Large studies demonstrated that moderate or severe patient-prosthesis mismatch (PPM) occurs in 44.2% to 65% of patients undergoing aortic valve replacement. If there is general agreement that patients with PPM have worse outcome than patients without, it is difficult to understand how to prevent this dangerous complication. The formula used to calculate the effective orifice area (EOA) of an implanted aortic prosthesis has many weak points that produce inconsistent results using the same prosthetic valve (type and size). The observed EOA (3 to 6 months postoperatively) of a #23 biological prosthesis can range from 0.9 to 3.5 cm², making PPM prevention impossible using projected EOA, where only the mean value is reported (1.83 cm² for the same #23 biological prosthesis). An EACTS-STS-AATS Valve Labelling Task Force has been established to suggest the manufacturers to present essential information on valvular prosthesis characteristics in standardized Valve Charts. For valves used in the aortic position, Valve Charts should include a standardized PPM chart to assess the probability of PPM after implantation. This will not solve completely the conundrum of prevention, but most likely it will be a step ahead.
Non-A non-B aortic dissections are an infrequent occurrence and represent a small proportion of aortic dissections. Treating this life-threatening medical emergency often requires surgeons to undertake some one of the most challenging surgical or endovascular cases in medicine. This literature review aims to define and classify non-A non-B dissections, describe their epidemiology as well as their pathology. This review also aims to discuss the range of surgical techniques employed in their treatment and management and to investigate the patient outcomes associated with each technique.
A simplified delivery technique for the frozen elephant trunk procedure allows the distal suture to be performed on a perfused and loaded aorta in moderate hypothermia—or even normothermia—reducing circulatory arrest time to just a few minutes. Two surgical sealing tourniquets are placed around the aortic arch, usually between the brachiocephalic trunk (BCT) and the left common carotid artery and the aorta is cross-clamped and cardioplegia started. Once in mild hypothermia, the BCT is disconnected and circulatory arrest is initiated while cerebral perfusion is maintained. This modified technique can be used in all pathologies, including dissections.
Objective: Although elderly patients undergoing surgery for acute type A aortic dissection (ATAAD) is increasing, their physical activities are not fully understood. We report the physical activities and surgical outcomes in the elderly patients who underwent ATAAD. Methods: From 2009 to 2019, 103 consecutive patients underwent surgery for ATAAD at our institution. Surgical outcomes along with pre- and postoperative physical activities in 52 elderly patients (≥70 years old) were compared with those in 51 younger patients (<70 years old). Postoperative walking difficulty was defined as taking ≥30 days to regain the ability to walk 200 m postoperatively or as the inability to walk at discharge. Results: It took longer for elderly patients to regain the ability to walk 100 or 200 m postoperatively. ROC analysis revealed the AUC of the duration for walking 200 m postoperatively as a prognostic indicator for late deaths was 0.878, with the highest accuracy at 30 days (sensitivity = 83.3%, specificity = 91.8%). Hospital mortality within 30 days was 3.8%, and 1-, 3-, and 5-years survival rates were 92%, 84.7%, 84.7%, respectively, for elderly patients, with no significant differences between groups. Cox proportional hazard analysis showed postoperative walking difficulty was an independent risk factor for late mortality in all cohorts (P = 0.017). Conclusions: Elderly patients undergoing surgical ATAAD repair showed acceptable surgical outcomes. However, they were more likely to decrease their physical activities postoperatively. Postoperative difficulty in walking was an independent risk factor for the late mortality in patients with ATAAD.
