Dear Editor,We read with interest the published article by Ikeda et al. , they performed thoracic endovascular aortic repair (TEVAR) in a patient with Marfan syndrome (MFS) for acute complicated type B aortic dissection (TBAD) during COVID-19 pandemic.The evidence around TEVAR for MFS is scarce and open repair remains the gold treatment. During the COVID-19 pandemic, many patients are either being denied treatment or given inferior options on the basis of age, comorbidities and risk of COVID pneumonia; however, the guidelines for aortic intervention in the United Kingdom have remained largely unchanged from pre-COVID-19 era . Our questions to the authors relate to whether their solution was an unnecessary compromise. There is no clear indication defined in their case as a cold leg doesn’t necessary means an ischaemic limb. The TEVAR procedure performed aiming to minimise hospital stay, yet this approach may have put the patient at higher risk of developing paraplegia and visceral organ malperfusion, while compromising her long-term care.There is need to clarify if she had risk factors that prone her to a higher risk acquiring severe COVID-19 which necessitated deviating from the traditional open surgery recommended for MFS patients with TBAD . The authors did not report on renal function, evidence of bowel malperfusion or whether there was resistant hypertension that needed immediate intervention. If the need to expediate intervention was the fear of limb ischaemia, is it conceivable a femoro-femoral bypass could have saved the limb and definitive open surgery on her aorta could have been performed at a later stage, especially since she was haemodynamically stable.Moreover, as Marfan-diseased aortas are prone to further dilatation, we believe their justification for opting for endovascular repair should also have been more balanced, exploring the know high rate of long-term TEVAR-associated complications in MFS patients including endoleaks, retrograde dissection, stent-graft-induced new entry tears, surgical conversions and reintervention. There is also need for imaging follow-up to assess the success of TEVAR and early detection of aforementioned complications.
Cryoglobulinemia is a cold-reactive autoimmune disease. A 64-year-old man with active cryoglobulinemia presented Stanford type A acute aortic dissection. He had been treated with immunosuppressive drugs and plasma exchange (PE) at our hospital; subsequently, qualitative analysis of cryogobulin (CG) was negative. He underwent emergency ascending aorta replacement using cardiopulmonary bypass (CPB) under deep hypothermia circulatory arrest with selective cerebral perfusion. The total CPB time, aortic cross clamp time, and selective cerebral perfusion time were 255, 153, 56 minutes, respectively, and the minimal nasopharyngeal temperature was 17.3°C. Our patient had no significant perioperative complications. Hence, if PE is performed appropriately and CG is negative, patients with cryoglobulinemia who exhibit severe preoperative symptoms can safely undergo surgery with deep hypothermia.
Transcatheter repair systems are becoming increasingly popular as a potential solution for high-risk and inoperable patients with mitral regurgitation. The Cardioband (Edwards Lifesciences, Irvine, California) is a transcatheter direct annuloplasty device, based on the concept of an undersized ring annuloplasty. We report a case of minimally invasive surgical explantation of a failed Cardioband device 21 months after its implantation. Intraoperatively, it was found that3 anchors of the Cardioband device were detached from the posterior annulus at P2. In this report, a “cut and unscrew” technique with some tips and tricks is presented for the removal of the device.
We want to thank Dr. Raveenthiran and Dr. Harky for their interest in our paper and in the topic of Marfans in the setting of pregnancy. Certainly, the reduction of adverse outcomes would be improved with early knowledge of Marfans syndrome in the mother which would aid in preparation and clinical consideration during the perioperative period, and, prior to pregnancy.
