More than 1.6 million Americans have at least moderate to severe tricuspid regurgitation, yet fewer than 8000 tricuspid valve operations are performed annually in the USA.The under-treatment for isolated tricuspid regurgitation might be related to the fact that in the past years no clear guidelines on how and when to treat tricuspid regurgitation were issued. Here, we discuss the meta-analysis by Sarris-Michopoulos et al, and we comment what is available in literature on diagnosis and decision making for tricuspid valve intervention.
Resection or exclusion of scars following a myocardial infarction on the LAD territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a “revisitation” of what described before. In some case old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.
Large osteochondroma arising from chest wall and sternum is uncommon and presentation with airway compression is further uncommon. Here we present a case of large chest wall osteochondroma as a part of Hereditary multiple exostoses in a 9 years old boy presented with a history of stridor and shortness of breath. The bony mass of the right chest wall was extending up to a suprasternal notch and compressing the trachea. The case was successfully managed by initial femoro-femoral cardiopulmonary bypass under local anesthesia prior to the induction of anesthesia to prevent respiratory collapse, followed by debulking surgery was done.
The literature describes multiple approaches for the repair of stenosed branch pulmonary arteries. Regardless of the technique, restenosis is undesirably and notoriously common. We describe a case of severe left pulmonary artery stenosis repaired with a novel technique in consideration of factors leading to restenosis. The native main pulmonary artery was transected and turned down to create a direct anastomosis with the left pulmonary artery. The child had a normal sized main pulmonary artery with tricuspid atresia and pulmonary atresia with ductus arteriosus feeding the severely stenosed left pulmonary artery. Our novel technique resulted in hemodynamically gratifying results with a tension free tissue-tissue anastomosis with potential for growth.
Objective Affecting 1 in 500 individuals; Hypertrophic cardiomyopathy (HCM) is an autosomal dominant cardiovascular disorder which is prevalent throughout the world. Surgical myectomy and alcohol septal ablation (ASA) are two methods currently used for the management of drug refractory Hypertrophic obstructive cardiomyopathy (HOCM). ASA may prove to be a useful, less invasive tool when confronting patients with HOCM especially those who are more elderly or deemed to be a higher surgical risk. Methods Electronic literature search was conducted to identify relevant articles that discussed invasive methods to treat drug refractory HOCM. No limits were placed on timing of the publication or the type of article. Key words and MeSH terms were used to conduct the search and the results were summarized in the relevant section. Results Current evidence suggests that alcohol septal ablation is a safe and effective procedure in treating patients with HOCM with similar short- and long-term outcomes when compared with surgical myectomy. Selection of patient with appropriate assessment is the key for satisfactory outcomes. Conclusion ASA has been shown to be a safe and reliable procedure; advanced imaging techniques and dedicated multi-disciplinary teams can be used to carefully select patients with HOCM. Though surgical myectomy is recommended as gold standard treatment for drug refractory HOCM, however, ASA may play an increasing role in the near future due an ageing population; both ASA and SM can have a synergistic effect in treating those who are affected by HOCM.
Background: Acute type A aortic dissection (ATAAD), is a surgical emergency often requiring intervention on the aortic root. There is much controversy regarding root management; aggressively pursuing a root replacement, versus more conservative approaches to preserve native structures. Methods: Electronic database search we performed through PubMed, Embase, SCOPUS, google scholar and Cochrane identifying studies that reported on outcomes of surgical repair of ATAAD through either root preservation or replacement. The identified articles focused on short- and long-term mortalities, and rates of re-operation on the aortic root. Results: There remains controversy on replacing or preserving aortic root in ATAAD. Current evidence supports practice of both trends following an extensive decision-making framework, with conflicting series suggesting favourable results with both procedures as the approach that best defines higher survival rates and lower perioperative complications. Yet, the decision to perform either approach remains surgeon decision and bound to the extent of the dissection and tear entries in strong correlation with status of the aortic valve and involvement of coronaries in the dissection. Conclusions: There exists much controversy regarding fate of the aortic root in ATAAD. There are conflicting studies for impact of root replacement on mortality, whilst some study’s report no significant results at all. There is strong evidence regarding risk of re-operation being greater when root is not replaced. Majority of these studies are limited by the single centred, retrospective nature of these small sample sized cohorts, further hindered by potential of treatment bias.
