Abstract Objectives: The use of minimally invasive or transcatheter interventions rather than standard full sternotomy operations to treat Tricuspid valve disease is increasing. Debate however is still open regarding venous drainage management during cardiopulmonary bypass and wheatear or not superior and inferior vena cava should be occluded during opening of the right atrium to avoid air entrance in the venous line. The aim of the present study is to report operative outcomes and mid-term follow-up results of minimally invasive tricuspid valve surgery performed without caval occlusion. Methods: This is a retrospective outcome evaluation from institutional records with prospective data entry. We searched for all the patients who underwent right mini-thoracotomy tricuspid valve surgery isolated or combined with mitral valve surgery during the period June 2013 – February 2020. Results: During the study period 68 consecutive patients underwent minimally invasive tricuspid valve surgery without occlusion of cava veins. Survival at a 5-year and 8-year follow up was 100% and 79%, respectively. At follow-up no patient had an NHYA class greater than two, only one patient was re-hospitalized for heart failure for an atrial fibrillation episode. One patient was hospitalized for a pericardiocentesis twenty days after discharge No severe tricuspid regurgitation was evident at echocardiographic follow up. Five patients had 2+ TR. Conclusion Our results show that performing tricuspid surgery without caval occlusion is safe. There is no clinical evidence of gas embolism. Mid-term follow up data confirm that minimally invasive approach does not alter the quality of surgery.
Mitral valve repair (MVR) is undisputedly associated with better clinical and functional outcomes than any other type of valve substitute. Conventional mitral valve surgery in dedicated high-volume centers can assure excellent results in terms of mortality and freedom from mitral regurgitation (MR) recurrence but requires cardiopulmonary bypass (CPB) and cardioplegic heart arrest. Trying to replicate the percentage of success of surgical MVR is the aim of all new transcatheter mitral dedicated devices. In particular transapical beating-heart mitral valve repair by artificial chordae implantation with transesophageal echocardiography (TEE) guidance is an expanding field. The safety and feasibility of the procedure have already been largely demonstrated with Neochord and more recently with Harpoon systems. Wang et al. present the outcomes of the first-in-human experience using a novel artificial chordae implantation device, the Mitralstitch system. Despite a quite small cohort of only 10 patients treated, 1-year results are satisfying and comparable to the early experience with former devices (4 patients with moderate or more MR recurrence). The comparison with surgical MVR is still unfavorable and requires further studies and significant procedure improvement. However, the device permits the treatment of anterior and posterior leaflets prolapse and performs quite easily edge-to-edge reparation. It will be interesting to evaluate longer follow-up in larger cohorts of patients as well as the possibility to shift to the transfemoral approach.
Abstract: Critical airway stenosis presents a challenge for surgeons and anesthesiologists alike in securing a reliable airway for adequate ventilation. The use of veno-venous (VV) extra-corporeal membrane oxygenation (ECMO) has been described as a strategy to provide adequate gas exchange in such instances. We present a case of a young female with a complex paratracheal mass significantly compressing the trachea in whom a planned intra-operative VV ECMO was instituted to allow safe oro-tracheal intubation of a double lumen endotracheal tube for lung isolation and tumor resection.
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.
OBJECTIVES: The frozen elephant trunk (FET) technique has become an important tool in the treatment of acute type A aortic dissection. The aim of this study was to evaluate the effect of long FET on spinal cord injury (SCI) and distal aortic remodeling after acute type A aortic dissection based on clinical and radiological outcomes. METHODS: From January 2018 to November 2019, 158 patients [mean age 51.8 years (range 32 - 78 years), 88.6% male] with acute type A aortic dissection were treated by FET with 100 mm (n=113) or 150 mm (n=45) open hybrid stent graft prosthesis. Patients were divided into two groups according to the length of FET. The clinical and radiological outcomes of the patients were reviewed retrospectively. RESULTS: Postoperative outcomes did not differ significantly: in-hospital mortality (9.7% vs 6.7%, P=0.758) and SCI (5.3% vs 2.2%, P=0.674). Aortic remodeling, which was evaluated by aortic diameter, true lumen diameter, false lumen diameter and the rate of false lumen complete thrombosis, was more positive in long FET group in the descending thoracic aorta during the follow-up period. At the abdominal level, there was no statistically significant difference between the two groups. CONCLUSIONS: The long version of FET does not increase the risk of SCI in patients with acute type A aortic dissection. The application of long FET can achieve better results in terms of remodeling of the thoracic aorta in the short- and medium-term follow-up.