ABSTRACT Introduction and Objective: There are various management options for newborns with single ventricle physiology, ventriculoarterial discordance and subaortic stenosis (SOS), classically involving the early pulmonary banding and aortic arch repair, the restricted bulboventriculer foramen(BVF) enlargement or the Norwood and the Damus Kaye Stansel (DKS) procedures. The aim of this study is to evaluate the midterm results of our clinical experience with palliative arterial switch operation (pASO) for this subset of patients. Method: We hereby retrospectively evaluate the charts of patients going through pASO, as initial palliation through Fontan pathway, starting from 2014 till today. Results: 10 patients underwent an initial palliative arterial switch procedure. 8 of 10 patients survived the operation and discharged. 7 of 10 patients completed stage II and 1 patient reached the Fontan completion stage and the other six of ten (6/10) patients are doing well and waiting for the next stage of palliation. There are two mortalities in the series (2/10) and one patient lost to follow-up (1/10). Conclusions: The pASO can be considered as an alternative palliation option for patients with single ventricle physiology, transposition of the great arteries and systemic outflow obstruction. It not only preserves systolic and diastolic ventricular function, but also provides a superior anatomic arrangement for following stages. Keywords: Congenital Heart Disease, Single Ventricle, Arterial Switch Operation
Under the unprecedented pressures of the global coronavirus disease 2019 (COVID-19) pandemic, there is an urgent requisite for successful strategies to safely deliver cardiac surgery. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first described in early December 2019, and the rapid spread and emergence of this virus has caused significant disruptions in the delivery of healthcare services worldwide.1,2 In particular, provision of cardiac surgery has been disproportionally affected due to reallocation of intensive care resources, such as ventilators.2Additionally, patients with pre-existing cardiovascular disease are likely to have comorbidities which are associated with poorer clinical outcomes in confirmed SARS-CoV-2 cases.3,4 Despite this, Yandrapalli and colleagues have reported the first case of a successful coronary artery bypass graft (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection, which offers insights into how cardiac surgery could be adapted to solve the challenges of this pandemic.5In response to the burden of COVID-19 on healthcare systems in the United Kingdom (UK), elective cardiac surgeries have been delayed owing to the redistribution of intensive care resources and the unquantifiable risk of acquiring COVID-19.2 Likewise, cardiac surgery services have undergone structural remodelling into a centralised system in an attempt to continue provisions of emergency surgery alongside hospital management of COVID-19 patients.2Unsurprisingly, most cardiac surgery units across the globe have seen a sharp decline in surgeries as a result, and one unit reported an 83% reduction in cardiac index cases between 23rd March to 4th May 2020.2 Similar models have been used in Europe to manage healthcare services and increase intensive care capacity. For example in the Lombardy region of Italy, 16 out of 20 cardiac surgical units discontinued services and all urgent cases have been consequently diverted to the remaining four units for centralised services.6 Whilst these measures have been beneficial for supporting the focused management of COVID-19 patients, it is important to reflect upon the future consequences of delayed elective cardiac surgery. Indeed, such patients are likely to have progressive conditions and further work is needed to investigate the long-term impact of COVID-19 on mortality and morbidity in this cohort.The case report by Yandrapalli and colleagues highlight the importance of routine SARS-CoV-2 testing for all patients requiring cardiac surgery, especially for detecting asymptomatic or subclinical infections.5 Active SARS-CoV-2 infection may precipitate an overproduction of early response proinflammatory cytokines in post-operative period, leading to unfavourable surgical outcomes.7,8 Moreover, preliminary studies have shown that patients with established cardiovascular diseases may have a greater risk of increased SARS-CoV-2 infection severity and prognosis.9 Taken together, assessment for active infection is crucial for risk stratification. In addition, clinicians should consider the threshold for surgery when selecting patients for cardiac surgery. An international, multi-centre cohort study by COVIDSurg Collaborative which included 1128 confirmed SARS-CoV-2 patients undergoing a broad range of surgeries revealed that 30-day mortality risk was significantly associated with the patient demographics of male sex, an age of 70 years or older, and poor preoperative physical health status.10 Collectively, the risks and benefits of cardiac surgery should be carefully considered in such patients due to higher mortality risk.10Alternative therapeutic procedures with rapid discharge, such as percutaneous intervention or medical therapy, may be more appropriate to reduce SARS-CoV-2 related mortality and nosocomial