Keeping up with the surgical training might be difficult during the time of COVID-19 pandemic: with most of the health care resources dedicated to face this reality, trainees can improve themselves deep diving in scientific literature, study, Telemedicine and Social Media professional platforms. Moreover, they might be directly involved in COVID patient care, facing a still a still elusive disease with a high lethality rate. Often the frustration of having no valid treatment and a poor incisiveness on the natural course of the COVID19 could lead to a blue mood or a burnout. Eventually, the natural adaptability and the survival instinct prevail and teach us the real meaning of resilience. Every trainee has to be prepared for the second phase, when the new normality will force everyone to cohabit with the virus. Even the obvious teething troubles, this could be the right moment for all the Residents to “grow-up” and develop their own future Character.
Background: We analysed the results of the modified Bentall procedure in a high-risk group of patients presenting with acute type A aortic dissection (ATAAD). Methods: ATAAD patients undergoing a modified Bentall between 1996 and 2018 (n=314) were analysed. Mechanical composite conduits were used in 45%, and biological using either a bioprosthesis implanted into an aortic graft (33%) or xeno-/ homograft root conduits (22%) in the rest. Preoperative malperfusion was present in 34% of patients and cardiopulmonary resuscitation required in 9%. Results: Concomitant arch procedures consisted of hemiarch in 56% and total arch / elephant trunk in 34%, while concomitant coronary artery surgery was required in 24%. Average crossclamp and cardiopulmonary bypass times were 126 ± 43 and 210 ± 76 minutes, respectively, while average circulatory arrest times were 29 ± 17 minutes. A total of 69 patients (22%) suffered permanent neurologic deficit, while myocardial infarction occurred in 18 cases (6%) and low cardiac output syndrome in 47 (15%). In-hospital mortality rate was 17% due to intractable low cardiac output syndrome (n = 29), major brain injury (n = 16), multiorgan failure (n = 6) and sepsis (n = 2). Independent predictors of in-hospital mortality were critical preoperative state (OR, 5.6; p < 0.001), coronary malperfusion (OR, 3.6; p = 0.002), coronary artery disease (OR, 2.6; p = 0.033) and prior cerebrovascular accident (OR, 5.6; p = 0.002). Conclusions: The modified Bentall operation, along with necessary concomitant procedures, can be performed with good early results in high risk ATAAD patients presenting.
Heart allotransplantation has become one of the methods of choice in the treatment of severe heart failure. In the face of its difficulties, such as the unmet balance between organ supply and demand, the use of xenotransplantation might be an attractive option in the near future, even more with the ongoing progress achieved regarding the avoidance of hyperacute rejection and primary organ disfunction, maintenance of xenograft function and control of xenograft growth. To make possible this translational challenge, some points must be taken into account indeed, and they are the equipoise of human benefit and animal suffering, the risk of unknown infections, a well prepared informed consent, ethical and religious beliefs, and the role of cardiac xenotransplantation in a ventricular assistance device era.
To the Editor: The interesting and timely paper by Cain et al.1, in press in the Journal of Cardiac Surgery , provides important details concerning the devastating consequences of Mycobacterium chimaera (MC ) infection. In their patient extreme fragility of the mediastinal tissues was observed after repair of an acute aortic dissection; during follow-up multiple reoperations were required to treat recurrent dehiscence of the aortic grafts. Despite repeat explantation of foreign materials infection persisted with mediastinitis and eventual systemic diffusion with fatal outcome.MC infection after open cardiac surgery using cardiopulmonary bypass has been recently reported as a clinical outbreak worldwide and identified as originating by contaminated water in heater-cooler units2. Current experience shows that MC causes a slow-growing and extremely difficult to treat infection with an incubation period which has been recently demonstrated to be as long as >12 years3.We have recently treated a patient, quite similar to that reported by Cain et al.1, who presented with a pseudoaneurysm of the distal suture line twelve years after repair of type A aortic dissection4. At first operation replacement of the ascending aorta and hemiarch using of a Djumbodis®dissection system (Saint Come-Chirurgie, Marseille, France) was performed. At reoperation extremely fragile tissues were noted and, after removing the metallic stent, the aortic arch was replaced with a frozen elephant trunk technique. Cultures of the excised material grewMC . In this case we hypothesized that the stent played an important role in the onset of infection for at least 2 reasons: presence of foreign material in the blood stream and injury to the aortic wall by the edges of the stent. The case described by Cain et al.1 also supports our belief that extreme fragility of the aortic tissues caused by MB was a further important factor in the occurrence of this complication.Interestingly, a delayed diagnosis occurred in both cases; this most likely played a critical role in favouring development of extra‐cardiac manifestations of the disease, in reducing the effectiveness of antibiotic therapy due to immunologic impairment and causing a negative outcome in both patients.MB infection may have different locations ranging from single-organ to systemic manifestations5. When it involves the mediastinum and particularly the major vascular structures often results in life-threatening complications despite proper antimycobacterial treatment. An early diagnosis, even with significantly extended surveillance, appears extremely difficult due to slow-growing and long incubation period of MB .Although no specific guidelines are so far available, intra-operative prevention with improvement of setting and development of heater-cooler units is mandatory and should be based on specific recommendations5.
