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.
Null hypothesis significance testing (NHST) and p-values are widespread in the cardiac surgical literature but are frequently misunderstood and misused. The purpose of the review is to discuss major disadvantages of p-values and suggest alternatives. We describe diagnostic tests, the prosecutor’s fallacy in the courtroom, and NHST, which involve inter-related conditional probabilities, to help clarify the meaning of p-values, and discuss the enormous sampling variability, or unreliability, of p-values. Finally, we use a cardiac surgical database and simulations to explore further issues involving p-values. In clinical studies, p-values provide a poor summary of the observed treatment effect, whereas the three- number summary provided by effect estimates and confidence intervals is more informative and minimises over-interpretation of a “significant” result. P-values are an unreliable measure of strength of evidence; if used at all they give only, at best, a very rough guide to decision making. Researchers should adopt Open Science practices to improve the trustworthiness of research and, where possible, use estimation (three-number summaries) or other better techniques.
There is increasing attention being given toward social and ethical implications of xenotransplantation that may begin relatively soon. IN a recent commentary by Loebe and Parker, the authors address many of the social and ethical issues in regard to xenotransplantation, but do so only superficially. This letter to the editor responds to many of the points they raise.
Stress KillsBerhane Worku MD1, Shudhanshu Alishetti2, Kumudha Ramasubbu21. New York Presbyterian Brooklyn Methodist Hospital/Weill Cornell Medical Center Department of Cardiothoracic Surgery, Brooklyn, NY 112152. New York Presbyterian Brooklyn Methodist Hospital Division of Cardiology, Brooklyn NY 11215Corresponding AuthorBerhane Worku MDDepartment of Cardiothoracic SurgeryNew York Presbyterian Brooklyn Methodist Hospital506 6th StreetBrooklyn, NY 11215The medical, economic, and social consequences of the COVID-19 pandemic have been profound. Severe respiratory failure as well as inflammatory and thrombotic complications have resulted in hundreds of thousands of deaths. Political controversy continues regarding optimal strategies for large scale control of the pandemic. Social distancing policies have led to reduced transmission rates but the economic effects have been devastating. Optimal treatment strategies continue to evolve, and vaccine solutions are on the horizon. In addition to these more obvious issues, other severe consequences of the pandemic are slowly being recognized.In the current report, Kir et. al. describe two postmenopausal women presenting with signs and symptoms of acute coronary syndrome in the setting of severe psychological stress related to social isolation during the COVID-19 pandemic (1). Both were COVID negative and both had unremarkable coronary angiograms. Both were diagnosed with takotsubo cardiomyopathy based on the characteristic findings of angina, mild troponin elevation, electrocardiographic changes, and apical akinesis on echocardiogram. Both admitted to severe anxiety and stress in the days prior to the onset of symptoms. Both improved with conservative management including beta-blockers and anxiolytics with resolution of apical akinesis on follow up echocardiogram.Takotsubo or stress cardiomyopathy is a now well recognized entity typically presenting as angina or dyspnea in the setting of a severe emotional or physical stressor. Postmenopausal women are more frequently affected and a history of psychiatric disorders is frequently noted. Electrocardiographic abnormalities and mild troponin elevations are common. Diagnosis is based on the InterTAK diagnostic score. Echocardiography classically demonstrates apical ballooning with basal hyperkinesis, but other wall motion abnormalities are described usually extending beyond a traditional coronary artery distribution. Coronary angiography is frequently performed to rule out acute coronary syndrome but is unremarkable. The syndrome is typically self-limited, requiring conservative supportive management, but in severe cases can lead to heart failure and shock requiring high-dose pharmacologic support, mechanical circulatory support, and in ~5% of cases can be fatal (2).Emotional and physical stress are risk factors for a variety of conditions including cardiovascular disease. Furthermore, psychiatric disorders such as depression and anxiety are associated