infection risk.11Current evidence is limited for postoperative outcomes in cardiac surgery cases. In the aforementioned cohort study by COVIDSurg Collaborative, the 30-day mortality rate was 23.8%.10In addition, the study reported that 51.2% of patients had postoperative pulmonary complications, which was associated with a higher mortality rate of 38.0%.10 In another case report describing an emergency CABG operation, the asymptomatic patient succumbed to pulmonary complications arising from a SARS-CoV-2 infection confirmed postoperatively.12 The authors acknowledge that the undiagnosed infection may have triggered a refractory pathological response after cardiac surgery. Indeed, recent literature has suggested that patients with SARS-CoV-2 are at higher risk of developing thromboembolisms, possibly mediated by the interaction with angiotensin-converting enzyme 2 (ACE2) receptors.13Similarly, there is a consensus that SARS-CoV-2 has direct adverse effects on the myocardium due to high expression of ACE2.14 As such, SARS-CoV-2 can potentially trigger multisystem complications which require vigilant monitoring, especially in patients requiring cardiopulmonary bypass and at high risk of developing thromboembolisms. Cardiac surgery patients represent a vulnerable patient population, and this cohort may experience worse outcomes with SARS-CoV-2 infection based on the current available evidence. In the latest recommendation, UK currently advises all patients who are listed for elective cardiac surgery to self-isolate for 14 days prior to surgery date, in a measure to limit and contain the exposure of such cohort to the smallest possibilities of acquiring COVID-19.Currently, the future of cardiac surgery after the pandemic is unclear as the evidence is still emerging. However, the lessons learnt from these unprecedented times can be taken forward to inform future service planning. Moving forwards, routine screening of patients for SARS-CoV-2 infection will undoubtedly play a key role in identifying asymptomatic or subclinical infections. The preoperative UK National Health Service testing recommendations should be broadened so that all patients undergoing cardiac surgery are screened, given the higher risk of postoperative complications in this population. Similarly, repeat testing is important for monitoring patients for concomitant infections. Alongside changes to hospital protocol, service delivery will inevitably shift. The successful application of telemedicine during the pandemic has already been reported in the delivery of oncology services.15 Moreover, the benefits of telecardiology outside of the COVID-19 era have been previously reported, and cardiology services will likely embrace the utilisation of telemedicine for managing outpatient consultations.16 Units will also have to address the vast backlog of surgeries caused by cancellation of elective cardiac operations in a sustainable manner, with adequate hospital space and personal protective equipment availability.17 In order to resume success services, planning for this eventuality should begin now and patients at significant mortality risk due to delayed surgery need to be prioritised.Ultimately, clear guidelines should be implemented to ensure safe resumption of surgical services, whilst also reassuring patients concerned about safety.3 Whilst the future trajectory of this pandemic is uncertain, the insights from the impact of COVID-19 on cardiac surgery will undoubtedly shape the future delivery of cardiac surgery.
Background: This study evaluated 20-year survival following adult orthotopic heart transplantation (OHT). Methods: The United Network of Organ Sharing Registry database was queried to study adult OHT recipients between 1987-1998 with over 20-year posttransplant follow-up. The primary and secondary outcomes were 20-year survival and cause of death following OHT, respectively. Multivariable logistic regression was used to identify significant independent predictors of long-term survival, and long-term survival was compared among cohorts stratified by number of predictors using Kaplan Meier survival analysis. Results: 20,658 patients undergoing OHT were included, with median follow-up of 9.0 (IQR 3.2-15.4) years. Kaplan-Meier estimates of 10-, 15-, and 20-year survival were 50.2%, 30.1%, and 17.2%, respectively. Median survival was 10.1 (IQR 3.9-16.9) years. Increasing recipient age (>65 years), increasing donor age (>40 years), increasing recipient BMI (>30), black race, ischemic cardiomyopathy, and longer cold ischemic time (>4 hours) were adversely associated with 20-year survival. Of these 6 negative predictors, presence of 0 risk factors had the greatest 10-year (59.7%) and 20-year survival (26.2%), with decreasing survival with additional negative predictors. The most common cause of death in 20-year survivors was renal, liver, and/or multisystem organ failure whereas graft failure more greatly impacted earlier mortality. Conclusions: This study identifies six negative preoperative predictors of 20-year survival with 20-year survival rates exceeding 25% in the absence of these factors. These data highlight the potential for very long-term survival following OHT in patients with end-stage heart failure and may be useful for patient selection and prognostication.