A Preliminary Argument for the Selective Use of the Robicsek WeaveJohn S. Ikonomidis MD, PhDDivision of Cardiothoracic Surgery, University of North Carolina at Chapel HillWord Count: 886References: 4Address correspondence to:John S. Ikonomidis MD, PhDProfessor and Chief,Division of Cardiothoracic SurgeryUniversity of North Carolina at Chapel Hill3034 Burnett Womack Building160 Dental Circle,Chapel Hill, NC27599e-mail: firstname.lastname@example.orgTel: (919) 966-3381Proper execution of median sternotomy and its subsequent closure are critical to the success of cardiac surgical outcomes. It is essential that the sternum be divided directly in the midline, and table fractures must be avoided if at all possible by avoiding excessive spreading if the sternum for exposure of the heart. Multiple methods have been described regarding primary sternal closure technique, but the conventional technique of wire circlage, either linear or figure-of-eight, has endured and is also the most cost-effective. Sternal wound complications have an incidence of 0.8% to 1.5% patients, and this number rises to as high as 8% when bilateral internal mammary artery harvest is undertaken. Further established risk factors for deep sternal wound complications include breaches in sterility in the operating room, lengthy operations, re-exploration for bleeding, undrained retrosternal hematoma, incomplete wound closure, obesity, advanced age, diabetes, chronic obstructive pulmonary disease, hospital acquired pneumonias, renal failure, requirement for dialysis, and prolonged mechanical ventilation. Mortality from sternal dehiscence and related complications ranges from 6% to 70%. It is generally felt that early treatment reduces mortality.1Deep sternal wound complications and dehiscence were once thought to be highly feared and challenging complications of cardiac surgery. Modern primary closure techniques, tissue flap coverage options, and negative pressure wound therapy have made these complications more manageable. Nevertheless, it behooves surgeons to avoid this complication due to its considerable negative clinical impact.There are many methods currently available for reconstruction of the sternum after its dehiscence, the most common of which is the sternal weave first described by Robicsek and colleagues in 1977.2 This technique is often used to reinforce the sternum with primary sternal closure in instances where the sternotomy was off the midline leaving a thin weak section of sternum on one side or where some fracturing has occurred, but has also been used as a first line for sternal reconstruction after its dehiscence from primary closure. Data are not available regarding the overall success rate of reinforcement using the Robicsek weave, but at least one multicenter, randomized controlled trial showed that in patients with an increased risk for sternal instability and wound infection after cardiac surgery, sternal reinforcement using the Robicsek technique prior to primary sternal closure did not reduce dehiscence rate.3In addition to the above, antecedent sternal weaving weave may complicate further attempts at sternal closure should dehiscence recur. In this issue of the Journal of Cardiac Surgery,4Seyrek et al. conducted a retrospective review of patients at a single institution with noninfectious sternal dehiscence (NISD) after median sternotomy who received thermoreactive nitinol clips (TRNC) for sternal closure. The authors studied 34 cases who received TRNC treatment between December 2009 and January 2020 out of 283 patients with NISD who underwent sternal refixation. These cases were divided into two groups: patients who had a previously failed Robicsek procedure before TRNC treatment (group A, n=11) and patients who had been directly referred to TRCN treatment (group B, n= 23). The results showed that the postoperative complication rate and length of hospital stay was significantly higher with use of the Robicsek weave. Further, operative time was significantly shorter and blood loss was significantly lower in patients referred for sternal refixation without having first undergone a Robicsek weave.Part of the reason for the above results may lie with the surgical requirements for performance of the Robicsek weave. Substernal and lateral dissection is required to define the margins of the sternum before placing the weave. This increases the technical difficulty of the reclosure operation and puts the patient at risk for inadvertent injury to the heart, great vessels, and other mediastinal structures. This dissection may also compromise blood flow to the sternal half. Further, intercostal arteries may be squeezed by weave as it runs anteriorly and posteriorly around the ribs, which may occlude blood supply to the sternum. This could worsen pre-existing ischemia, which would delay sternal healing, promote bacterial colonization, and cause bone necrosis and additional sternal fragmentation, thus complicating any additional closure attempts.Use of TRNC may represent an advance in sternal reconstruction therapy due to the simplicity of use and lack of requirement for a complex mediastinal dissection prior to application. The authors contend that a previously failed Robicsek procedure caused significantly higher morbidity, additional operative risk and lower success rate in later TRNC treatment of high-risk cases and hence speculate that patients at high risk for sternal separation should proceed directly to TRNC treatment. In the light of the above study, this approach seems reasonable, but a prospective trial should be considered to provide the definitive answer.