Background: Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the pre-operative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies. Methods: As part of routine pre-operative patient contact, patients scheduled for major surgery were prospectively ‘eyeballed’ (ICE) by two experienced clinicians prior to more detailed history taking that also included American Society of Anaesthesiologists score classification. Each patient was subjectively judged to be either ‘frail’ or ‘not frail’ by ICE and ‘fit’ or ‘unfit’ from thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of post-operative outcomes using established CPET ‘cut-off’ metrics incorporating peak pulmonary oxygen uptake ( V̇O 2PEAK), V̇O 2 at the anaerobic threshold ( V̇O 2-AT) and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single-centre prospective National Health Service database. Data were analysed using the Chi-square automatic interaction detection decision tree method. Results: A total of 127 patients examined that comprised 58 % male and 42 % female patients aged 69 ± 10 y with a BMI of 29 ± 7 kg/m 2. Patients were poorly conditioned with a peak pulmonary oxygen uptake almost 20 % lower than that predicted for age, sex-matched healthy controls with 35 % exhibiting a V̇O 2-AT <11 mL/kg/min. Disagreement existed between the subjective assessments of risk with ~34 % of patients classified not frail on ICE were considered unfit by notes review ( P < 0.0001). Furthermore, ~35 % of patients considered not frail on ICE and ~31 % of patients considered fit by notes review exhibited a V̇O 2-AT <11 mL/kg/min and of these, ~28 % and ~19 % were classified as intermediate-to-high risk. Conclusions: These findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help improve perioperative risk assessment and better direct critical care provision in patients scheduled for ‘high-stakes’ surgery including open TAAA repair.
The incidence of mechanical complications of acute coronary syndromes (ACS) needing cardiac surgery has reduced significantly in the last years due to early diagnosis and treatments. Covid-19 pandemic, however, would generate in the patients a sense of fear regarding access to the ERs so they probably underestimate symptoms such as chest pain or angina equivalents until situation does not became critical. In this way, this behaviour could create a vast pool of patients who will enter the hospital in much more critical situations and with mechanical complications of an evolving ACS needing cardiac surgery treatment.
Abstract The first clinical implantation of the “Essen I prosthesis” took place in 2005, which was then followed by E-Vita open plus. With further advancements E-Vita Neo and E-Novia was introduced. These devices enable the surgeons to perform FET in zone 0/1 which eventually reduce the incidence of paraplegia, recurrent laryngeal nerve palsy and proximalization of supraaortic arch vessels. E-vita open plus and successors alleviate frozen elephant trunk operations rendering more stable results in promoting positive remodelling of the distal aorta.
On Time Surgery Start: Is Standardization The Answer?Olufunke Folasade Dada MD, Tanaya Sparkle M.B.B.S.University of Toledo Medical Center, Anesthesiology Department,3000 Arlington Avenue, Toledo, Ohio, USACorresponding Author: Dr. Tanaya Sparkle, M.B.B.S.Address for correspondence:University of Toledo Medical Center, Anesthesiology Department,3000 Arlington Avenue, Toledo, Ohio - 43614E-mail: email@example.comPhone: 419-383-3531
Background Since the introduction of the E-Vita Open NEO aortic prosthesis in 2020, several incidences of post-anastomotic oozing from the polyester portion of the graft have emerged. The use of BioGlue to prime E-Vita Open NEO to prevent this has been suggested as a way to mitigate this worrying complication. We investigate the extent of graft oozing in E-Vita Open NEO and evaluate the use of BioGlue in preventing oozing, both experimentally and in terms of potential clinical complications. Methods and materials E-Vita Open NEO (in straight and branched configurations) was implanted in a perfused model. The distal stent-graft and side branches were clamped, and the graft pressurised with blood to 120 mmHg. The volume of blood (ml) oozing from the graft within 60 seconds was measured. Non-pressurised grafts were coated with BioGlue up to a thickness 1-, 2-, and 3 mm, and the volume (mm3) of BioGlue required to do so was recorded. Results Within 60 seconds, 250.0 ml of blood oozed from the grafts tested. 43.694 mm3, 87.389 mm3, and 174.778 mm3 of BioGlue was required to coat the device with 1-, 2-, and 3 mm of BioGlue. Conclusion Graft oozing from E-Vita Open NEO represents an omnipresent and worrying risk. The use of BioGlue herein is likely associated with several adverse consequences, which are an additional risk on top of that posed by graft oozing. These risks call into question the suitability of E-Vita Open NEO, especially when compared to alternative devices not affected by oozing.
