Background Stroke remains a devastating complication of cardiac surgery. The aim of this study was to characterise the incidence of stroke and analyse the impact of stroke on patient outcomes and survival. Methods A retrospective analysis was performed of patients with a CT-confirmed stroke diagnosis between 01/01/2015 and 31/03/2019 at a single centre. 2:1 propensity matching was performed to identify a control population. Results Over the period 165 patients suffered a stroke (1.99%), with an incidence ranging 0.85% for CABG to 8.14% for aortic surgery. The mean age was 70.3 years and 58.8% were male. 18% had experienced a previous stroke or TIA. Compared to the comparison group, patients experiencing post-operative stroke had a significantly prolonged period of ICU admission (8.0 vs 1.1 days p<0.001) and hospital length of stay (12.94 vs 8.0 days p<0.001). Patient survival was also inferior. In-hospital mortality was almost 3 times as high (17.0% vs 5.9%; p<0.001). Longer-term survival was also inferior on Kaplan-Meier estimation (p<0.001). The 1-year and 3-year survival were 61.5% and 53.8% respectively compared to 89.4% and 86.1% for the comparison group. Conclusion Perioperative stroke is a devastating complication following cardiac surgery. Perioperative stroke is associated with significantly inferior outcomes in terms of both morbidity and mortality. Notably a 28% reduction in 1-year survival. The potential to reduce morbidity and mortality with the emergence of mechanical thrombectomy, demonstrates the need for clear links between cardiothoracic and stroke teams to support individuals affected by perioperative stroke.
The authors of “Outcomes of truncus arteriosus repair and predictors of mortality” carried out a retrospective analysis of more than 3000 infants with truncus arteriosus using the National Inpatient Sample dataset of the Healthcare Cost and Utilization Project database. Logistic regression was used to identify factors associated with in-hospital mortality. The authors also identified a seemingly protective effect of 22q11.2 deletion. But do these findings offer a complete understanding of surgical risk factors for patients with truncus arteriosus?
We report an emergent complex hybrid repair of a type A Intramural Hematoma with a tear of the aortic arch at the site of Kommerell's Diverticulum and an Aberrant Right Subclavian Artery. We identified a type Ia endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.
Individuals with single-ventricle congenital heart disease who are palliated to a Fontan circulation are at risk for heart failure and liver disease, with recurrent ascites being one potentially debilitating cause of late morbidity. Although ascites associated with heart failure or liver failure is usually characterized by a high serum-ascites albumin gradient (SAAG), we have observed multiple instances of ascites in Fontan patients with low SAAG, suggesting an inflammatory process. We present three cases in which recalcitrant ascites severely and adversely impacted quality of life, and describe our initial experience with intraperitoneal corticosteroids in this setting.
It is known that LIMA-to-LAD is the major determinant of the patient’s prognosis and long term survival for a large percentage of the population with coronary artery disease Off pump, minimally invasive LIMA-to-LAD provides excellent long-term results ). As Awad et al state, this pandemic has disrupted and challenged delivery of health care services worldwide ). LIMA-to-LAD can be performed with minimal resources in an isolated area from COVID-19 facilities within the hospital.Hybrid treatment of coronary heart disease is another option for patients under these circumstances . Surgeons must take the lead and play an active role in the decision process. . As the authors conclude, given fluidity of the current situation, there is need for new processes and clinical decision – making that will allow patients to receive appropriate treatment,
Objective: Re-exploration after cardiac surgery still remained a troublesome complication. There is still scarcity of data about the effect of re-exploration after off-pump coronary arterial bypass grafting (OPCABG). We here represent our experience of re-exploration following OPCABG. Method: Total 5990 OPCABG were performed at our center, out-off these 132 (2.2%) patients were re-explored in the OR and were included in this study. The medical records of these patients were retrospectively reviewed. Results: The most common cause of re-exploration was bleeding (83.3%) and most common site of bleeding was from graft/anastomosis (53.8%). Mean time to re-exploration was 9.75±8.65 hours. 30-day mortality was 1.41%.On univariate and multiple regression analysis, emergency surgery, preoperative low platelet count, and number of grafts were found to be an independent risk factor for re-exploration. On multiple regression, emergency surgery, euroscoreII, low platelet count, low ejection fraction, re-exploration, time to re-exploration, blood products used, high post-op serum creatinine and bilirubin, were found to be an independent factor (p<0.001) for mortality. On receiver-operating characteristic analysis, optimum cut off for time to re-exploration was 14 hours with sensitivity 81.3%, specificity of 80% and area under curve of 0.798. Patients who re-explored late (>14 hour) had significantly high mortality (30.55%vs7.3%) and morbidity. Conclusion: Delaying the re-exploration is associated with three-fold increase in mortality and morbidity. So strategy of minimizing the incidence of re-exploration like use of minimally invasive surgery and early re-exploration with judicial use of products should be use to improve outcome after re-exploration following off-pump CABG.