Background and aim of the study Guidelines on myocardial revascularization indicate for type V myocardial infarction (MI) that postoperative troponin elevations need not be exclusively ischemic but may also be caused by direct epicardial injury. Additional complexity arises from the introduction of high-sensitive troponin markers. The present study attempts to contribute to the understanding of postoperative high-sensitive cardiac troponin T (hs-cTnT) increase. Methods Type of surgery, potential factors affecting the postoperative hs-cTnT increase, and possible thresholds indicative of type V MI were analyzed. Results Among 400 included patients, 2.8% had intervention-related ischemia analogous to the type V MI definition. Receiver-operating characteristics confirmed good discriminatory power for hs-cTnT and creatine kinase myocardial band (CK-MB), with ischemia indicating thresholds for hs-cTnT (1705.5 ng/l) and for CK-MB (113 U/l). The median postoperative hs-cTnT/CK-MB increase differed significantly depending on the type of surgery, with the highest increase after mitral valve and the lowest after off-pump coronary surgery. Regression analysis confirmed Maze procedure (p<0.001), cardiopulmonary bypass time (p=0.03), emergency indications (p= 0.01) and blood transfusion (p=0.02) as significant factors associated with hs-cTnT increase. In contrast, CK-MB increase was also associated with mortality (p=0.002). Intra-pericardial defibrillation was the only ischemia-independent factor additionally associated with proposed thresholds (p<0.001). Conclusions The present results confirm the influence of the type of surgery and other intervention-related parameters on the postoperative hs-cTnT increase. Type V MI-indicating thresholds may require reassessment, especially using high-sensitive markers.
Background: Acute type A aortic dissection(ATAAD) is life-threatening and requires immediate surgery. Sudden chest pain may lead to a risk of misdiagnosis as acute coronary syndrome and may lead to subsequent antiplatelet therapy. We used the Chinese Acute Aortic Syndrome Collaboration Database (AAS) to study the effects of antiplatelet therapy (APT) on clinical outcomes. Methods: The AAS database is a retrospective multicentre database where 31 of 3092 had APT with aspirin or clopidogrel or both before surgery. Before and after propensity score matching, the incidence of complications and mortality was compared between APT and non-APT patients by using a logistic regression model. The sample remaining after PSM was 30 in the APT group and 80 in the non-APT group. Results: The sample remaining after matching was 30 in the APT group and 80 in the non-APT group. We found 10 cases with percutaneous coronary intervention in the APT group(33.3%). The APT group received more volume of packed red blood cell (RBC), 8.4±6.05 units; plasma, 401.67±727 ml, and platelet transfusion(14.07±8.92 units). The drainage volume was much more in the APT group( 5009.37±2131.44ml, P=0.004). Mortality was higher in APT group(26% vs 10%, P=0.027). The preoperative APT was independent predictor of mortality(OR 6.808, 95% CI1.554-29.828, P = 0.011). Conclusion: APT prior to ATAAD repair was associated with more transfusions and higher early mortality. The timing of surgery should be carefully considered based on the patient’s status and the surgeon’s experience.
Objective: The aim of the study is to assess the therapeutic effect and applicability of pectoralis major muscle turnover flap reconstruction for treatment of deep sternal wound infection after cardiac surgery in infants and children. Methods: From march 2013 to october 2021, 23 patients with deep sternal wound infection after cardiac surgery underwent pectoralis major muscle turnover flap reconstruction.The data and outcomes of the patients were retrospectively analyzed. Results: 20 patients were treated with unilateral pectoralis major muscle turnover flap reconstruction,3 patients were treated by bilateral pectoralis major muscle turnover flap. All of the sternal wounds healed successfully. All patients survived and were discharged without evidence of infection. In a follow-up period, ranging from 15 to 83 months (mean 32.6 months), all patients demonstrated normal development with no limitations to limb movements. There were no signs of chronic sternal infection in all of them. Conclusion:Pectoralis major muscle turnover flap reconstruction is a simple,feasible and effective treatment of deep sternal wound infection after cardiac surgery in infants and children,with minimal developmental problems.