Background: The present study aimed to explore the relationship between serum anion gap (AG) and long-term mortality in patients undergoing coronary artery bypass grafting (CABG). Methods: Clinical variables were extracted among patients undergoing CABG from Medical Information Mart for Intensive Care III (MIMIC III) database. The primary outcome was four-year mortality following CABG. An optimal cut-off value of AG was determined by receiver operating characteristic (ROC) curve. The Kaplan-Meier (K-M) analysis and multivariate Cox hazard analysis were performed to investigate the prognostic value of AG in long-term mortality after CABG. In order to eliminate the bias between different groups, propensity score matching (PSM) was conducted to validate the findings. Results: The optimal cut-off value of AG was 17.00 mmol/L. Then a total of 3,162 eligible patients enrolled in this study were divided into a high AG group (≥17.00, n=1,022) and a low AG group (<17.00, n=2,140). A lower survival rate was identified in the high AG group based on K-M curve (p<0.001). Compared with patients in the low AG group, patients in the high AG group had an increased risk of long-term mortality [One-year: HR 2.309, 95% CI (1.672-3.187), P<0.001; two-year: HR 1.813, 95% CI (1.401-2.346), P<0.001; three-year: HR 1.667, 95% CI (1.341-2.097), P<0.001; four-year: HR 1.710, 95% CI (1.401-2.087), P<0.001] according to multivariate Cox hazard analysis. And further validation of above results were consistent in the matched cohort after PSM. Conclusions: The AG is an independent predictive factor for long-term all-cause mortality in patients following CABG, where a high AG value is associated with an increased mortality.
Title pageTitle: Letter to the Editor: Aortic valve repair in patients with ventricular septal defectArticle type: Letter to the editorDeepak RajaniContact: +923350326757 Email: [email protected]: Shaheed Mohtarma Benazir Bhutto Medical College Liyari,KarachiAddress: Maira garden,Garden west, KarachiCo-author: Zoaib Habib TharwaniContact: +923343975434 Email: [email protected]: Dow University of health Sciences (DUHS), Dow Medical College, KarachiAddress: Al-Yasrab, Garden East, KarachiSatesh KumarContact:+92-3325252902 Email: [email protected]: Shaheed Mohtarma Benazir Bhutto Medical College Liyari,KarachiAddress: Parsa citi near police headquarter Garden East Karachi
Surgical treatment of type A dissections is based on best evidence practice for the lack of controlled randomized studies providing definitive scientific evidence. Despite its widespread use, axillary cannulation still remains a debated topic as the preferred method of cannulation and perfusion strategy in the treatment of this complex condition.
Frozen Elephant Trunk (FET) has revolutionized management of aortic arch and proximal descending aorta pathologies. Despite significant advancement in FET prosthesis design in recent years, adverse outcomes related with neurologic and visceral ischemic events remained unsolved. To address this issue, several publications evaluated protection strategies to reduce body lower ischemic time. In the present commentary we put the technique promoted as “Release and Perfuse Technique” on scale that is for achievement of less lower body circulatory arrest time.