Background: Despite recent advancements in prevention, treatment, and management options, cardiovascular diseases contribute to one of the leading causes of morbidity and mortality. Several studies highlight the compelling evidence for the existence of healthcare inequities and disparities in the treatment and management control of cardiovascular diseases. Aims: To explore the role of racial disparities in the treatment of various cardiovascular diseases, highlighting the role of socioeconomic and cultural factors, and ultimately postulate solutions to eliminate the disparities. Methods: A comprehensive review of literature was conducted using appropriate keywords on search engines of SCOPUS, Wiley, PubMed, and SAGE Journals. Conclusion: By continued research to eliminate healthcare inequalities, there exists a potential to improve health-related outcomes in minority populations.
Background: Hemostatic disturbances with coronavirus disease 2019 (COVID-19) can predispose to tricuspid and right heart thrombi in very rare instances. Aim: We describe a 29-year-old female patient without previous cause of thrombosis who developed large tricuspid valve thrombus (TVT) and moderate-to-severe tricuspid regurgitation (TR) during the course of COVID-19 infection. Materials and methods: Persistant fever and tachycardia with thrombocytopenia and high D-dimer increased the index of suspicion. The diagnosis was made by bedside transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR). Surgery was performed for thrombectomy and tricuspid valve replacement with a tissue valve. Discussion and conclusion: Detection of TVT in COVID-19 patients on the basis of high index of suspicion, bedside TTE and non-invasive CMR helps early surgical treatment and subsequent reduction of mortality and hospital stay.
Coronavirus disease 2019 (COVID-19) is a remarkably challenging health issue that provoked all the health-care providers to contemplate some measures about the situation. All the health-care workers frontline (esp. emergency service, pulmonologists, infection disease specialist and anesthesiologist) have produced recommendations on prevention and taking care of COVID-19 patient (1,2). Whereas, at the second line another important issue is the ongoing healthcare for the continual disease situations.There are two main critical issues on cardiovascular surgery in this pandemic. Firstly, to delay the elective surgeries is essential to sustain the health-care service. Elective case triage is trickier for cardiovascular procedures which are relatively progressive conditions. Definitive decision to defer a procedure should be made regarding firstly to the capacity of health-care system, and then availability of surgical/anesthesia staff, intensive care unit beds, need for isolation beds, ventilators, cardiopulmonary bypass machine, extracorporeal membrane oxygenator, supplies such as sutures, grafts, valves and blood and blood product availability. The patient status should be taken into account to defer or to perform the procedure, as well. Therefore, we developed “Level of Priority” (LoP) statement for cardiovascular procedures (3). Elective cases are defined as LoP I that may be postponed as much as possible. LoP II to IV cases should be reconsidered by individual basis by “Heart Team”. The situations that can be managed by percutaneous coronary intervention, endovascular procedures and etc. may be handled by non-operative manners.The second one is the personal protection equipment and infection measures while dealing with a suspected / confirmed COVID-19 patient. It is obvious that a suspected / confirmed COVID-19 patient ought to be assessed with specific measures for any medical or surgical intervention. Personal protection equipment (PPE) is the most crucial measure during the pandemic. It is recognized that many centers are facing PPE shortages and there are recommendations to re-sterile the masks to be effective for reuse.(4) More measures should be taken into consideration for sterile environment such as surgical procedures. Some added measures such as face shield may be recommended for surgical procedures. The surgical team who scrubbed in, must wear extra equipment such as surgical coat and double gloves. It may be recommended to fix the long-sleeve gloves to the surgical coat by adhesive drapes (3). It is obvious that this kind of working environment with all this equipment is challenging, sometimes irritating and disquieting. One other big problem is the fraught feeling of health-care providers to be diseased or to be contagious for their family. Therefore, health-care providers may need enormous support for burnouts during the pandemic.The other measures such as preparation of the operating room (OR), anesthesiologic management, transportation of patients and disinfection of OR were discussed in the referring article (3).In conclusion, it is important to assess the “Level of Priority” for surgical procedures to support the service of health-care facility. More than that, whole surgical team should be protected by adequate PPE and should take the time to get full protected.