Introduction Thoracic endovascular aortic repair (TEVAR) became the standard of care for treating type B aortic dissections and descending thoracic aortic aneurysms. We aimed to describe the racial/ethnic differences in TEVAR utilization and outcomes. Methods The National Inpatient Sample was reviewed for all TEVARs performed between 2010 and 2017 for Type B aortic dissection and descending thoracic aortic aneurysm (DTAA). We compared groups stratifying by their racial/ethnicity background in whites, black, Hispanic, and others. A mixed-effects logistic regression was performed to assess the relationship between race/ethnicity and the primary outcome, in-hospital mortality. Results A total of 25,260 admissions for TEVAR during 2010–2017 were identified. Of those, 52.74% (n= 13,322) were performed for aneurysm and 47.2% (n= 11,938) were performed for type B dissection. 68.1% were white, 19.6% were black, 5.7% Hispanic, and 6.5% were classified as others. White patients were the oldest (median age 71 years; <0.001), with TEVAR being performed electively more often for aortic aneurysm (58.8% vs. 34% vs. 48.3% vs. 48.2%; p<0.001). In contrast, TEVAR was more likely urgent or emergent for type B dissection in black patients (65.6% vs 41.1% vs 51.6% vs 51.7%; p<0.001). Finally, the black population showed a relative increase in the incidence rate of TEVAR over time. The adjusted multivariable model showed that race/ethnicity was not associated with in-hospital mortality. Conclusion Although there is a differential distribution of thoracic indication and comorbidities between race/ethnicity in TEVAR, racial disparities do not appear to be associated with in-hospital mortality after adjusting for covariates.
Objectives: We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. Methods: EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. 892 results were obtained, 27 represented best evidence (2-Meta-analyses, 1-RCT and 24 retrospective cohort studies). Results: 474,160 operative outcomes were assessed for 434,535 CABG (431,329 on-pump vs 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital and 4797 thoracic procedures. 398,058 cases were performed by trainees and 75,943 by consultants. 159 cases were indeterminate. There were no statistically significant differences in the patients’ pre-operative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function and re-operation cases that were undertaken by consultants. There were no differences in CPB and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the post-operative outcomes including peri-operative myocardial infarction, resternotomy for bleeding, stroke, renal failure, ITU length of stay and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or mid-term mortality out to five-years. Discussion: Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.
Background: Atrial fibrillation (AF) is common in patients with reduced left ventricle ejection fraction (RLVEF). The impact of concomitant surgical atrial fibrillation ablation (SAFA) in patients with RLVEF is uncertain. The purpose of this study was to assess the outcomes of concomitant SAFA in patients with RLVEF undergoing heart surgery on heart failure (HF) rehospitalization and mortality. Methods: Using a local registry and electronic health records linked with provincial civil register survival data from July 2002 to April 2019, we analyzed treatment and outcomes in a cohort of patients with AF and HF defined by left ventricle ejection fraction (LVEF) ≤ 40%. Health records were used to collect treatment and International Classification of Diseases (ICD 10) codes to determine outcomes. A negative binomial model was used to compare outcomes such as all-cause mortality and rehospitalization for heart failure. Results: The cohort included 682 patients with RLVEF and AF who underwent coronary artery bypass graft and/or valve surgery. A total of 196 patients (29%) underwent concomitant SAFA. After matching, 132 patients with concomitant SAFA were compared to 159 patients who did not undergo concomitant SAFA. At 6.0±3.7 years of follow-up, concomitant SAFA was not associated with lower all-cause mortality (P=0.9861) and reduction in rehospitalizations for heart failure decompensation (P=0.31) compared to patients who did not have concomitant SAFA performed. Post-operatively, concomitant SAFA might be associated with less vasopressor and mechanical support use (p=0.01). Conclusions: Concomitant SAFA during index cardiac surgery is safe but does not reduce mortality or rehospitalizations for HF. The effects of concomitant SAFA in the context of RLVEF needs to be better studied with prospective trials.