with poorer outcomes in the setting of cardiovascular disease. Proposed mechanisms for this include behavioral factors such as noncompliance with medications and lifestyle modifications (diet, exercise, smoking cessation). Biological factors are also suggested, including altered autonomic nervous system activity with elevations in catecholamine levels and inflammatory responses amongst others (3). Similar hypotheses have been put forth regarding the mechanism of takotsubo stress cardiomyopathy and perhaps some overlap exists between the cardiovascular manifestations of psychiatric disorders and overt stress cardiomyopathy.The COVID-19 pandemic has had several medical consequences beyond those related to viral infection itself. The suspension of certain medical and surgical services potentially allows for the natural history of various diseases to take their course. Unemployment impairs the ability of many to access what medical services remain available. Psychiatric disorders are inflamed in the setting of social, economic, and other stressors. A four to five-fold increase in the incidence of stress cardiomyopathy has been noted during the months following the COVID-19 outbreak unrelated to COVID-19 infection itself, presumably the consequence of stress related to the abovementioned effects of the pandemic and our response to it. (4). COVID-19 has taught us that stress kills.REFERENCESKir D, Beer N, De Marchena EJ. Takutsobo cardiomyopathy caused by emotional stressors in the Coronavirus Disease 2019 (COVID-19) pandemic era. J Card Surg in pressDe Chazal HM, Del Buono MG, Keyser-Marcus L, Ma L, Moeller FG, Berrocal D, Abbate A. Stress cardiomyopathy diagnosis and treatment. J Am Coll Cardiol 2018;72:1955-71Takagi H, Ando T, Umemoto. Perioperative depression or anxiety and postoperative mortality in cardiac surgery: a systematic review and meta-analysis. Heart Vessels 2017;32:1458-1468Jabri A, Kalra a, Kumar A, Alameh A, Adroja S, Bashir H, Nowacki AS, Shah R, Khubber S, Kanaa’N A, Hedrick DP, Sleik KM, Mehta N, Chung MK, Khot UN, Kapadia SR, Puri R, Reed GW. Incidence of stress cardiomyopathy during the coronavirus disease 2019 pandemic. JAMA Netw Open 2020 Jul 1;3(7):e2014780. doi: 10.1001/jamanetworkopen.2020.14780
Closure of muscular ventricular septal defects remains a challenge for cardiac surgeons and interventional cardiologists. Different techniques, approaches, and devices are available to increase the success of these procedures. Changwe et al, in this issue of the Journal, describe a novel approach with the usage of a probe-guided system, with encouraging results.
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: This study explores the strategy and effect of emergency surgical treatment for total anomalous pulmonary venous connection (TAPVC). Methods: From March 2009 to February 2020, 78 patients with TAPVC underwent emergency surgical correction. There were 51 males and 27 females. The median age was 39.5 days, and the median weight was 4.0 kg. The preoperative percutaneous oxygen saturation was 80.8±4.5%. Results: Of the cases investigated, seven died during the perioperative period, 16 had delayed chest closure, 19 had early pulmonary vein obstruction, two had secondary tracheal intubation, one had a brain complication, and one had third-degree atrioventricular block. Low weight, younger age, cardiopulmonary bypass time, and aortic cross-clamp time were identified as risk factors for early mortality. During the follow-up from four to 137 months, 12 cases did not respond to follow up. Ten patients died within one to six months after discharge. One patient underwent reoperation due to pulmonary vein obstruction. The longer hospital stays after operation and intensive care unit time were identified as risk factors for late mortality. Conclusions: Emergency surgery for severe TAPVC patients after admission had achieved good results in the near future. Prenatal diagnosis should be strengthened to save more patients. The higher late mortality rate indicates that such patients should strengthen post-discharge management to reduce the occurrence of post-discharge deaths.
Hybrid coronary revascularization (HCR) consists of left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and transcatheter revascularization of the non-LAD stenosis in specific settings to achieve complete coronary revascularization. Technique to perform the LITA to LAD graft has ranged from median sternotomy with cardiopulmonary bypass to robotically assisted totally endoscopic coronary bypass surgery using beating heart revascularization.