Importance: Cardiac tamponade requiring emergent intervention is a possible complication of COVID-19 infection. Favorable clinical outcomes are possible if timely management and drainage are performed, unless ventricular failure develops. Observations: Cardiac tamponade in COVID-19, based on the limited reported cases, seems to be more common among middle-aged men. Prognosis is worse amongst patients with concomitant ventricular failure. Design and methods: This is a case series of three COVID-19 patients complicated by cardiac tamponade, requiring surgical intervention at a single institution in New York. Interventions: Pericardial window, Pericardiocentesis Outcomes: One patient had recurrence of cardiac tamponade with hemorrhagic component but fully recovered and was discharged home. Two patients developed cardiac tamponade with concomitant biventricular failure, resulting in death. Conclusions and Relevance: Cardiac Tamponade with possible concomitant biventricular failure can develop in COVID-19 patients; incidence seems to be highest at the point of marked inflammatory response. Concomitant ventricular failure seems to be a predictor of poor prognosis.
ABSTRACT Background: COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11st, 2020. Responses to this crisis integrated resource allocation for the increased amount of infected patients, while maintaining an adequate response to other severe and life-threatening diseases. Though cardiothoracic patients are at high risk for Covid-19 severe illness, postponing surgeries would translate in increased mortality and morbidity. We reviewed our practice during the initial time of pandemic, with emphasis on safety protocols. Methods: From March 11st to May 15th 2020, 148 patients underwent surgery at the Department of Cardiothoracic Surgery of CHUSJ. The clinical characteristics of the patients were retrospectively registered, along with novel containment and infection prevention measures targeting the new Corona Virus. Results: The majority of adult cardiac patients were operated on an urgent basis. Hospital mortality was 1.9% (n = 2 patients). Most of adult thoracic patients were admitted from home, with a diagnosis of neoplasic disease in 60% patients. Hospital mortality was 3.3% (1). Fifteen children underwent cardiothoracic surgery. There was no mortality. The infection prevention procedures applied, totally excluded the transmission of Covid-19 in the Department. Conclusion: While guaranteeing a prompt response to emergent, urgent and high priority cases, novel safety measures in individual protection, patients circuits and pre-operative diagnose of symptomatic and asymptomatic infection were adopted. The surgical results corroborate that it was safe to undergo cardiothoracic surgery during the initial time of Covid-19 pandemic. The new policies will be maintained while the virus stays in the community.
Hypertrophic obstructive cardiomyopathy (HOCM) is one of the more common genetic disorders. The pathophysiology and natural history of the disease have been well studied. Left ventricular outflow tract (LVOT) obstruction and systolic anterior motion (SAM) of the anterior mitral leaflet can result in sudden cardiac death, progressive heart failure and arrythmias. Surgical septal myectomy for HOCM is the standard of care and is routinely performed through a median sternotomy. Septal myectomy has also been performed using the trans-atrial, trans-mitral approach either directly or with robotic assistance. In cases with severe LVOT obstruction in the setting of only mild to moderate proximal septal hypertrophy, intrinsic problems with the mitral valve contribute. Typically, these are hyper-mobile papillary muscles and or excessive height of the anterior mitral leaflet. Combining septal myectomy with reorientation of hyper-mobile anteriorly positioned papillary muscles has shown to prevent SAM and thereby additionally decrease the sub-valvular aortic outflow obstruction. Our extensive experience in both septal myectomy and robotic mitral valve repair has given us a different perspective in approaching the primary mitral regurgitation in HOCM patients where a combined septal myectomy, papillary muscle reorientation and complex mitral valve repair has been safely performed using the less invasive robotic-assisted approach. Our objective here is to discuss the technical aspects of the procedure.