ABSTRACT: Background: Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has become a valuable option in patients with bioprosthetic failure. However, potential issues with ViV TAVR may occur in patients with high risk anatomy for coronary obstruction and patients with baseline smaller bioprosthetic valves at risk for patient prosthesis mismatch. The purpose of this study was therefore to use preoperative electrocardiography (ECG)-gated, multidetector computed tomography (MDCT) in patients undergoing isolated surgical aortic valve replacement (SAVR) to 1) identify which would be high risk for coronary occlusion with ViV TAVR, and 2) predict intraoperative SAVR sizing. Methods: Among 223 patients from our institutions’ database that underwent SAVR for aortic insufficiency (AI) or aortic stenosis (AS) between January 2012 and January 2020, 48 patients had MDCT imaging prior to surgery (AI; n=31, AS; n=17). Of all patients, 67% (n=32) were bicuspid morphology. Results: With the use of virtual valve implantation, all patients with AI and bicuspid AS had feasible anatomy for ViV TAVR, while 38% of patients with tricuspid AS were high risk for coronary obstruction. There was a strong correlation between actual valve size implanted and preoperative MDCT measurements using annulus average diameter, area and/or perimeter. Conclusion: Preoperative MDCT in patients undergoing SAVR is a useful tool for lifetime management, particularly in patients with tricuspid AS. Decisions for surgical management may change based on MDCT’s ability to predict intraoperative SAVR size and determine which patients may be high risk candidates for future ViV TAVR due to coronary artery obstruction.
Background: Hybrid coronary revascularization (HCR) constitutes a left internal mammary artery (LIMA) graft to the left anterior descending (LAD) coronary artery, coupled with percutaneous coronary intervention (PCI) for non-LAD lesions. This management strategy is not commonly offered to patients with complex multi-vessel disease. Our objective was to evaluate 8-year survival in patients with triple-vessel disease (TVD) treated by HCR, compared with that of concurrent matched patients managed by traditional coronary artery bypass grafting (CABG) or multi-vessel PCI. Methods: A retrospective review was undertaken of 4805 patients with TVD who presented between January 2009 and December 2016. A cohort of 100 patients who underwent HCR were propensity-matched with patients treated by CABG or multi-vessel PCI. The primary end-point was all-cause mortality at 8 years. Results: Patients with TVD who underwent HCR had similar 8-year mortality (5.0%) as did those with CABG (4.0%) or multi-vessel PCI (9.0%). A composite end-point of death, repeat revascularization, and new myocardial infarction, was not significantly different between patient groups (HCR 21.0% vs. CABG 15.0%, p = 0.36; HCR 21.0% vs. PCI 25.0%, p = 0.60). Despite a higher baseline SYNTAX score, HCR was able to achieve a lower residual SYNTAX score than multi-vessel PCI (p = 0.001). Conclusions: In select patients with TVD, long-term survival and freedom from major adverse cardiovascular events (MACE) after HCR are similar to that seen after traditional CABG or multi-vessel PCI. HCR should be considered for patients with multi-vessel disease, presuming a low residual SYNTAX score can be achieved.
