acute DeBakey type I aortic dissection and modified it to enhance its adaptability. However, whether the patients treated by the modified stent would achieve better long-term prognosis is unknown. Methods: This study enrolled 147 patients with acute DeBakey type I aortic dissection. The original integrated triple-branched stents were used in 57 patients (group A) between July 2012 and August 2013, and the modified stents in 90 patients (group B) between September 2013 and March 2015. Clinical characteristics, surgical data, postoperative complications, mortality, and follow-up data of the two groups were analyzed. Results: The two groups presented comparable early death rate (group A=7.0%, group B=5.9%, p=0.719). The incidence of postoperative acute kidney injury was lower in group B (10.0%) vs group A (24.6%) (p=0.018). Compared with the original integrated triple-branched stent graft, the modified stent could reduce the risk of early postoperative acute kidney injury [OR (95%CI)=0.36(0.14, 0.94)]. Early endoleak rate was lower in group B (1.0%) vs group A (9.4%) (p=0.004). During follow-up, there were five deaths in group A (9.4%) and six deaths in group B (7.2%) (p=0.646). Chronic kidney injury (7.5% vs 3.6%, p=0.311), delayed endoleak (11.3% vs 4.8%, p=0.157), and late reinterventions (7.5% vs 2.4%, p=0.155) in the two groups were similar. Conclusions: In patients with acute DeBakey type I aortic dissection, the modified stent could provide feasible and safe treatment outcomes, with better protection of kidney function and reduced early endoleak. However, they had similar long-term effects.
Background: The COVID19 pandemic gripped every nation’s healthcare system and provisions on all levels. In cardiac and aortic surgery, as it is with most specialities, elective surgeries were halted. Aims of the study: We captured reflections, contingencies, and current practices across of high-volume centres in cardiac and aortic surgery globally. We also aimed this study to assess decision on prioritization of the surgical patients, the need for personal protection equipment and choice of preoperative investigations in current dynamic and fluid climate. Methods: A validated web-based questionnaire was constructed and was circulated to the international surgeons amongst high volume cardiac and aortic surgery centres. Their intrinsic feedback on decision making, impact of the lockdown and perspectives for the future ahead us all were noted. Mixed method approach was constructed. Qualitative data analysis was introduced to signify the impact globally. Results: Overall, 23 centers from 18 countries participated in this international study. 91.7% of the respondents stopped operating on elective patients during the pandemic. Majority of the surgeons agreed that acute aortic dissection (87.1%) should be operated as emergency procedure and stable triple vessel disease (87.1%) to be considered as elective procedure. Three-fifth (60%) of the respondents relied on CT chest as a preoperative screening modality. Conclusion: In the present climate where there is paucity of evidence, this will give an interim consensus for the cardiac surgeons. With the increase in cumulative number of COVID19 patients, careful utilization of the resources regarding hospital beds and manpower is of paramount importance.
ABSTRACT: Objective To investigate the Aneurysmal of the left sinus of Valsalva, and to improve the understanding of the disease and the level of diagnosis and treatment. Methods This article mainly reports a case of huge Aneurysmal of the left sinus of Valsalva patients treated with surgical treatment. Results After surgery, the prognosis of the case was good. Conclusion Aneurysmal of the left sinus of Valsalva has low incidence，which is rare in clinical with no clinical specific symptoms leading to difficulty in early detection. The appropriate surgical method should be considered to the patient condition, to prevent the tumor rupture and the death of patients.
Objectives: Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via left small thoracotomy. Methods: We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency and completeness of revascularization. Clinical variables during hospitalization and follow-up were collected and analyzed. Results: All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2–5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3/186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491/510) [98.3% (171/174) for left internal thoracic artery grafts and 95.2% (318/334) for saphenous vein grafts]. The rate of complete revascularization was 98.8% (510/516) of the total grafts in 180 of 186 (96.8%) patients. Conclusions: Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for patients with multivessel disease.
Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery.
We present a rare case of atrial septal defect and ventricular septal defect with a vascular ring. The ring was formed by a right-sided aortic arch with an aberrant left subclavian artery that gave rise to a patent ductus arteriosus connecting to the main pulmonary artery. We performed a single-stage repair of the intra-cardiac defects and division of vascular ring with a novel sternotomy approach instead of the traditionally practised dual approach. Our novel approach included implantation of the aberrant left subclavian artery to the left carotid artery after transection. We could perform single-stage division of vascular ring along with the closure of both septal defects.
An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery and encircles the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve/root procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy with three different prostheses without valve downsizing.
Dear Dr Harky et. al,We appreciate your inquiry regarding our case report. Dr Harky et. al suggested that TEVAR for a Marfan patient could be an unnecessary approach even during the COVID-19 pandemic.We believe in this particular case, the endovascular approach was fully justified as the patient had clear signs of end organ ischemia at presentation. He presented with extreme right leg ischemia with diffuse numbness. There was no detectable distal arterial flow of the right extremity by a Doppler and physical evaluation. Contrast computed tomography scan showed a completely occluded right common iliac artery and diminished flow to the right renal and celiac arteries due to the compression of the true lumen from the false lumen. Preoperative creatinine was elevated to 1.2 mg/dl. She was also suffering ongoing right kidney malperfusion.It was during the time when COVID-19 epidemic started spreading rapidly in New York City. Our hospital beds were filled with COVID-19 patients and there was a shortage of medical supplies with no ventilators immediately available. It was important to reduce exposure of the individual to the hospital environment and minimize length of stay and ventilator needs. As such, we chose to proceed with TEVAR to minimize the risk of lung injury which can occur in open repair. Postoperative respiratory failure is a major issue in open thoracic aortic repair . The patient did not have a risk of respiratory comorbidities but we believed that this pandemic placed all patients at risk for contracting COVID-19 and subsequent acute respiratory distress .Due to the high risk of spinal cord ischemia in this particular patient, we performed TEVAR with a distal bare metal component to preserve the blood flow into spinal cord arteries . The initial clinical treatment plan was to perform the TEVAR as a bridge to open repair. We obviously will need to follow-up with her carefully and if any signs of failure of TEVAR is detected, open repair will ultimately be required.Dr Harky et. al suggested axillary femoral artery bypass to rescue the ischemic leg, however, this patient also suffered malperfsuion of the renal and celiac arteries, so further intervention was required.Thank you for your insightful suggestions.References1) Khan FM, Naik A, Hameed I, et al. Open repair of descending thoracic and thoracoabdominal aortic aneurysms: a meta-analysis. Ann Thorac Surg . 2020;S0003-4975(20)30865-1.2) Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020;323:1406–7.3) Lombardi JV, Cambria RP, Nienaber CA, et al. Five-year results from the study of Thoracic Aortic Type B Dissection Using Endoluminal Repair (STABLE I) study of endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2019; 70:1072-81.
