Background: Acute type A aortic dissection (ATAAD) is a life-threatening medical condition requiring urgent surgical attention. It is estimated that 50% of ATAAD die within 24 hours of onset, with the mortality rate is increasing by 1-2% every additional hour without prompt intervention. A variety of ATAAD surgical repair techniques exist which has sparked controversy within the literature, with the main two strategies being proximal aortic replacement (PAR) and total arch replacement (TAR). Nevertheless, the question of which of these two strategies if the more optimal is still debatable. Aims: This commentary aims to discuss the recent study by Sa and colleagues which presents a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing aggressive (TAR) and conservative (PAR) approaches to manage ATAAD patients. Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Google Scholar, EMBASE and Scopus in order to collate the relevant research evidence. Results: The more aggressive TAR approach for treating ATAAD seems to yield more favourable results including more optimal long-term survival as well as a lower need for reoperation. The frozen elephant trunk (FET) technique can be considered the mainstay TAR technique. Conclusion: It is valid to conclude that TAR with FET is the superior strategy for managing ATAAD patients.
LETTER TO THE EDITOR RESPONSEWe thank Dr. Del Giglio et al. for their comments. As it was stated in our paper1, our primary goal was to describe our approach and procedural details to MIAVR by way of RALT. For further reading we would also like to draw attention to our video tutorial regarding RALT-MIAVR2. Nevertheless, we would like to congratulate Dr. Del Giglio and his colleagues for their significant contribution to the field of minimally invasive aortic valve treatment3 4 56.We completely agree with Dr. Del Giglio et al. that our statement regarding preoperative CT-scanning being mandatory is somehow misleading. However, other colleagues also consider a preoperative CT scan obligatory for RALT-MIAVR7 providing important additional information over TEE8. Three-dimensional reconstructed multidetector CT images allow virtual planning of the exposure leading to a reduced ischemia time and a reduced conversion rate9. It has also been shown that systematic preoperative CT screening in MIMVS is associated with lower risk of postoperative stroke and a trend towards lower operative mortality10. Although we agree with Dr. Del Giglio et al. that CT assessment is helpful at the beginning, it remains accommodating throughout the complete learning curve and thereafter. Andre Plass et al.11 wrote that preoperative planning with multi-slice CT leads to an improved mental preparation and to an efficient and accurate surgical strategy including the choice of the optimal ICS. In their Letter to the Editor , Dr. Del Giglio et al. wrote that surgical access site selection does not require a CT scan, that the third ICS is the right one in most cases and that the surgeon could easily change to the second ICS from the same skin incision. We agree that changing ICS is easily possible, yet it also means added surgical damage and this should be avoided whenever possible. An automated method determining the closest ICS to the STJ as the optimal incision location for MIAVR has already been introduced12. A novel MIAVR tool that combines 3D imaging with quantitative planning measures has also been described13. The access angle is strongly associated with procedure complexity13 and with CPB time, x-clamping time and access difficulty13. Moodley et al.14 reported that mandatory CT-screening of the chest, abdomen and pelvis revealed significant subclinical aorto-iliac atherosclerosis resulting in a change in surgical approach in 21% of asymptomatic or mildly symptomatic patients scheduled for MIMVS (Figures 1 through 3). Regarding the interpreting and reconstructing of CT scans we agree with Dr. Del Giglio et al. that this means technological skills, time and financial resources. But with transcatheter cardiac procedures becoming more popular, it is important for the society of surgeons to master all aspects of case planning, which not only includes analysis and measurement but also the reconstruction of CT scans. As pointed out by Dr. Del Giglio et al. MIAVR has to reproduce the gold-standard conventional procedure in terms of safety, effectiveness and especially operative times through a respectful approach; yet in our opinion, preoperative non-invasive CTA screening in every patient scheduled for a RALT-MIAVR procedure remains crucial.In view of truly MIAVR, we believe that arterial