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.
The coronavirus disease 2019 (COVID-19) is an infectious disease which has rapidly evolved into a pandemic. Though it has affected all disciplines of medical sciences but it has some serious implications pertaining to cardiovascular sciences which have presented unique challenges in front of cardiac surgeons in particular. To flatten the curve of this pandemic, routine cardiac surgeries are being deferred indefinitely resulting in the pool of sick cardiac patients rising day by day. A different perspective is presented on this global catastrophe from the viewpoint of a cardiac surgeon.
Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery.
Background: Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterised by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimised cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that Thoracic Endovascular Aortic Repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. Aims: This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention. Methods: We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus in order to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. Results: TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodelling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. Conclusions: Further research is required into both short and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines.
We present a reply to the invited commentary by Jubouri and Abdelhaliem published in response to our original article titled: Prevention vs Cure: is BioGlue priming the optimal strategy against E-Vita Neo graft oozing? The authors highlight key issues associated with the E-Vita Open NEO aortic arch prosthesis, chiefly, the propensity for the prosthesis to exhibit post-anastomotic oozing. We read with great interest their commentary and concur that the issues highlighted therein are significant and warrant discussion.
Background: The COVID19 pandemic gripped every nation’s healthcare system and provisions on all levels. In cardiac and aortic surgery, as it is with most specialities, elective surgeries were halted. Aims of the study: We captured reflections, contingencies, and current practices across of high-volume centres in cardiac and aortic surgery globally. We also aimed this study to assess decision on prioritization of the surgical patients, the need for personal protection equipment and choice of preoperative investigations in current dynamic and fluid climate. Methods: A validated web-based questionnaire was constructed and was circulated to the international surgeons amongst high volume cardiac and aortic surgery centres. Their intrinsic feedback on decision making, impact of the lockdown and perspectives for the future ahead us all were noted. Mixed method approach was constructed. Qualitative data analysis was introduced to signify the impact globally. Results: Overall, 23 centers from 18 countries participated in this international study. 91.7% of the respondents stopped operating on elective patients during the pandemic. Majority of the surgeons agreed that acute aortic dissection (87.1%) should be operated as emergency procedure and stable triple vessel disease (87.1%) to be considered as elective procedure. Three-fifth (60%) of the respondents relied on CT chest as a preoperative screening modality. Conclusion: In the present climate where there is paucity of evidence, this will give an interim consensus for the cardiac surgeons. With the increase in cumulative number of COVID19 patients, careful utilization of the resources regarding hospital beds and manpower is of paramount importance.
Some would argue that kids aren’t just little adults, but what about their sternums? We are reviewing a manuscript by Horriat, McCandless, and colleagues in the Journal of Cardiac Surgery1 describing their experience with managing sternal wound infections (SWI) after congenital heart surgery. They report encouraging results in 14 patients who required plastic surgery consultation to manage their sternal wounds. The nature of congenital cardiac abnormalities and the necessary steps to repair them leads to physiologic derangements predisposing patients to SWI. Rates of SWI vary and have been reported at 1.53% in this population. There is little guidance on how the management of the congenital cardiac surgery patient should differ from the adult patient.2
Background Use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (e.g. acute Type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favour of improved surgical access and outcomes. This review seeks to elucidate whether proximalisation of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes. Methods We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. Results Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. Conclusion Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review therefore recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalisation of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.
In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with an intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating bio-humoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendinae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor β (TGF-β), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-β activation facilitates leaflet growth, excessive TGF-β activation, as after a myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity and to explain why the equation “large heart=moderate/severe mitral regurgitation” and “small heart=no/mild mitral regurgitation” does not work into the clinical practice.