Although mid- and long-term outcomes after the Ross procedure for aortic valve disease have been increasingly improving over the years, this is still a rather challenging operation in neonates and small children. This is particularly true for patients with associated congenital heart defects and critical clinical conditions. Herein we describe the application of this procedure as a rescue operation in emergency circumstances in a low-birth-weight neonate with severe aortic stenosis, aortic regurgitation and mitral regurgitation after a previous aortic coartectomy.
Heart failure and atrial fibrillation are often associated. Both conditions share pathophysiology and risk factor; as an example, atrial fibrillation may be regarded as either the ‘cause’ or the ‘consequence’ of heart failure. If coexistent, they are associated to very poor outcome. With this in mind, finding effective therapy for patients presenting with both heart failure and atrial fibrillation remains of paramount importance. There are also little evidence of the role and benefit of surgical atrial fibrillation ablation concomitant to heart surgery (i.e., coronary or valve surgery).
TITLE: Letter to the Editor: Impact of antimicrobial selection for prophylaxis of left ventricular assist device surgical infections.ARTICLE TYPE: letter to the editorCORRESPONDENCE: 1. SYED ABDUL REHMAN SHAHContact; +92 3350238188 Email; [email protected]: Dow University of Health Sciences, karachiAddress; H#2 G#50/4/2/2 Umar bungalows A Rehman street garden east Karachi
Background: While prior data have suggested worse outcomes in women after acute type A aortic dissection (ATAAD) repair when compared to men, results have been inconsistent across studies over time. This study sought to evaluate the impact of sex on short- and long-term outcomes after ATAAD repair. Methods: This was a retrospective study utilizing an institutional database of ATAAD repairs from 2007 to 2021. Patients were stratified according to sex. Kaplan-Meier survival estimation and multivariable Cox regression were performed. Supplementary analysis using propensity score matching was also performed. Results: Of the 601 patients who underwent ATAAD repair, 361 were males (60.1%) and 240 (39.9%) were females. Females were significantly older, more likely to have hypertension, and more likely to have chronic lung disease. Females were also significantly more likely than males to undergo hemiarch replacement, while males were significantly more likely than females to undergo total arch replacement and frozen elephant trunk. Operative mortality was 9.4% among males and 13.8% among females, though this was not a statistically significant difference (p=0.098). Postoperative complications were comparable between groups. Kaplan-Meier survival estimates were similar for men and women, and, on multivariable Cox regression, sex was not significantly associated with long-term survival (HR 1.00, 95% CI: 0.73, 1.37, p=0.986). Outcomes remained comparable after supplementary propensity score matched analysis. Conclusion: ATAAD repair can be performed with comparable short-term and long-term outcomes in both men and women.