Background: Institutional factors have been shown to impact outcomes following orthotopic heart transplantation (OHT). This study evaluated center variability in the utilization of induction therapy for OHT and its implications on clinical outcomes. Methods: Adult OHT patients between 2010 and 2018 were identified from the UNOS registry. Transplant centers were stratified based on their rates of induction therapy utilization. Mixed-effects logistic regression models were created with drug-treated rejection within 1-year as primary endpoint and individual centers as random parameter. Risk-adjusted Cox regression was used to evaluate patient-level mortality outcomes. Results: In 17,524 OHTs performed at 100 centers, induction therapy was utilized in 48.6% (n=8411) with substantial variability between centers (IQR 21.4 – 79.1%).There were 36, 30, and 34 centers in the low (<29%), intermediate (29-66%), and high (>67%) induction utilization terciles groups, respectively. Induction therapy did not account for the observed variability in the treated rejection rate at 1-year among centers after adjusting for donor and recipient factors (p=0.20). No differences were observed in postoperative outcomes among induction utilization centers groups (all, p>0.05). Furthermore, there was a weak correlation between the percentage of induction therapy utilization at the center-level and recipients found to have moderate (r=0.03) or high (r=0.04) baseline risks for acute rejection at 1-year. Conclusions: This analysis demonstrates there is substantial variability in the use of induction therapy among OHT centers. In addition, there was a minimal correlation with baseline recipient risk or 1-year rejection rates, suggesting a need for better-standardized practices for induction therapy use in OHT.
Extracorporeal membrane oxygenation (ECMO) is a technology that has allowed for further cardiopulmonary support in the setting of respiratory failure refractory to mechanical ventilation. While it has evolved since its first description, one area of improvement continues to be its implementation. With advancements in cannulation techniques, in recent years, there has been a plethora of new cannulas that has been introduced to the market. For urgent venous-venous cannulation, the right internal jugular vein along with either femoral veins remain the most utilized strategy due to minimal need for imaging support. This allows for safe bedside cannulation. However, as the number of days of ECMO support continue to increase bridging patients to an easier to ambulate and more comfortable cannulation strategy is preferred. Therefore, we describe a method for bridging right jugular-femoral cannulation to left subclavian placement of the CrescentTM Dual Lumen Catheter without interrupting ECMO support.
Fulminant myocarditis is a rapidly progressive myocardial inflammation that commonly requires advanced therapies circulatory support. We report our management for a case of fulminant myocarditis and cardiogenic shock. The patient is a 36 year old gentleman who was admitted after a one week history of malaise. Upon admission he was lethargic with jugular venous distension to 10 cm. He was taken immediately for a heart catheterization and intra-aortic balloon pump placement. There was no obstructive coronary disease, and hemodynamics were consistent with biventricular failure. After multidisciplinary evaluation, we elected to proceed with emergent extracorporeal membranous oxygenation (ECMO). We utilize a Protek Duo Rapid Deployment (LivaNova, Mirandola, Italy) which is inserted via modified Seldinger technique through the left ventricular apex, terminating in the ascending aorta. Percutaneous right IJ bicaval via a y-ed Avalon Elite (Getinge, Goteborg, Sweden) approach is employed for venous drainage (Figure 1). We believe that with this alternative ECMO cannulation platform, we address the multitude of drawbacks that plague peripherally cannulated extracorporeal circulatory support, minimizing patient deconditioning and upper/lower extremity over/under perfusion complications, while providing sternal sparring antegrade arterial flow with ventricular unloading/venting. For two weeks the patient was ambulatory, but because we were unable to obtain an adequate offer during this interval, we transitioned to a bridge to bridge therapy. This case highlights an alternate strategy for central walking VA ECMO in the rare presentation of one patient’s progression from IABP to VA ECMO to durable BiVAD to heart transplantation during a single admission.
Background: Controversy exists regarding durability and survival after mitral valve repair between sternotomy and a small right anterior thoracotomy approaches. Methods: Between February 2004 and July 2015, 410 patients underwent mitral valve repair via either sternotomy (ST, n=135) or small right anterior thoracotomy (RAT, n=275). Mean follow up was 72.7 38.9 months. Postoperative echocardiograms were obtained in 310 patients (75.6%) at a mean of 20.3 21.4 months. Results: Overall survival at 1, 3, 5, and 10 years were 96.3, 93.0, 93.0, and 91.4% for the ST group and 99.3, 98.9, 98.4, and 97.0% for the RAT group (Log-Rank p = 0.004). There was no difference between groups in the cumulative incidence of need for mitral valve reoperation or progression of mitral regurgitation (MR) considering death as a competing outcome over time (p=0.94 and 0.53, respectively). Propensity score weighted multivariate Cox Proportional hazard modeling built on baseline differences between the RAT and ST groups, showed presence or absence of posterior or anterior leaflet pathology was not associated with mortality, need for reoperation, or progression of MR. A RAT approach was associated with a decreased mortality on adjusted analysis (hazard ratio, 0.32, 95% confidence interval, 0.13-0.82, p=0.018), however, this result was less significant when those with coronary artery disease were removed (hazard ratio, 0.34, 95% confidence interval, 0.12-0.96, p=0.041). Conclusions: Mitral valve repair via a small right anterior thoracotomy incision in select patients can be performed with surgical results and survival that are equivalent to the sternotomy approach.
