A 62-year-old man presents to the Cardiology Department with a two years history of angina on exertion. Invasive coronary angiography revealed a severe three vessels coronary artery disease. The “Hybrid Heart Team” successfully performed a fully robotically-assisted hybrid revascularization combining RE-MIDCAB on the LAD and R-PCI on non-LAD lesions.
BACKGROUND Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects. CASE PRESENTATION We report the case of a 75-years-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a Pectoralis-Intercostal Rectus Sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 hours for postoperative pain management without others pain relievers. CONCLUSION Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.
Patients suffering retrograde type A dissection after TEVAR for type B dissection are at a higher risk of mortality than their spontanous counterparts and the kind of optimal therapy remains obscure. We present a rare case of successful open surgical repair where distal open anastomosis was accomplished cutting off the un-covered stent portion and suturing a vascular prosthesis to the dissected distal aortic arch including the covered stent part. The clinical course was regular. Immediate and radical repair in the aortic arch may be the adequate response in such instances.
Title : Submitral Aneurysm: Exploring a Rare PathologyAuthors : Kellen Round BS1, Jake L. Rosen BA1, Colin C. Yost BA1, T. Sloane Guy MD, MBA21Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St #100, Philadelphia, PA 191072Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Curtis Bldg, Ste 620, 1015 Walnut St Philadelphia, PA 19107Running Title: Submitral Aneurysm Commentary
t’s time for a fivesome. Commentary to: “The predictive value of five glomerular filtration rate formulas for long-term mortality in patients undergoing coronary artery bypass grafting” Coronary artery disease is an extremely common condition and coronary artery bypass-grafting is still one of the most important therapeutic strategy to treat it. Chronic kidney disease is often affecting patients with CAD. Nevertheless, the literature is still debating what formula estimate the best the glomerular filtration rate in patients undergoing CABG. Indeed, the formulas used in clinical practice have some differences some are more accurate in patients with diabetes, while there are some bias given by age and body mass index. In cardiac surgery, the choice of the most fitting formula to evaluate GFR has important clinical implication and, up to now, three formulas have been compared at most. Eilon Ram et al. present a retrospective study which compares the 5 most used formulas (CG, MDRD, CKD-EPI, Mayo, and IB) to derive GFR to evaluate the one with the best accuracy in predicting long-term mortality. In order to do so, they divided 3744 patients in three groups according to the estimated GFR by means of all 5 formulas: significant CKD according to all formulas, non-significant CKD according to all formulas and discordant results (meaning that at least one formula gave normal GFR and at least one formula gave abnormal GFR). Patients with the highest mortality were the ones with significant CKD according to all formulas.
Background: Aortic complications, such as aortic tears and dissections, during cannulation must be managed urgently and often require hypothermic circulatory arrest. We report a unique management strategy to repair an aortic tear without dissection by modifying a Dacron ascending aortic graft with side-arm to serve both as a patch for the aortic tear and inflow for the bypass circuit. Case Presentation: A 32-year-old female patient undergoing reoperative cardiac surgery suffered an unexpected aortic tear during cannulation for cardiopulmonary bypass. After promptly transitioning to femoral cannulation and hypothermic circulatory arrest, the tear was repaired by utilizing a physician-modified ascending aortic graft with side-arm, in which the surrounding skirt of the side-arm was cut from the circumferential graft to patch the defect. The patient was rewarmed with the side-arm serving as arterial inflow for the bypass circuit, and the remainder of the operation proceeded without complication. Conclusion: This type of aortic repair for aortic tears without dissection can offer the patient the benefit of avoiding multiple aortotomies in a weakened aorta, reducing circulatory arrest time, and re-establishing a central cannulation strategy for cardiopulmonary bypass, consequently reducing the likelihood of distal limb ischemia.
Changes in the heart allocation system have led to transplant programs traveling greater distances for donor organs. At the same time, several new technologies have emerged to provide improvements in donor organ protection when compared with traditional strategies. These new developments have increased the need for a better understanding of risks associated with donor injury related to various types of ischemia.
The potential benefit of concomitant surgical revascularization represents a controversial topic of the surgical treatment of post-infarction ventricular septal rupture (VSR). Beliaev and colleagues presented a case series interestingly focusing on this issue and showed how the possibility to perform coronary artery bypass grafting at time of VSR repair was associatd with better early and late mortality and improved cardiac function. However, a few more aspects deserve further comments in this controversial topic, especially considering late survival and postoperative cardiac function, although it seems reasonable to conclude that the presence of coronary artery disease not amenable to revascularization represents a strong negative prognostic factor in surgically treated VSR patients.
Understanding the aortic annulus is important for obtaining reproducible and durable aortic valve repair and allowing advances for TAVR treatment of aortic regurgitation. Significant limitations exist when using echocardiography and CT-based imaging with feature tracking at the aortic annulus. Cardiac Magnetic Resonance is used to obtain Regional Longitudinal Strain (RLS) and can be modified to obtain circumferential annular strain at the fibrous and muscular portions of the aortic valve annulus. Holst and colleagues use a novel method to characterize and prove that adverse annular deformation occurs at the muscular portion of the aortic valve annulus in patients with aortic regurgitation. The direction of muscular annular deformation in patients with aortic regurgitation is opposite to the direction of muscular annular deformation in patients with normal aortic valves.