Minimally invasive mitral valve surgery can be performed with or without robotic assistance. In this issue of the journal Zheng et al compare between these two approaches in a propensity matched study over a 5 year period and show that the two techniques have similar successful short and mid term outcomes. Although we are proponents of the robotic approach, we agree with their conclusions and discuss in this commentary some of the previously published studies that have shown similar findings.
A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supraannular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. As current data is limited, a literature review concerning subtle aortic dissection is provided.
Background: This study investigates the use of modern machine learning (ML) techniques to improve prediction of survival after orthotopic heart transplantation (OHT). Methods: Retrospective study of adult patients undergoing primary, isolated OHT between 2000-2019 as identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was one-year post-transplant survival. Patients were randomly divided into training (80%) and validation (20%) sets. Dimensionality reduction and data re-sampling were employed during training. Multiple machine learning algorithms were combined into a final ensemble ML model. Discriminatory capability was assessed using area under receiver-operating-characteristic curve (AUROC), net reclassification index (NRI), and decision curve analysis (DCA). Results: A total of 33,657 OHT patients were evaluated. One-year mortality was 11% (n=3,738). In the validation cohort, the AUROC of singular logistic regression was 0.649 (95% CI 0.628-0.670) compared to 0.691 (95% CI 0.671-0.711) with random forest, 0.691 (95% CI 0.671-0.712) with deep neural network, and 0.653 (95% CI 0.632-0.674) with Adaboost. A final ensemble ML model was created that demonstrated the greatest improvement in AUROC: 0.764 (95% CI 0.745-0.782) (p<0.001). The ensemble ML model improved predictive performance by 72.9% ±3.8% (p<0.001) as assessed by NRI compared to logistic regression. DCA showed the final ensemble method improved risk prediction across the entire spectrum of predicted risk as compared to all other models (p<0.001). Conclusions: Modern ML techniques can improve risk prediction in OHT compared to traditional approaches. This may have important implications in patient selection, programmatic evaluation, allocation policy, and patient counseling and prognostication.
Background: Partial anomalous pulmonary venous connection (PAPVC) occurs when at least one pulmonary vein drains into the right atrium or its tributaries rather than the left atrium, most commonly connecting with the superior vena cava (SVC). The Warden procedure involves transecting the SVC proximal to the uppermost connection of the pulmonary vein followed by proximal SVC reattachment to the right atrial appendage. However, descending thoracic aortic homograft replacement for SVC translocation has recently been introduced as a modified technique. Aims: This commentary aims to discuss the recent study by Said and colleagues who reported their experiences with 6 PAPVC cases undergoing a modified Warden procedure using thoracic aortic homograft SVC translocation. Methods: A comprehensive literature search was performed using multiple electronic databases in order to collate the relevant research evidence. Results: The Warden procedure is associated with a 10% incidence of SVC obstruction with many requiring reintervention. Meanwhile, using the aortic homograft for SVC translocation, Said et al. observed no SVC obstructions. In addition, this modified technique does not require anticoagulation and has demonstrated an improvement in long-term SVC patency. Nevertheless, it can be considered an expensive procedure. Moreover, since the thoracic aortic homograft utilised is biological tissue, only long-term follow-up will determine whether calcification and graft degeneration is an issue. Conclusion: It can be concluded that the modified Warden procedure is a safe and effective method to reconstruct the systemic venous drainage into the right atrium when a direct anastomosis under tension might be prone to re-stenosis.
The emergence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in December 2019, presumed from the city of Wuhan, Hubei province in China and the subsequent declaration of the disease as a pandemic by the World Health Organization (WHO) as COVID-19 in March 2020, had significant impact on health care systems globally. Each country responded to this disease in different ways but broadly by fortifying and prioritising health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on 23rd of March 2020 and all health care services were focussed to challenge the impact of COVID-19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so-called “Nightingale Hospitals” were created de novo to bolster bed provision and industries were asked to direct efforts to the production of ventilators. A government led public health campaign was publicised under the slogan of: “Stay home, Protect the NHS (National Health Service), Save lives”. The approach had a significant impact on delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on Aorto-vascular disease. We describe our Aorto-vascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID-19 pandemic.
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.