Background: We report our experience in aortic arch repair with the E-vita Open hybrid prosthesis and describe the changes in our technique over time. Methods: Between October 2013 and December 2019, 56 patients underwent a total aortic arch replacement with the E-vita Open hybrid prosthesis. Main indications were thoracic aorta aneurysm (n=27) and acute type A aortic dissection (n=18). We analyze the technique and results in the overall series, and compare both between our early (Group I, 25 patients) and late experience (Group II, 31 patients). Results: Overall in-hospital mortality was 7.1% (4), and permanent stroke and spinal cord injury were 3.6% and 1.8% respectively. 15 patients (26.8%) underwent a planned second procedure on the distal aorta: 13 endovascular, 1 open and 1 hybrid. Survival at 1 and 3 years was 90.7% and 80.7%. Group II included more patients with acute dissection (45.2% vs 16%, p=0.02), a higher rate of bilateral cerebral perfusion (100% vs 64%, p<0.001), left subclavian artery perfusion during lower body circulatory arrest (87.1% vs 0%, p<0.001), early reperfusion (96.8% vs 40%, p<0.001), and zone 0-2 distal anastomosis (100% vs 72%, p=0.02). In-hospital mortality (3.2% vs 12%) and permanent stroke (0% vs 8%) tended to be lower in Group II. Conclusions: Total arch replacement with E-vita Open hybrid prosthesis in complex thoracic aorta disease is safe. One-stage treatment is feasible when pathology does not extend beyond the proximal descending thoracic aorta. In any case, it facilitates subsequent procedures on distal aorta if needed.
Background and aim: Revascularization guidelines support routine heart team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes hasn’t been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. Methods: We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease referred for HT discussion between 2016-2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005-2015 (No HT group). Results: There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery (STS) score (2.5± 3 vs. 3 ±3 p=0.32) and the mean SYNTAX score was low and similar in both groups (21±6 vs. 19±6 p=0.59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the no HT group (p<0.01). HT discussion led to a significant delay to PCI (8±5 vs. 1.8±4 days, p=0.02), while surgical revascularization times were not affected. Conclusion: HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated.
The Coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is overwhelming healthcare resources and infrastructure worldwide. Cardiac surgical operating capacity during the COVID-19 pandemic is dramatically lower due to postponement or cancellation of elective or semi-urgent procedures. Earlier reports have demonstrated complicated post-operative courses and high fatality rates in patients undergoing emergent cardiothoracic surgery who were diagnosed post-operatively with COVID-19. These reports raise the possibility that active COVID-19 might precipitate a catastrophic pathophysiogical response to infection in the post-operative period and lead to unfavorable surgical outcomes. Hence, it is imperative to screen patients with SARS-CoV-2 infection prior to surgery and to carefully monitor them in the post-operative period to identify any early signs of active COVID-19. In this report, we present the successful outcome of coronary artery bypass grafting (CABG) operation in a patient with asymptomatic SARS-CoV-2 infection presenting with an acute coronary syndrome and requiring urgent surgical intervention. We employed a meticulous strategy to identify subclinical COVID-19 disease, and after confirming the absence of active disease, proceeded with the CABG operation. The patient outcome was successful with the absence of any overt COVID-19 manifestations in the post-operative period.