Aortic valve stenosis is the most common adult valve disease in industrialized countries. The ageing population and the increase in comorbidities urge the development of safer alternatives to the current surgical treatment. Sutureless bioprosthesis have shown promising results, especially in complex procedures and in patients requiring concomitant surgeries. Objectives: Assess the clinical and hemodynamic performance, safety, and durability of the Perceval ® prosthetic valve. Methods: This single center retrospective longitudinal cohort study collected data of all adult patients with aortic valve disease who underwent aortic valve replacement with a Perceval ® prosthetic valve between February 2015 and October 2020. Of the 196 patients included (mean age 77.20±5.08 years; 45.4% female; mean EuroSCORE II 2.91±2.20%), the majority had aortic stenosis. Results: Overall mean cross-clamp and cardiopulmonary bypass times were 33.31±14.09 and 45.55±19.04 minutes, respectively. Mean ICU and hospital stay were 3.32±3.24 and 7.70±5.82 days, respectively. Procedural success was 98,99%, as two explants occurred. 4 valves were reimplanted due to intra-operative misplacement. Mean transvalvular gradients were 7.82±3.62 mmHg. Pacemaker implantation occurred in 12.8% of patients, new-onset atrial fibrillation in 21.9% and renal replacement support was necessary in 3.1%. Early mortality was 2.0%. We report no structural valve deterioration, strokes or endocarditis and one successfully treated valve thrombosis. Conclusions: Our study confirms the excellent clinical and hemodynamic performance and safety of a truly sutureless aortic valve, up to 5-year follow-up. These results were consistent in isolated and concomitant interventions, solidifying this device as a viable option for treatment of isolated aortic valve disease.
Background: Chest X-rays are routinely obtained after removal of chest drains in patients undergoing cardiac and thoracic surgical procedures. However, a lack of guidelines and evidence could question the practice. Routine chest X-rays increase exposure to ionising radiation, increase healthcare costs and lead to overutilisation of available resources. This review aims to explore the evidence in the literature regarding the routine use of chest X-rays following the removal of chest drains. Materials & Method: A systematic literature search was conducted in PubMed, Medline via Ovid, Cochrane central register of control trials (CENTRAL) and ClinicalTrials.gov without any limit on the publication year. The references of the included studies are manually screened to identify potentially eligible studies. Results: A total of 375 studies were retrieved through the search and 18 studies were included in the review. Incidence of pneumothorax remains less than 10% across adult cardiac, and paediatric cardiac and thoracic surgical populations. The incidence may be as high as 50% in adult thoracic surgical patients. However, the re-intervention rate remains less than 2% across the populations. Development of respiratory and cardiovascular symptoms can adequately guide for a chest X-ray following the drain removal. As an alternative, bedside ultrasound can be used to detect pneumothorax in the thorax after the removal of a chest drain without the need for ionising radiation. Conclusion: A routine chest X-ray following chest drain removal in adult and paediatric patients undergoing cardiac and thoracic surgery is not necessary. It can be omitted without compromising patient safety. Obtaining a chest X-ray should be clinically guided. Alternatively, bedside ultrasound can be used for the same purpose without the need for radiation exposure.
anomalous pulmonary veins drain into the right side of the left atrium is an uncommon variety of anomalous pulmonary venous return. Rarely, anomalous pulmonary venous drainage combined with cor triatriatum and atrial septal defect. We presented the imaging findings of a male patient who had anomalous pulmonary venous drainage which has not previously been described.
Management of aortic arch pathologies remains challenging. Open total arch replacements have been associated with significant morbidity and mortality owing to the need for cardiopulmonary bypass and circulatory arrest. On the other hand, aortic arch branched stent grafts are not widely available. In this context, hybrid techniques combining open arch debranching with endovascular graft placement have been identified as an attractive option in select patients. However, there still is a paucity of literature on their application and outcomes. A case is presented of an elderly frail patient diagnosed with a pseudoaneurysm of the aortic arch and who was successfully treated by an off-pump arch debranching followed by endovascular arch repair. This case highlights (i) the feasibility of hybrid debranching techniques, (ii) their technical challenges, and (iii) the need for long-term follow-up data.