Background: Mesenteric malperfusion is a complication with a higher risk of in-hospital mortality because diagnosing mesenteric ischemia before necrotic change is difficult, and when it occurs, the patient’s condition has worsened. Although it contradicts the previous consensus on central repair-first strategy, the revascularization-first strategy was found to be significantly associated with lower mortality rates. The aim of this study is to present our revascularization-first strategy and assess the postoperative results for acute aortic dissection involving mesenteric malperfusion. Methods: Among 58 patients with acute type A aortic dissection at our hospital between January 2017 and December 2019, mesenteric malperfusion was noted in six. Four hemodynamically stable patients underwent mesenteric revascularization with endovascular intervention in a hybrid operation room before central repair, and two hemodynamically unstable patients underwent central repair before mesenteric revascularization. Results: No in-hospital mortality was recorded. All four patients with mesenteric revascularization-first strategy recovered with no symptoms related to mesenteric ischemia. Two patients with central repair-first strategy developed paralytic ileus for 1 week; one of them needed explorative laparotomy, but no patients needed colon resection. Conclusion: The revascularization-first strategy in cases of acute type A aortic dissection with mesenteric malperfusion may achieve favorable results. However, in cases with other-major organ malperfusion or having hemodynamically unstable status, the appropriate strategy is controversial. Close evaluation of mesenteric perfusion using multiple modalities and prompt revascularization are mandatory in these complicated cases. A hybrid operation room provides an ideal environment for this revascularization-first strategy.
Background: Transannular patch, which results pulmonary insufficiency (PI), is usually required during repair of Tetralogy of Fallot (TOF). In this study, we compared 3 types of pulmonary valve reconstruction techniques during transannular repair of TOF. Methods: Between February 2014 and January 2018, 50 patients with TOF underwent total repair with transannular patch. These patients were divided into three groups. In group 1, (n= 15), a single gluteraldehyde treated autologous pericardial monocusp (standard method) was reconstructed. In group 2, (n= 16) Nunn’s bileaflet pulmonary valve reconstruction technique was used with autologous pericardial patch. In group 3, (n= 19), Nunn’s bileaflet technique was performed with expanded polytetrafluoroethylene (e-PTFE) membrane. Outcomes of the patients with early and mid-term competency of the pulmonary valves were analyzed. Results: All three pulmonary valve reconstruction techniques were significantly effective in early postoperative period. Freedom from moderate to severe PI were 73.3%; 100% and 89.4% respectively. Mortality, duration of intensive care unit and hospital stay were similar between the groups. The mean follow-up period was 17.5±13.0 (3 to 57) months. Freedom from moderate to severe PI decreased to 40%; 81.2% and 73.7% respectively at the end of the follow-up period. Presence of moderate to severe PI was significantly higher in group 1 (p: 0,018 between group 1 and 2, p: 0,048 between group 1 and grup 3). Conclusions: All three pulmonary valve reconstruction techniques provided competent pulmonary valves. Nunn’s bileaflet technique had better outcome at midterm. This technique has a potential to delay right ventricular dysfunction at long-term.
Background: Over-resuscitation in post-cardiac patients is associated with significant morbidity and mortality. Accordingly, there is a growing interest in concentrated human albumin and hypertonic saline for resuscitation in cardiac patients following revascularization surgery. In this article, we will review the use of hyperosmolar fluid therapies for resuscitation in post-cardiac surgical patients from the current literature. Methods: A literature search was conducted in MEDLINE (PubMed) utilizing keywords, narrowing publications to 2010-2019. Results: Patients receiving concentrated albumin after cardiac surgery required less fluid bolus therapy, less time on vasopressors and were found to have a less positive fluid balance compared to patients receiving crystalloids. The impact on cardiac output and mean arterial pressure in those given concentrated albumin compared to crystalloid boluses was inconsistent. There was no difference in mortality in those given 20% albumin compared to crystalloids post-revascularization. Hypertonic saline showed some positive immunomodulatory effects in patients post-revascularization. Studies identifying the impact of hypertonic saline on fluid balance and mortality compared to normal saline in patients following revascularization surgery are on-going. Conclusions: In this analysis, publications on resuscitation with hyperoncotic albumin and hypertonic saline in patients post-revascularization surgery were reviewed. While there is data in support of using these alternative fluid therapies in other critically ill patient populations, the limited literature in support of using concentrated albumin and hypertonic saline for resuscitation in following cardiac surgery is equivocal.
We describe two cases of favorable and unexpected recovery in positive patients with COVID-19, suffering from multiorgan comorbidity and already assisted with the left ventricular assist device. We have observed that, although in the presence of more comorbidities, when the maintenance of a valid support of the cardiovascular function is guaranteed, the possibility of successfully overcoming the SARS-CoV-2 infection is still alive.
The current coronavirus (COVID-19) pandemic is associated with severe pulmonary and cardiovascular complications. This report describes a young patient with COVID-19 without any comorbidity presenting with severe cardiovascular complications, manifesting with pulmonary embolism, embolic stroke, and right heart failure. Management with short-term mechanical circulatory support, including different cannulation strategies, resulted in a successful outcome despite his critical cardiovascular status.