and venous central cannulation both at the same time through the same incision does not reduce surgical trauma and could lead to central working port obstruction or significant narrowing. We believe that peripheral cannulation of the femoral vasculature is as safe and reproducible as central cannulation if the individualized anatomical characteristics allow for it. When carrying out percutaneous femoral arterial cannulation, we never perform a blind puncture of the femoral vessels. We prefer to have zoomed-in snapshots from our reconstructed CT scans on display in the OR to accurately puncture the CFA as displayed in figures 1 and 2 for example. Data set published by Eugene A. Grossi et al.15, suggest that if in older patients a femoral perfusion technique is chosen, preoperative evaluation of the aorta and distal vasculature would demonstrate that a given patient would not be at increased neurological risk15. This would include CTA of the aorta with runoff and TEE evaluation of the descending aorta15. They also published that RAP is associated with an increased risk of stroke in patients with severe PVD and should be reserved for selected patients without significant atherosclerosis. Such a thoughtful screening approach has been used also by Murphy and associates16 in robotic mitral valve surgery for example15. M. Murzi et al.17 were able to show that the use of RAP in MIMVS was associated with a higher incidence of neurological complications in older patients (>70 years old) with atherosclerotic burden compared with AAP. Still, their study had several limitations as it was based on a retrospective analysis of patients undergoing consecutive MIMVS over a 12-year period and potential bias might have been present17. The observational retrospective analysis of K. Bedeir et al.18 proved that femoral artery cannulation may be associated with increased stroke rates in isolated mitral valve surgery and that antegrade arterial cannulation (direct aortic or axillary cannulation (figure 2)) may be preferable in MIAVR. However, their consensus was that these preliminary data should trigger a larger-scale randomized prospective trial to confirm or refute these findings18.In pursuance of reducing hemolysis during CPB19, body temperature is maintained at around 34°C and DO2-guidance (goal-directed-perfusion). This is also helpful in regard to optimal venous drainage as it allows the surgeon1,2, to safely reduce the calculated pump flow. Furthermore, we augment venous drainage with the use of vacuum assistance (−20 to −35 mmHg) to decompress the right heart1. On one hand, R.K. Mathews et al.20 were not able to show a significant increase in hemolysis or sub-lethal red blood cell membrane damage, associated with the use of augmented venous drainage. On the other hand, D. Goksedef et al.21 showed that based on their results, negative suction at 80 mmHg may cause greater hemolysis than non-vacuum-assisted drainage or vacuum-assisted drainage at 40 mmHg. For this reason, we try to keep the vacuum assistance between 0 and -35 mmHg. Besides, it has been proved that application of a controlled, negative low pressure to the venous return does not cause hemolysis worse than gravitational CPB22.At last, Dr. Del Giglio et al. reported concerns about our SLL-PEEP (maximum 20 cmH2O) technique to inflate the left lung which pushes the aorta towards the surgical access. It is true that increased airway pressure or the application of high tidal volumes may cause damage or disruption of alveolar epithelial cells, by generating transpulmonary pressures that exceed the elastic properties of the lung parenchyma above its resting volume23. It has been demonstrated that the duration of mechanical stress defined as the stress versus time product affects the development of pulmonary inflammatory response23. However, in a recent meta-analysis of postoperative pulmonary complications after intraoperative ventilation, only a high driving pressure was associated with an increased incidence24. Therefore, it is highly unlikely that in an apneic patient on CPB, the elevation of the PEEP-level of 5 to 20 cmH2O without a resulting change of driving pressure has any significant negative effect on pulmonary outcome.In summary, we agree with the important points addressed by Del Giglio et al. Central cannulation and its AAP is possible without the need for preoperative CT scanning. However, for the sake of MIAVR (no rib resection, no IMA sacrifice) we prefer peripheral percutaneous cannulation. For such a RAP cannulation strategy, there is sufficient convincing literature that preoperative CTA scanning should be considered.