A 60-year-old male presented with sudden onset chest pain and pulmonary oedema. Investigation confirmed torrential aortic regurgitation of a bicuspid valve. At surgery a ruptured chordae tendineae was identified which had been supporting the left-right cusp commissure with loss of attachment to the aortic wall. This case demonstrates that chordae tendineae may be present as a supporting structure of the aortic valve, and rupture can be a rare cause of torrential aortic regurgitation, similar in pathogenesis to how it may be associated with acute severe mitral regurgitation.
Background: Remote ischemic preconditioning (rIPC) has been applied to attenuate tissue injury. We tested the hypothesis that rIPC applied to fetal lambs undergoing cardiac bypass (CB) reduces fetal systemic inflammation and placental dysfunction. Methods: Eighteen fetal lambs were divided into 3 groups: sham, CB control, and CB rIPC. CB rIPC fetuses had a hindlimb tourniquet applied to occlude blood flow for 4 cycles of a 5-minute period, followed by a 2-minute reperfusion period. Both study groups underwent 30 minutes of normothermic CB. Fetal inflammatory markers, gas exchange, and placental and fetal lung morphological changes were assessed. Results: The CB rIPC group achieved higher bypass flow rates (p<.001). After CB start, both study groups developed significant decreases in PaO2, mixed acidosis and increased lactate levels (p<.0004). No significant differences on tissular edema were observed on fetal lungs and placenta (p>.391). Expression of toll-like receptor-4 and ICAM-1 in the placenta and fetal lungs did not differ among the 3 groups, as well as with VCAM-1 of fetal lungs (p>.225). Placental VCAM-1 expression was lower in the rIPC group (p<.05). Fetal interleukin-1 (IL-1) and thromboxane A2 (TXA2) levels were lower at 60 minutes post-CB in the CB rIPC group (p<.05). There was no significant differences in TNF-α, PGE2, IL-6 and IL-10 plasma levels of the three groups at 60-minute post-bypass (p>.133). Conclusion: Although rIPC allowed for increased blood flow during fetal CB and decreased in IL-1 and TXA2 levels and placental VCAM-1, it did not prevent placental dysfunction in fetal lambs undergoing CB.
Deep sternal wound infection (DSWI) with prosthetic graft infection is a rare, though lethal, complication after cardiovascular surgery via median sternotomy. This commentary is a review of a report by Takagi et al. published in the Journal of Cardiac Surgery that reported favorable outcomes in patients with DWSI with prosthetic graft infection treated with an enhanced strategy consisting of hydro-debridement with pulsed lavage and negative pressure wound therapies.
Cervantes-Salazar and colleagues report the long-term surgical outcomes of 414 patients with total anomalous pulmonary venous connection (TAPVC) from January 2003 to June 2019. With an overall survival rate of 87.2% from 2003 to 2019, the authors found that an increased mortality risk was associated with infra-cardiac TAPVC, pulmonary venous obstruction (PVO), and postoperative mechanical ventilation. Their comprehensive study with a large sample size of varying age groups, and patients with late referrals for surgery, provide valuable insight into TAPVC surgical outcomes. Improved survival for these patients continues to be a major goal of clinical teams striving to transform treatment paradigms. The comprehensive and promising results of the study reported by Cervantes-Salazar and colleagues gives our field hope for a better future for these patients.
Title Page:Title: Letter To The Editor: Long-Term Renal Function After Venoarterial Extracorporeal Membrane Oxygenation.Article Type: Letter To The EditorCorrespondence: 1. Rohit KumarContact No: +923332669103 Email: [email protected]: Dow Medical CollegeAddress: Baba-e-urdu road, KarachiCo-Authors: 2. Sunil KumarContact No: +923008088669. Email: [email protected]: Liaquat University of Medical and Health Sciences.Word Count: 476Conflict of interest : NoneAcknowledgment : NoneDeclaration: NoneDisclosure : NoneFunding : None
- The Gerbode type of ventricular septal defect is rare and can be congenital or acquired. - The defect can be closed retrograde or through the transvenous approach. - Short term follow-up suggests that transcatheter closure of the Gerbode type defect is feasible, safe, and effective and should be considered an alternative to surgical repair
Title pageTitle: Reply to Jasinski M et al.: ´Indeed, there is still room for improvement in long‐term durability of BAV repair´Authors: Tomas Holubec, MD, PhD, Mojyan Safari, MD, Arnaud Van Linden, MD, Anton Moritz, MDInstitutions and Affiliations: Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, Frankfurt, GermanyCorresponding author: Assoc. Prof. Tomas Holubec, MD, PhD, Theodor-Stern-Kai 7, 60596 Frankfurt/Main, Germany, Tel.: +49 69 6301 80094, Email: [email protected]
Significant dilemma exists regarding management of the aortic root pathology in acute aortic dissections. Several strategies for both repair and replacement exist and there is a lack of clarity on the superiority of one over the other. Important factors that influence management strategies include involvement of the sinuses, competence of the aortic valve, presence of Marfan's syndrome and connective tissue disorders, as well as availability of surgical expertise. The wide variability in these factors makes it unlikely for any one technique to be suitable for management of all aortic roots and the root pathology has to be tailored to an individual patient.