Advantages of combined distal-first and visceral branch-first technique: A universal fit for extensive thoracoabdominal aortic aneurysm?Kenji Okada, MD, PhD, Taishi Inoue, MDDivision of Cardiovascular Surgery, Department of Surgery,Kobe University Graduate School of Medicine, Kobe, Japan.Corresponding author: Kenji OkadaDepartment of Cardiovascular Surgery, Kobe University Graduate School of Medicine7-5-2 Kusunoki-cho, Chuo-ku, Kobe , Hyogo 630-0005, JapanTel: +81-78-382-5942;Fax: +81-78-382-5959;E-mail: kokada@ med.kobe-u.ac.jpWord counts; 743 wordsMinimization of end organ ischemia is a key tenet in successful thoracoabdominal aortic aneurysm (TAAA) surgery. In recent years various techniques have been inspired and refined to reduce the duration and risk of visceral ischemia such as mild, moderate, or deep hypothermic repair with left heart bypass, or complete or partial cardiopulmonary bypass combined with selective perfusions to vital viscera, the lower extremities and the spinal cord. (1) (2) (3) Despite advances in surgical technique and organ protection strategies, open surgical repair for TAAA remains associated with considerable levels of morbidity and mortality. Moulakakis and colleagues conducted a meta-analysis which summarized the surgical outcomes of 9963 patients in experienced surgical centers and found that the mortality after repair of extent I-IV TAAA was 11.3%. (4) These results can be attributed to the nature of open surgical repair of TAAA, which represents the pinnacle of invasive cardiovascular surgery and comes with the burden of a relatively high association of comorbidities.Estrera and colleagues reported the “distal first approach” assumes the advantage of providing a distal fenestration and ensuring adequate antegrade blood flow at an early stage for patients with chronic aortic dissection. (5) Previous reports have described the utility of “visceral branch-first techniques” in reducing visceral ischemic time with minimal reperfusion injury. (6) (7) Marchenko and colleagues also successfully devised a novel “iliac branch first” strategy combined with the distal-first approach for Crawford extent II TAAA using a “neo-graft.” (8) A bifurcated graft of the neo-graft was anastomosed to the common iliac arteries first, followed by reattachments of the left renal artery, superior mesenteric artery and celiac axis without aortic cross-clamp. Ischemic time was no longer than 7 minutes for each anastomosis and extremely short compared to previous reports from experienced centers. This may minimize the risk or degree of ischemia-reperfusion injury even if no selective organ perfusion was applied. Since the right renal artery is located on the bottom of the aneurysm, the reconstruction was performed after initiating a left heart bypass (LHB). During these reattachments, antegrade pulsatile blood flow to the spinal cord was guaranteed not only via the Adamkiewicz artery but also the collateral network, which ultimately minimizes spinal cord ischemia. Next, the thoracic intercostal arteries were reimplanted using the island technique followed by proximal anastomosis of the main graft at the aortic isthmus. Overall LHB time was merely 32 minutes. The “iliac branch first” strategy eliminated the need for femoral artery exposure, which is particularly beneficial in obese patients.At a glance, these procedures appear to be a highly promising addition to the existing armamentarium of TAAA surgical techniques; however, the question remains whether they are applicable to all types of aortic pathologies? Starting with the simplest answers, the branch reconstructions prior to aortic decompression made it difficult to adjust the length of the branches, particularly in huge aneurysms. Longer branch grafts—in particular those to the left renal artery—the may cause kinking. Secondly, some iliac arteries are not always healthy and there unsuitable for end-to-side anastomosis, which may obstruct the establishment of the primary inflow source. Third, the current procedure is indeed suitable for chronic dissecting aortic aneurysms. By ligating the visceral branches prior to the aortic procedure, this technique not only reduced visceral ischemic time but also avoided the embolization of debris or thrombi. Therefore the “branch-first” technique appears to be a desirable option in terms of preventing embolic complications in the visceral organs. But let’s suppose that the aortic pathology is an atherothrombotic one (e.g. shaggy aorta). Yokawa and colleagues reported on thoracoabdominal repair in patients with shaggy aorta (atherothrombotic aorta)—a significant risk factor for organ infarction—and showed the relationship with spinal cord injury (SCI), acute kidney injury and perioperative mortality. (9) A shaggy aorta does not always allow segmental aortic cross-clamping such as at the levels of the diaphragm and the middle third of the descending aorta for reimplantation of the intercostal arteries. Furthermore, it may be difficult to reattach the major targeted intercostal arteries if the Adamkiewicz artery exists at lower levels such as Th12 or L1. Marchenko and colleagues used the current approach in 29 patients, but the aortic pathology of the patients is unknown. Therefore, the question remains whether the incidence of spinal cord ischemia in patients with atherothrombotic aorta could be reduced by the current technique.The approach comes with inherent advantages and we eagerly await the next series of evolution along with a report on the long-term results.