Background: The treatment of complex thoracic aorta pathologies remains a challenge for cardiovascular surgeons. After introducing Frozen Elephant Trunk (FET), a significant evolution of surgical techniques has been achieved. The present meta-analysis aimed to assess the efficacy of FET in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on post-operative neurologic outcomes. Methods: A standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was conducted for all observational studies of patients diagnosed with ATAAD undergoing total arch replacement with FET reporting in-hospital mortality, bleeding, and neurological outcomes. A random-effect meta-analysis was performed using STATA software (StataCorp, TX, USA). Results: Thirty-five studies were eligible for the present meta-analysis, including 3211 patients with ATAAD who underwent total arch replacement with FET. The pooled estimate for in-hospital mortality, postoperative stroke, and spinal cord injury were 7% (95% CI 5 – 9; I2 = 68.65%), 5% (95% CI 4 – 7; I2 = 63.93%), and 3% (95% CI 2 – 4; I2 = 19.56%), respectively. Univariate meta-regression revealed that with increasing the duration of hypothermic circulatory arrest time, the effect sizes for postoperative stroke and SCI enhances. Conclusions: It seems that employing the FET procedure for acute type A dissection is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET.
Background – The impact of post-operative complications on long-term survival is not well characterized. We sought to study the prevalence of post-operative complications after cardiac surgery and their impact on long-term survival. Methods – Operative survivors (n=26,221) who underwent coronary artery bypass grafting (CABG) (n=13054, 49.8%), valve surgery (n=8667, 33.1%) or combined CABG and valve surgery (n=4500, 17.2%) from 1993 to 2019 were included in the study. Records were reviewed for post-operative complications and long-term survival. The associations between post-operative complications and survival were assessed using a Cox-proportional model. Results – Complications occurred in 17,463 (66.6%) of 26,221 operative survivors. A total of 17 post-operative complications were analyzed. Post-operative blood product use was the commonest (n=12397, 47.3%), followed by atrial fibrillation (n=8399, 32.0%), prolonged ventilation (n=2336, 8.9%), renal failure (n=870, 3.3%), re-operation for bleeding (n=859, 3.3%) and pacemaker/ICD insertion (n=795, 3.0%). Stroke (HR 1.55, 95%CI 1.36-1.77), renal failure (HR 1.45, 95% CI 1.33-1.58) anticoagulant-related events (HR 1.26, 95%CI 1.02-1.56) and pneumonia (HR 1.23, 95%CI 1.11-1.36) had the strongest impact on long-term survival. Long-term survival decreased as the number of post-operative complications increased. Conclusions – Post-operative complications after cardiac surgery significantly impact outcomes that extend beyond the post-operative period. The presence, number and type of post-operative complications adversely impact long-term survival. Stroke, renal failure, anticoagulant-related events and pneumonia are particularly associated with poor long-term survival.
Infections and pandemics will condition us in an increasingly predominant way regarding diagnostic, medical and surgical activities in all specialist areas; and this particularly in cardiovascular one. Nevertheless in the future the need to cohabit with pandemic events and to be able to continue an elective and not only emergency cardiac surgery program represents an imperative.
Severe shortage of donor hearts has increased the mortality of patients on the transplant waiting list. However, donor hearts with valvular dysfunction are rarely used. Utilizing donor hearts with valvular lesions that can be repaired or replaced at the time of transplant will decrease waitlist mortality and offer many patients a second chance in life.