Background The Carpentier-Edwards Perimount valves have a proven track record in aortic valve replacement: good durability, hemodynamic performance, rates of survival, and infrequent valve-related complications and PPM. The St. Jude Medical Trifecta is a newer valve that has shown comparable early and midterm outcomes. Studies show reoperation rates of Trifecta are comparable to Perimount valves, with a few recent studies bringing into focus early SVD, and increased midterm SVD in younger patients. Given that midterm data for Trifecta is still sparse, we wanted to confirm the early low reoperation rates of Trifecta persist over time compared to Perimount. Methods The Maritime Heart Centre Database was searched for isolated AVR or AVR+CABG between January 2011 and December 2016. Primary end point of the study was all-cause reoperation rate. Results 711 Perimount and 453 Trifecta implantations were included. The reoperation hazards were determined for age: 0.96 (0.92-0.99, p=0.02), female (vs male): 0.35 (0.08-1.53, p=0.16), smoker (vs non-smoker): 2.44 (0.85-7.02, p=0.1), and Trifecta (vs Perimount): 2.68 (0.97-7.39, p=0.06). Kaplan-Meier survival analysis in subgroups—age < 60, age ≥ 60, male, female, smoker, and non-smoker—showed Perimount having lower reoperation rates than Trifecta in patient younger than 60 (p=0.02) and those with smoking history (p<0.01). Conclusions The rates of reoperation of Perimount and Trifecta were comparable, with Trifecta showing higher rates in patients younger than 60 years, and current smokers. Continued diligence and further independent reporting of midterm reoperation and SVD rates of the Trifecta, including detailed echocardiographic follow up, are needed to confirm these findings.
Background and aim. Classical and paradoxical low-flow, low-gradient aortic stenosis (LFLGAS) are the most challenging aortic stenosis (AS) subtypes. The current therapeutic options are aortic valve replacement (AVR) and conservative management. The matter is controversial because AVR promotes long-term survival, but it is invasive, while no aortic valve replacement (noAVR) in non-invasive, but it is associated with poor prognosis. This meta-analysis aims to investigate the survival rate in patients with LFLGAS undergoing AVR versus noAVR interventions. Methods. A meta-analysis was conducted comparing the outcomes of AVR and noAVR in terms of survival. A meta-regression was carried out to investigate the impact of preserved and reduced left ventricular ejection fraction (LVEF) on survival in both the AVR and noAVR group. Results. The log IRR of survival between AVR group and noAVR group was 0.58 [0.28, 0.87] (p-value = 0.0001), suggesting that survival is significantly better in the AVR group compared to the noAVR group. The meta-regression revealed that low LVEF is related to higher survival rates in the AVR group (p-value = 0.04) when compared to preserved LVEF. LVEF has no impact on survival in the noAVR group (p-value = 0.18). Conclusions. Patients with LFLGAS have better survival in the AVR group rather than in the noAVR group. Reduced LVEF was related to better survival than preserved LVEF in the AVR, and no difference between low and preserved LVEF was found in the noAVR group.
Background : To evaluate the long-term results of implantation of homogeneous large size of pulmonary homograft (PH) for reconstruction of the right ventricular outflow tract (RVOT). Methods : Between January 2000 and December 2017, 107 patients were implanted with PH for reconstruction of the RVOT. Data were collected retrospectively in this single-center study. PH failure was defined as a peak of gradient > 40 mmHg and/or as a pulmonary regurgitation > grade 2. Primary endpoint was the re-operation of the RVOT during follow-up. Secondary endpoints were overall survival, occurrence of PH failure and the rate of re-operation for all cause. Results : Mean age of the recipients was 26.13 13.59 years. Mean size of PH was 23.02 6.87 mm. Re-operation of the RVOT occurred in 8 patients (7.8%). Time before re-operation was 2.74 years (Interquartile Range: 6.41). Freedom from re-operation for RVOT at 5 and 10 years was respectively 95.7% and 90.0%. Overall survival at 10 years was 95.2%. PH failure occurred in 13 patients (12.0%). Mean time before PH failure was 5.00 4.35 years. Freedom from PH failure at 10 years was 81.6%. Re-operation for PH failure occurred in 4 patients (3.9%). Concomitant tricuspid valve surgery (p=0.037), initial pulmonary stenosis (p=0.04), recipient of PH < 16 years old (p=0.043) were risk factors of late reoperation in univariate analysis. Multivariate analysis showed no independent risk factor of late reoperation. Conclusions : Implantation of large PH for RVOT reconstruction provides excellent mid-term results in terms of re-operation.