High volume ECMO centers have developed mobile ECMO programs in recent years to facilitate implementation of ECMO support at hospitals with lower capabilities, and transfer these patients for further care. We report a case of mobile ECMO on patient with COVID-19 related ARDS, and discuss the potential application in current SARS-CoV-2 pandemic.
Objective: The arterial switch operation is the standard treatment for the transposition of the great arteries. The timely variation in the residual pressure gradient across the pulmonary arteries is ill-defined. This work is aimed to study the progressive changes in the pressure gradient across the pulmonary valve and pulmonary arteries after arterial switch operation (ASO). Methods: All eligible patients for this study who underwent arterial switch operation between 2000 and 2019 were reviewed. Transthoracic echocardiography (TTE), was used to estimate the peak pressure gradient across the pulmonary artery and its branches. The primary outcome was the total peak pressure gradient (TPG) which is the sum of peak pressure gradients across the main pulmonary artery and pulmonary artery branches. Furthermore, a longitudinal data analyses with mixed effect modeling were used to determine the independent predictors for the changes in pressure gradient. Results: 309 patients were included in the study. Over 17-year follow up, the freedom from pulmonary stenosis reintervention was 95% (16 out of the 309 patients underwent reintervention = 5%). the Longitudinal data analyses of serial 1844 echocardiographic studies for the included patients revealed that the TPG recorded in the first postoperative echocardiogram across pulmonary valve, right and left pulmonary artery branches was the most significant predictor for reintervention. Conclusion: The total peak gradient measured in the first postoperative echocardiogram is the most important predictor for reintervention. We propose that a total peak gradient in the first postoperative echocardiography of 55 mmHg or more is a predictor for reintervention
We present an unusual combination of lesions in an eight months old child diagnosed with Tetralogy of Fallot (TOF), Anomalous origin of Right Pulmonary artery (AORPA) and anomalous coronary artery (ACA) crossing the pulmonary annulus. The association of AOPA and TOF is extremely rare with an incidence of 0.4%. (1) The incidence of anomalous coronary artery in TOF is 10.3%. (3) However a combination of all three lesions poses challenges to surgical repair and has not been previously reported.
There are a significant number of symptomatic aortic stenosis (AS) patients not referred to the traditional methods for some complexity conditions. We described a case of a 61-year-old female with severe symptomatic AS, calcific small aortic annulus (16.6 mm), narrow porcelain ascending aorta (aortic root 14.6 mm, internal diameter 14.0 mm), chronic renal insufficiency and a history of previous sternotomy for mechanical mitral valve replacement (MVR) and coronary artery bypass grafting (CABG) who underwent aortic valve bypass (AVB) with favorable results. AVB has been proposed as a complementary to surgery operation of aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in high-risk AS patients.
The Revivent TC™ TransCatheter Ventricular Enhancement System (BioVentrix Inc, San Ramon, CA, USA) is intended for use in heart failure with cardiac dysfunction a previous myocardial infarction. The resultant increased left ventricular systolic volume and discrete, contiguous, non-contractile (akinetic and/or dyskinetic) scar located in the antero-septal, apical (may extend laterally) region of the left ventricle (LV) lends itself to Revivent. The procedure, called Less Invasive Ventricular Enhancement (LIVE), consists of the implantation of a series of micro-anchors pairs in order to exclude the scarred myocardium, in order to reduce and reshape the LV. We present the procedure step-by-step, as team coordination between the cardiac surgeon and the interventional cardiologist is essential to ensure good procedural outcomes. This is a novel and new technique to address Heart Failure secondary to Myocardial Infarction.
Background and Aims- A fracture and retention of guidewire after cardiac resynchronization therapy device implant has not been reported so far, although it is an uncommon but known complication during cardiac interventions like percutaneous coronary interventions and other cardiac catheterization procedures. Methods- A 53 years old female patient presented to us, who had been diagnosed as a case of dilated cardiomyopathy with severe left ventricular dysfunction and underwent cardiac resynchronization therapy (CRT-D) device implant three years back and subsequently underwent lead replacement 6 months back due to lead dysfunction, with severe pain over the left arm and shoulder for last 1-2 days. On evaluation, it was found that she had a coronary guidewire which might have fractured and retained inadvertently in previous surgical procedure and has caused her symptoms that might have been aggravated by the movements of her arm. Emergency surgical exploration was done and the guidewire which was impacted in deltoid muscle was removed. Results, and Conclusion- We are reporting the case due to a very unlikely and unusual delayed presentation of retained intervention guide-wire post cardiac resynchronization therapy, retrieved from left deltoid muscle.