Chow et al (1) report that significant financial resources are spent on surgical AF ablation in Canada with unclear long-term benefits and “scientifically rigorous” data regarding reduction in mortality and stroke risks. The authors call for large prospective studies examining clinically important outcomes to justify the routine use of concomitant surgical AF ablation (SA) and to guide allocation of healthcare funds. Based on their analysis, they assert that concomitant surgical AF ablation during cardiac surgery should be reconsidered. To better put these findings into context, it is important to examine the assumptions made and data utilized to assess both cost and benefit.The authors admit that their methods for cost derivation are significantly limited and do not “constitute the precision of a detailed prospective cost-utility analysis.” However, even their “simple methods” are incomplete and miss important alternative costs if SA is abandoned. They describe the incremental costs associated with surgical ablation of AF in a specific geographic location - Ontario (Canada). The authors aggregate costs from a variety of sources but base much of their calculations on an increased hospital length of stay (LOS) and increased pacemaker implantation rate from a recent systematic review and meta-analysis of RCTs of surgical ablation of AF (2).This systematic review describes an increased hospital LOS of ~ 1.67 days and a trend (not statistically significant) of increased permanent pacemaker implantation at hospital discharge, although risk of pacemaker implantation was not increased in the long term. Using this information plus Ontario-specific information of institutional costs, physician remuneration and device costs, they generate Ontario-specific financial costs for the procedure and calculate the incremental cost associated with this intervention as $4287 CAD per patient. The authors state that their calculations likely underestimate the true cost of surgical AF ablation but that at least over $10 million (CAD) was spent in Ontario province on surgical AF ablation between 2006-2017. The authors fail to consider, however, the alternative costs associated with NOT performing SA in patients with AF undergoing surgery. While surgery for the primary structural abnormality may alleviate the patients’ symptoms, it is likely that patients with pre-existing AF will continue to have AF if SA is not performed. Patients whose AF is left untreated could continue to have symptoms related to AF necessitating multiple procedures, including cardioversions, hospitalization for initiation of antiarrhythmic drugs, and catheter ablation. Even patients with asymptomatic to minimally symptomatic AF are often treated with this multiplex of therapies, each of which has more limited efficacy than SA. Given the likelihood of multiple treatments and procedures if SA is not performed, any clinically relevant cost analysis must incorporate this real cost. Consequently, the true incremental cost of SA is likely substantially less than the numbers generated by Chow et al.When analyzing the benefits of SA, the conclusions draw heavily from a recent systematic review and meta-analysis that describes several key points regarding surgical AF ablation: 1) surgical AF ablation during cardiac surgery improved freedom from AF at 12 months; 2) there was no statistically significant evidence of impact on mortality, thromboembolic or neurovascular events with limited long-term follow-up; and 3) the evidence for improvement in health-related quality of life was limited (2). It is important to note that of the 23 studies in this meta-analysis, only 5 had follow-up >12 months and only 1 > 24 months. This reported time frame may be inadequate to detect significant differences in clinical outcomes, particularly long-term outcomes such as incident stroke and mortality.As a comparison, in the world of catheter-based ablation, we have recently had the results of the CABANA trial (3). In the intention-to-treat analysis, this trial did not demonstrate statistically significant differences between catheter ablation and anti-arrhythmic drug therapy with regard to the primary composite endpoint of death, disabling stroke, serious bleeding, or cardiac arrest. However, there was a substantial and clinically important benefit of catheter ablation over drug therapy in reducing recurrent symptomatic and asymptomatic AF over 5 years of follow-up (4). There were also clinically important and significant improvements in quality of life (QOL) at 12 months in symptomatic patients (5). There was also a signal for decreased cardiovascular hospitalizations, although not centrally adjudicated, and there may be a signal for mortality benefit of catheter ablation in the subgroup of patients with systolic dysfunction (6). On-treatment analysis showed even more significant benefits, even with mortality reduction.Currently, the American Heart Association and the European Society of Cardiology provide a Class IIa recommendation for concomitant surgical AF ablation to maintain sinus rhythm in symptomatic patients. The guidelines consider surgical AF ablation with cardiac surgery a “reasonable” treatment, including patients with persistent or permanent AF (7, 8). The recent 2017 STS guidelines outline that concomitant surgical ablation to restore normal sinus rhythm during mitral valve procedures is a Class 1 recommendation, level of evidence A. Similarly, surgical