ARTIFICIAL CHORDAE FOR ANTERIOR LEAFLET PROLAPSE: ARE ALL THE ROADS LEADING TO ROME?Antonio Maria Calafiore (a), MD, Antonio Totaro (a), MD, Sotirios Prapas (b), MD, Diego Magnano, MD (a), Stefano Guarracini (c), PhD, Massimo Di Marco (d), MD, Michele Di Mauro (c,e), PhDDepartment of Cardiovascular Diseases, Gemelli Molise, Campobasso, ItalyDivision of Cardiac Surgery A, Henry Dunant Hospital, Athens, GreeceDepartment of Cardiology, “Pierangeli” Hospital, Pescara, ItalyDepartment of Cardiology, “S Spirito” Hospital, Pescara, ItalyCardio‐Thoracic Surgery Department, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
Background: The most worrisome complications in patients supported by left ventricular assist device (LVAD) are pump thrombosis, embolism, and bleeding. The actual rate of these events in patients with sickle-cell disease (SCD) has not well investigated. The aim of our study is to evaluate the outcomes of LVAD implantation in patients with sickle-cell hemoglobinopathy at our institution. Methods: This retrospective, observational, single-center study was conducted on patients with sickle-cell trait (SCT), who underwent LVAD implantation using the HeartMate3 LVAD. Results: LVAD devices were implanted in four patients with SCT. All procedures were performed successfully. All patients had uneventful post-implant course. Overall, the mean follow-up time was 25 months (range 21-28 months) and showed an unremarkable post-implant course. There was a significant improvement in hematological markers over the follow-up period. Conclusions: Despite the limited numbers of patients enrolled in this study, our findings indicate that LVAD surgery is safe in SCD patients and offers remarkable clinical improvement. Further studies are needed to provide more evidence regarding this type of patients undergoing LVAD implantation.
We reported a case of a 53-year-old patient with coarctation of aorta and multiple aneurysmatic changes on aortic arch. Enhanced CT and reconstruction revealed significant coarctation and multiple aneurysmatic dilatation. The patient underwent stent implantation and was discharged with symptoms relived. Follow-up examination progression of aneurysms, however, without symptoms.
A 57-year-old man suffered chest pain during the COVID-19 pandemic, but he delayed medical treatment due to fear of infection. Four months later, symptoms chest tightness and shortness of breath appeared. Electrocardiogram (ECG) revealed old myocardial infarction; color sonography and myocardial CT revealed apical myocardial defect. He refused surgery and percutaneous transcatheter closure, and follow-up observation. After 22 months, the symptoms of chest tightness and shortness of breath aggravated. He recovered after percutaneous transcatheter closure, and was discharged. This case shows delayed closure is one of the possible options for the patients without severe organ dysfunction or hemodynamic disturbance.
Cardiac involvement of hydatid cyst disease is a rare presentation but may lead to life-threatening complications such as cyst rupture and should be treated surgically A 10-year-old male patient with cranial and complicated cardiac hydatid cyst disease lesions that caused lower extremity peripheral arterial occlusion and aneurysmatic dilatation in the left ventricular apex is presented. Although the patient was in the pediatric age group, the Dor procedure was successfully applied to preserve the ventricular geometry. The Dor procedure for a ventricular aneurysm caused by a cardiac hydatid cyst was rarely applied in the pediatric age group. Inconclusion, this case differs from other cardiac hydatid cysts previously reported in the literature due to the advanced stage of the disease, atypical clinical presentation, and rare complications despite the young age of the case. The surgical method used in treating the patient makes the subject more interesting.