Background Aortic Aneurysm (AA) is a common atherosclerotic condition, accounting for nearly 6,000 deaths in England and up to 175,000 deaths globally each year. The pathological outward bulging of the aorta typically results from atherosclerosis or hereditary connective tissue disorders. AAs are usually asymptomatic until spontaneous rupture or detected on incidental screening. 8 in 10 patients do not survive the rupture and die either before reaching hospital or from complications following surgery. Similar to other cardiovascular pathologies (CVPs), AA is thought to be subject to chronobiological patterns of varying incidence. Methods We performed a literature review of the current literature to evaluate the association between circadian rhythms, seasonal variations, and genetic factors and the pathogenesis of AA, reviewing the impact of chronobiology. Results The incidence of AA is found to peak in the early morning (6 AM – 11 AM) and colder months, and conversely troughs towards the evening and warmer months, exhibiting a similar pattern of chronobiological rhythm as other CVPs such as myocardial infarcts, or cerebrovascular strokes. Conclusion Literature suggests there exists a clear relationship between chronobiology and the incidence and pathogenesis of ruptured AA; incidence increases in the morning (6am - 11am), and during colder months (December – January). This is more pronounced in patients with Marfan Syndrome, or vitamin D deficiency. The underlying pathophysiology and implications this has for chronotherapeutics, are also discussed. Our review shows a clear need for further research into the chronotherapeutic approach to preventing ruptured AA in the journey towards precision medicine.
Patient selection and cannulation arguably represent the key steps for the successful implementation of Extracorporeal Membrane Oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real-time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients’ critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite. Therefore, with the objective of avoiding delay with initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation. In the current pandemic, this strategy may have additional benefits for the care of patients with refractory acute respiratory distress syndrome (ARDS) due to COVID-19 decreasing risk of healthcare worker or other patients exposure to the novel SARS-CoV-2 virus occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation.
ABSTRACT Background: COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11st, 2020. Responses to this crisis integrated resource allocation for the increased amount of infected patients, while maintaining an adequate response to other severe and life-threatening diseases. Though cardiothoracic patients are at high risk for Covid-19 severe illness, postponing surgeries would translate in increased mortality and morbidity. We reviewed our practice during the initial time of pandemic, with emphasis on safety protocols. Methods: From March 11st to May 15th 2020, 148 patients underwent surgery at the Department of Cardiothoracic Surgery of CHUSJ. The clinical characteristics of the patients were retrospectively registered, along with novel containment and infection prevention measures targeting the new Corona Virus. Results: The majority of adult cardiac patients were operated on an urgent basis. Hospital mortality was 1.9% (n = 2 patients). Most of adult thoracic patients were admitted from home, with a diagnosis of neoplasic disease in 60% patients. Hospital mortality was 3.3% (1). Fifteen children underwent cardiothoracic surgery. There was no mortality. The infection prevention procedures applied, totally excluded the transmission of Covid-19 in the Department. Conclusion: While guaranteeing a prompt response to emergent, urgent and high priority cases, novel safety measures in individual protection, patients circuits and pre-operative diagnose of symptomatic and asymptomatic infection were adopted. The surgical results corroborate that it was safe to undergo cardiothoracic surgery during the initial time of Covid-19 pandemic. The new policies will be maintained while the virus stays in the community.
Objectives The impact of the COVID 19 pandemic on the treatment of patient with aortic valve stenosis is unknown and there is uncertainty on the optimal strategies in managing these patients. Methods This study is supported and endorsed by the Asia Pacific Society of Interventional Cardiology. Due to the inability to have face to face discussions during the pandemic, an online survey was performed by inviting key opinion leaders ( cardiac surgeon/interventional cardiologist/echocardiologist) in the field of transcatheter aortic valve implantation (TAVI) in Asia to participate. The answers to a series of questions pertaining to the impact of COVID-19 on TAVI were collected and analyzed. These led subsequently to an expert consensus recommendations on the conduct of TAVI during the pandemic Results The COVID 19 pandemic had resulted in a 25% (10-80) reduction of case volume and 53% of operators required triaging to manage their patients with severe aortic stenosis. The two most important parameters used to triage were symptoms and valve area. Periprocedural changes included the introduction of teleconsultation, pre-procedure COVD 19 testing, optimization of pre-tests and catheterization laboratory set up. In addition, length of stay was reduced from a mean of 4.4 to 4 days. Conclusion The COVID-19 pandemic has impacted on the delivery of TAVI services to patients in Asia. This expert recommendations on best practices may be a useful to guide to help TAVI teams during this period until a COVID 19 vaccine becomes widely available