ablation at the time of isolated AVR and AVR with CABG is a Class 1 recommendation, level of evidence B-NR (9).We believe the authors’ suggestion that the incremental cost of surgical AF ablation, based on this incomplete analysis, is too great to be shouldered by the taxpayers of Canada is unjustified. This manuscript touches on some interesting topics regarding the rendering of medical care, namely – what patient outcomes justify the financial costs of a procedure and what bar do we set for the level of evidence needed to justify the performance of a procedure but their cost-benefit analysis is incomplete requiring careful reevaluation of its conclusions.The importance of freedom from AF and protection from AF relapses for patients, in particular those with symptomatic AF, cannot be underestimated. Both catheter ablation studies such as CABANA and studies of surgical ablation support a clear decrease in AF burden with ablation. In CABANA, freedom from AF was long-lasting with the benefit of ablation sustained, although attenuated, at 5-year follow-up. Interestingly, the CABANA trial also included patients who had MI, PCI, or valve/bypass surgery > 3 months prior to enrollment although we do not have subgroup-specific data. In regard to freedom from AF, the surgical ablation data from the referenced meta-analysis only extends on average to 12 months (2), but we cannot exclude the possibility of a more sustained treatment effect like that seen in CABANA. In a study of SA, risk-adjusted survival differences were assessed in 372 propensity matched pairs; at last follow-up, 78% of SA patients were free of AF, and restoration of sinus rhythm was associated with improved survival (10). While large-scale data on mortality following SA remain sparse, the Society of Thoracic Surgeons’ report of over 28,000 propensity score matched patients with and without SA support improved survival at 30 days (11).There is strong evidence for improved symptoms and quality of life in patients after ablation. In the DISCERN AF study which evaluated symptomatic and asymptomatic episodes of AF pre and post radiofrequency ablation using long-term continuous monitoring, rates of symptomatic AF approached 50% (12). After ablation, arrhythmia events were 3 times more likely to be asymptomatic and the proportion of asymptomatic episodes approached 80%. This was also substantiated by CABANA trial data that showed that when AF recurred after catheter ablation it was more likely to be asymptomatic – at five years, freedom from recurrence of symptomatic AF episodes was ~ 80% (4). Health-related quality of life was also significantly improved at 12 months in the ablation group versus medical therapy (5). In the systematic review from McClure et al, there was a significant difference in physical role functioning post-operatively even though there were only two studies that could be included in the analysis (2). Granted, in patients undergoing cardiac surgery, health-related QOL outcomes are confounded by improvements in treating the underlying heart disease in addition to the restoration of sinus rhythm (13).Overall, the relatively small cost of $4287 CAD per patient, which would represent a much smaller incremental cost when accounting for the subsequent cost for AF treatment if SA is not performed, strongly supports undertaking this procedure despite the small increased risk of pacemaker implantation and increased hospital stay given the known and established benefits of freedom from AF and improvement in symptoms and quality of life. Additionally, the use of this procedure should not be halted since there is short-term and mid-term surgical mortality data that support its use (9-11), and we cannot rule out mortality and stroke benefit over a period of 5 or more years because of the limited data available. In this sense, we agree with the authors that updated long-term outcomes should be pursued to enhance our understanding and to refine decision making.
We report a first case with the use of extracorporeal carbon dioxide removal system as a bridge to re-do lung transplant in complete situs inversus patient. A 29-year-old female with Kartagener syndrome and complete situs inversus underwent a double lung transplant for end stage lung disease. Within one year after transplant the patient had primarily hypercapnic respiratory failure with radiographic signs of chronic lung allograft dysfunction. To optimize her nutritional status and muscle strength before re-do lung transplantation, we decided to bridge her with an extracorporeal carbon dioxide removal system due to anatomical difficulty. She was listed and underwent an uneventful re-do double lung transplant with cardiopulmonary support.
Tetralogy of Fallot (TOF) is rarely associated with partial anomalous pulmonary venous return (PAPVR). Unidentified PAPVR, however, might increase the risk of pulmonary valve replacement in repaired TOF patients by right ventricular (RV) dilatation and RV dysfunction. Here, we present a case of a 19-year-old male who received a correction of TOF 18 years ago and a rare type of PAPVR was identified during the follow up period. The anomalous pulmonary veins were connected to the left hepatic vein, left superior vena cava, and the right superior vena cava. Performing a pulmonary valve replacement, PAPVR was also corrected by an intra-atrial baffle with a new approach using the venous plexus between the left hepatic vein and the right hepatic vein.