Background: We aimed to determine the relationship between HbA1c levels and the development of postoperative atrial fibrillation (PoAF) . Methods: 288 patients diagnosed with diabet and undergoing on-pump coronary bypass were included in the study. Those with serum HbA1c levels between 5.5-7.0% were defined as Group 1, those with serum HbA1c levels between 7.1-8.9% were defined as group 2, while those with serum HbA1c levels 9.0% and above formed Group 3. Data between groups were compared. The predictive values of the independent variables for the development of PoAF were measured. Results: We did not found difference between groups in terms of development PoAF (p=0.170). Presence of hypertension was determined as an independent predictor for the development of PoAF (p=0.003) but not HbA1c levels (p=0.134). There was 50.5% sensitivity and 61.1% specificity for HbA1c values of 9.06% and above to predict PoAF (AUC: 0.571, p=0.049) Conclusions: HbA1c levels were not an independent predictor of PoAF development. However, we think that high HbA1c levels may be a risk factor for the development of PoAF.
The SARS-CoV-2, the causative agent of COVID-19, has been established to gain access to the human cell via the ACE2 receptor similar to its familial coronavirus SARS-CoV which led to the outbreak in 2003. A concern with the newer 2019 coronavirus is its 10-20-fold higher affinity to the ACE2 receptor that of SARS-CoV, aiding its effective human-to-human transmission which has led to this pandemic. ACE2 receptor expression is thought to be upregulated in use with ACE inhibitors. As ACE inhibitors are known to be a used extensively in the treatment of hypertension it was a concern regarding the risk of using these medications alongside a SARS-COV-2 infection. ACE inhibitors are also used in the treatment regime of other common conditions including diabetes and Cardiovascular disease (CVD). It is worth noting that ACE2 expression has found to be upregulated by the use of thiazolidinediones and ibuprofen too. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. Therefore, it would hypothesise that diabetes and hypertension treatment with ACE2-stimulating drugs would increase the risk of developing severe and fatal COVID-19.
We read with great interest the article by Khashkhusha TR et al “ACE inhibitors and COVID-19: We don’t know yet”. The authors discuss whether the use of angiotensin-converting enzyme (ACE) inhibitors (ACEIs) in novel coronavirus disease‐19 (COVID‐19) patients is beneficial or harmful. ACEIs and angiotensin receptor antagonists (ARBs) both upregulate ACE2 levels. We believe that ARBs should be preferred since, unlike ARBs, ACEIs may increase angiotensin II through the chymase pathway. We would like to discuss potential harms ACEI may cause through secondary bradykinin-chymase pathways.
Rupture of a congenital left ventricular diverticulum (CLVD), a rare anatomical anomaly, is a catastrophic event, with potential fatal consequences. Repair techniques documented in the literature include primary closure and single patch closure. We describe a case of a 57-year-old woman with symptomatic anterolateral CLVD. Our approach involves a linear incision through the epicardial surface of the diverticulum with exclusion of the cavity, and restoration of normal ventricular geometry via a two patch technique.
Background: In severe cases, the COVID-19 viral pathogen produces hypoxic respiratory failure unable to be adequately supported by mechanical ventilation. The role of extracorporeal membrane oxygenation (ECMO) remains unknown, with the few publications to date lacking detailed patient information or management algorithms all while reporting excessive mortality. Methods: Case report from a prospectively maintained institutional ECMO database for COVID-19. Results: We describe veno-venous (VV) ECMO in a COVID-19 positive woman with hypoxic respiratory dysfunction failing mechanical ventilation support while prone and receiving inhaled pulmonary vasodilator therapy. After nine days of complex management secondary to her hyperdynamic circulation, ECMO support was successfully weaned to supine mechanical ventilation and the patient was ultimately discharged from the hospital. Conclusions: With proper patient selection and careful attention to hemodynamic management, ECMO remains a reasonable treatment option for COVID-19 patients.
This program director survey attempts to determine how coronavirus 2019 (COVID-19) pandemic is impacting current training in cardiothoracic surgery. A transition to virtual didactic sessions may prove beneficial with increasing attendance. On the other hand, decreasing live simulation and case volumes may jeopardize achieving competency in surgical skills.