Background. Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (ACP) or retrograde. In recent years nadir temperature progressively increased to 26-28 °C (moderately hypothermic circulatory arrest, MHCA), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10-minute of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming, DR) can provide a neuroprotection and a lower body protection similar to that provided by MHCA+ACP. Methods. Two-hundred-ten patients were included in the study. DHCA+DR was used in 59 patients and MHCA+ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE) or permanent (permanent neurologic deficit, PND), and need of renal replacement therapy (RRT). Results. Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%) and PNDs in 10 (4.8%). Twenty-three patients (10.9%) needed RRT. Death+PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs and death+PND, but need of RRT (OR 7.39, CI 1.37-79.1) and composite endpoint (OR 8.97, CI 1.95-35.3) were significantly lower in DHCA+DR group compared with MHCA+ACP group. Conclusions. The results of our study demonstrate that DHCA+DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA+ACP. However, the data suggests that DHCA+DR when compared with MHCA+ACP provides better renal protection and reduced prevalence of composite endpoint.
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.
Background: Four factor prothrombin complex (PCC4), a concentrate of factors II, VII, IX, X and protein C and S, has been used selectively for reversal of oral anticoagulation prior to surgery. There is data to support PCC4 as opposed to supplemental fresh frozen plasma (FFP) to manage postoperative bleeding following cardiac surgery. The preemptive, intraoperative use of PCC4 in cardiothoracic surgery has not been studied though it may prevent postoperative bleeding, the need for blood transfusion and the risk of transfusion related acute lung injury, volume overload, and right ventricular (RV) heart failure. The purpose of this study is to evaluate the intraoperative administration of PCC4 to decrease bleeding and lower the rate of blood transfusion. Methods: A single institution retrospective chart review conducted from May 2020 to November 2021 of patients who received PCC4 intraoperatively during cardiothoracic surgery of high risk variety. Patients were evaluated for type of surgery, demographics, baseline anticoagulation, PCC4 dose, type and quantity of blood transfusion within 72 hours postoperatively, chest tube output, incidence of right ventricular failure, hypersensitivity reactions, acute kidney injury, thrombosis, acute lung injury, and mortality within 45 days of the operative dose of PCC4. Results: Thirty five patients received PCC4 at a mean dose of 2920 units. Sixty five percent of cases were LVAD or heart transplant. The protocol is to use PCC4 30 units/kilogram immediately after completion of protamine administration. Inclusion criteria are: cardiothoracic surgery with increased risk of postoperative right heart failure commonly secondary to blood product transfusion, or cardiothoracic surgery associated with increased risk of bleeding, including: heart transplant, LVAD implant, aortic dissection, and redo sternotomy (e.g. coronary artery bypass). Total chest tube output was recorded as a mean of 757 mL for 24 hours after surgery (32 ml/hr). Overall median event rates of fresh frozen plasma (FFP) and red blood cell (RBC) transfusion were 0 (interquartile range 0 - 3 units) and 4 (interquartile range 2-5 units). Overall, forty-three percent and eighty-nine percent of cases received FFP and RBC, respectively. There was one occurrence of right ventricular failure, one occurrence of acute kidney injury requiring renal replacement therapy, one occurrence of venoarterial extracorporeal membrane oxygenation, one occurrence of venous thromboembolism related to a central venous access line, and one death unrelated to surgery or PCC4 that was attributed to advanced heart failure not amenable to advanced therapies. Conclusion: Overall patients received a low rate of blood transfusion, had minimal chest tube output, and there was a small incidence of right heart failure. Patients did not have an increased risk of adverse effects such as acute kidney injury or venous thromboembolism. A randomized controlled clinical trial comparing the observed dose and timing of PCC4 versus routine postoperative bleeding management with blood product transfusion is recommended.
Objectives: New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1°C to 25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis. Methods: The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative morality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI). Results: A total of 34 studies were included, with a total of 12 370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio (OR), 1.46, 95% (confidence interval) CI, 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, P-value = 0.0029 and OR, 1.74, 95% CI, 1.09-2.77, P-value = 0.019). Conclusions: In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.