Abstract The objective of this study was to describe early respiratory outcomes of asymptomatic COVID-19 patients after cardiac surgery. In this retrospective clinical study (case series) we reviewed and analyzed patient clinical data of 25 covid-19 asymptomatic patients that underwent urgent or emergent cardiac surgery between February 29 and April 10, 2020 in Tehran Heart Center Hospital. Median of age was 63 years (IQR, 52-67), Euro SCORE 7.50 (IQR, 6.5-8.5) and body mass index 26.3 (IQR, 22.5-28.6). 68% of patients had one or more comorbidities. Hypertension (56%) was the most common followed by Diabetes type 2 (40%). Off-pump cardiac surgery was done in 4 patients and on-pump on 21 patients with median CPB time of 85 minutes (IQR, 50-147.50). Median anesthesia time was 4.5 hours (IQR, 4-5). Median oxygen index and Fio2 on ventilator were 10 cmH20 (IQR, 9.5-10.5) and 0.64(IQR, 0.60-0.64) respectively. Median pao2/Fio2 was 231(IQR, 184-261). There was one case of extubation failure. The Median intubation time and length of ICU stay were 13 hours (IQR, 9.5-18) and 3 days (IQR, 2-4) respectively. Overall mortality was 16%. Readmission rate to ICU was 16% with. In this group respiratory outcome was worse with median Pao2/Fio2 84.5 (75-122), oxygen index of 4.38(IQR, 3.77-5.1) and morality rate of 75%. Conclusion: Based on the results of this study, very early post-cardiac surgery respiratory outcomes in asymptomatic COVID-19 patients are apparently smooth; nonetheless, readmission to the ICU is high. Overall respiratory outcomes are poor especially for those who readmitted to ICU.
Comprehensive clinical and imaging-based surveillance represents a fundamental aspect in the management of thoracic aortic aneurysms (TAAs), affording the opportunity to identify intermediate-sized TAAs before the onset of worrying symptoms or devastating acute aortic dissection/rupture. Currently, size-based indices are favoured as the major determinants driving patient selection for surgery, as supported by aortic guidelines, although it is recognised that smaller sub-threshold TAAs may still confer substantial risks. Prophylactic aortic surgery can be offered within set timeframes at dedicated aortic centres with excellent outcomes, to mitigate the threat of acute aortic complications associated with repeatedly deferred intervention. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery which highlights important socio-economic disparities in TAA surveillance and follow-up.
The current coronavirus (COVID-19) pandemic is associated with severe pulmonary and cardiovascular complications. This report describes a young patient with COVID-19 without any comorbidity presenting with severe cardiovascular complications, manifesting with pulmonary embolism, embolic stroke, and right heart failure. Management with short-term mechanical circulatory support, including different cannulation strategies, resulted in a successful outcome despite his critical cardiovascular status.
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.
Telemedicine, telehealth and artificial intelligence in healthcare are becoming commonly utilized in various medical specialties. The article authored by Dr. Aminah Sallam and colleagues in the Journal provides data in support of the cardiac surgical patients, and the caring cardiac surgeons willingness to adopt telemedicine as a method of connectivity between patient and surgeon.
Patients in respiratory failure on VV ECMO may develop cardiovascular dysfunction necessitating additional hemodynamic support, while patients in cardiovascular failure on VA ECMO may require additional respiratory support for concurrent gas exchange abnormalities. A hybrid venoarterio-venous (VA-V) configuration provides both cardiac support via a traditional arterial reinfusion cannula and respiratory support via an additional venous reinfusion limb. We describe our single center experience using VA-V ECMO for patients (n = 14, median age 54) with combined cardiopulmonary failure or differential hypoxemia. Patients were treated with ECMO support for a median of 148.2 (IQR 122.6 – 174.4) hours, consisting of 0 (IQR 0 – 1.8) hours of VA and 92.4 (IQR 58 – 115) hours of VA-V followed by 46 (IQR 0 – 95.5) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%).