Objective: This study aimed to evaluate the long-term outcome of patients with PDA associated with UAPA. Methods: Patients diagnosed with PDA associated with UAPA were retrospectively enrolled from January 2005 to June 2019. Clinical data, treatment and follow-up information were evaluated. Results: 11 patients (5 males and 6 females) were diagnosed with PDA associated with UAPA. Percutaneous closure was conducted in 9 patients successfully. The median age was 37 months. The mean diameter of the PDA and occluders were 5.3±1.8mm (range 2-8.1 mm), 11.5±3.9 mm (4-16 mm) respectively. The median in 5 patients with the pulmonary: systemic flow ratio (Qp:Qs) was 1.41(1.28-8.7) and total lung resistance was 12 wood (1.8-13.6) . The mean systolic pulmonary artery pressure was 68.3±19.1mmHg（42-105mmHg). In 5 patients with pre- and post-procedure catheter data, the systolic pulmonary arterial pressure decreased significantly after closure 77.0±20.2 v 58.8±17.5 mmHg (p = 0.024), and so was the mean pulmonary arterial pressure 58.2±14.6 v 39.0±14.1 mmHg (p = 0.18). The pulmonary artery pressure and heart size gradually decreased to normal in 8 patients, and the quality of life was significantly improved. The ratio of lung to systemic circulation pressure in all these patients was less than 0.75. Conclusions: In appropriate patients with PDA associated with UAPA, transcatheter closure of PDA has the potential to improve the pulmonary artery hypertension. The ratio of lung to systemic circulation pressure less than 0.75 may be important reference index for predicting whether the pulmonary artery pressure could be reduced to normal after occlusion.
A 40-year-old male with Becker muscular dystrophy presented with severe mitral regurgitation and underwent mitral valve repair. Following the surgery, the patient became tachycardic, and developed a continuous high grade-fever and hyperbilirubinemia. The patient's condition worsened and we eventually tested his thyroid levels and discovered abnormally high thyroid levels. After diagnosing a severe thyroid storm, the patient was treated with oral administration of Lugol's iodine and thiamazole, as well as an intravenous steroid, which led to an immediate improvement of symptoms. The incidence of thyroid storm after open-heart surgery is extremely rare but highly life-threatening if unrecognized.
We present a case of coronary artery bypass grafting in a 78-year-old man with triple vessel disease and concomitant cardiac amyloidosis. Postoperatively he developed a profound low cardiac output state and multi-organ failure. He died 3 weeks following surgery. Bypass surgery is rarely performed in patients with cardiac amyloidosis, and there is little in the literature regarding outcomes. The few published cases present a bleak picture, and hence percutaneous coronary intervention should always be preferred.
The case report by Sicim et al. is the placement of extra-anatomical bypasses in bilateral common carotid arteries. The similar previous reports of the extra-anatomical bypass usually indicate unilateral bypass. Whether or not the Willis' circle is incomplete is difficult to judge during emergency surgery, and the authors' judgment seems to have been correct in the sense that it could maintain cerebral perfusion reliably and quickly. The direct perfusion and extraanatomical bypass of carotid artery is a reasonable strategy in patients with cerebral malperfusion.
Background: The radial artery (RA) is often utilized for diagnostic coronary angiography and percutaneous intervention. Recent high-level evidence supports RA use in preference to saphenous vein as a conduit for coronary revascularization. Aim: To demonstrate gross and histologic changes of the RA following transradial access. Methods: We present two patients who had open RA harvest for coronary bypass surgery after transradial catheterization. Results: Examination 8 years after transradial catheterization demonstrated thickened intima and dissection, and examination 12 years following transradial catheterization with percutaneous coronary intervention demonstrated chronic dissection with thickened intima and near occlusion of the lumen. Conclusion: Transradial access via the RA, even after several years, is associated significant injury, making it unusable as a conduit for surgical coronary revascularization. A RA that has been utilized for catheterization should not be considered for coronary revascularization.
Recovery of heart function during support with durable LVAD is uncommon, and there are few reports of cases that address the issue of eliminating the LVAD without the need for a heart transplant. Radical surgical removal of the LVAD may cause distortion of left ventricular cavity and thus affect its function, in addition to the associated risks of the operation. Innovative ways to de-activate the LVAD, relying mainly on implantation of vascular plugs in the outflow graft have been used. Few reports have shown the success of this method. In this case report, we review the story of a young patient with advanced heart failure, who underwent LVAD implantation, and after 6-month, there was a dramatic improvement of heart function that enabled successful de-activation of the device.