Introduction The Carpentier-Edwards PERIMOUNT Magna Ease valve is a third-generation bioprosthesis for aortic valve replacement (AVR). This is a postapproval study reporting on its 8‑year outcomes. Methods Adults undergoing AVR with the Magna Ease valve between October 2007 and December 2012 were enrolled for this prospective, nonrandomized, single‑arm, multicenter study. Assessments occurred preoperatively, at hospital discharge, 6 months, 1 year, and annually thereafter up to 8 years. Outcomes included safety endpoints, hemodynamic performance, and New York Heart Association (NYHA) Functional Class. Results Of the 258 study patients, 67.5% were in NYHA Class I or II, and 32.5% were in NYHA Class III or IV at baseline. Concomitant procedures were performed in 44.2%. Total follow-up was 1,597.6 patient-years, median follow‑up was 7 years (interquartile range: 5.5–8.0 years). Eight years following AVR, functional class remained improved from baseline with 93.9% in NYHA Class I/II and 6.1% in NYHA Class III; thirty-eight deaths had occurred, eight of which were valve related; freedom from all‑cause mortality was 80.7% (95% confidence intervals 74.9, 86.4); freedom from valve-related mortality was 95.8% (92.8, 98.8); freedom from reintervention, explant, major bleeding events, and structural valve deterioration were 89.8% (85.1, 94.6), 94.8% (91.7, 97.9), 85.1% (80.0, 90.1), and 90.1% (84.7, 95.4), respectively; effective orifice area was 1.5±0.5 cm 2, mean gradient was 14.8±8.3 mmHg, and 88.6% of patients had no or trivial aortic regurgitation. Conclusions This study demonstrated satisfactory safety and sustained hemodynamic and functional improvements at 8 years following AVR with the Magna Ease valve.
Background: The hemodynamics of most prosthetic valves are often inferior to that of the normal native valve, and a significant proportion of patients undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) have high residual transaortic pressure gradients due to prosthesis–patient mismatch (PPM). Since the experience with TAVR has increased and long-term outcomes are reported, a close look at the PPM literature is required in light of new evidence. Methods: For this review, we searched the Embase, Medline, and Cochrane databases from 2000 to 2022. Articles reporting PPM as an outcome following aortic valve replacements were identified and reviewed. Results: The impact of PPM on clinical outcomes aortic valve replacement has not been clear since multiple studies failed to report PPM incidence. However, the PPM after SAVR vary greater than after TAVR, ranging from 8% to almost 80% in SAVR and from 24%-35% in TAVR. Incidence of severe PPM following redo SAVR is ranging from 2 to 9% and following valve-in-valve TAVR is from 14 to 33%, however, while PPM is higher in valve-in-valve TAVR, patients had better survival rates. Conclusions: The gap between valve performance and clinical outcomes in TAVR and SAVR could be reduced by carefully selecting patients for either treatment option. Understanding predictors of PPM can add to the safety, effectiveness, and increased survival benefit of both TAVR and SAVR.
A 63-year-old male, with a history of coronary artery bypass grafting using bilateral internal thoracic artery grafts, underwent surgical aortic valve replacement. Avoiding the graft injury, we selected the right anterior mini-thoracotomy approach under cardiac arrest with systemic hyperkalemia with remaining bilateral internal thoracic artery grafts open. Deep hypothermia was induced to obtain more reliable myocardial protection. We believe this strategy can be considered as a therapeutic option in patients requiring aortic valve replacement but unsuitable for transcatheter aortic valve replacement.
Introduction. In this prospective multicenter analysis, we aimed to investigate the predictive role of neutrophil/lymphocyte ratio (NLR) in permanent pacemaker implantation (PPI) in patients undergoing transcatheter aortic valve replacement (TAVR). Material and methods. 179 consecutive patients without previous PPI underwent TAVR from February 2017 to September 2021. Patients were further divided based on presence (n=48) and absence of conduction abnormalities (CAs) at hospital admission (n=131). Results . In patients with previous CAs, NLR values did not differ significantly between patients requiring PPI (n=16, 33%) and those not requiring it. In contrast, in patients with no CAs at hospital admission, NLR values measured at admission and on TAVR day were significantly higher in patients requiring PPI (n=17, 13%) (4.07±3.22 vs 3.01±1.47, p=0.025, and 10.81±7.81 vs 5.84±3.78, p=0.000, respectively). Multivariable analysis showed that NLR at TAVR day was an independent predictor of PPI in patients without CAs (OR 1.294; 95% CI 1.028-1.630; p=0.028), but not in those with previous CAs. ROC curve analysis showed that the cut point was a NLR value of >7.25. Time to PPI was delayed till 21 days in patients without CAs. Conclusions. In this prospective study, higher NLR values on the day of TAVR day were associated with an increased PPI rate in patients undergoing TAVR with no previous CAs. It is advisable, being inflammation part of the process, to prolong the time of observation for all patients without CAs till at least 21 days not to miss any new CA necessitating PPI.