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%).
The authors present an revolutionary study aiming to evaluate the effect of alterations in potassium concentrations in transfused packed red blood cells (PRBC) on neonate and infant potassium levels after congenital cardiac surgery. By establishing a strict protocol which restricts the rate of transfusion, the age of the transfused PRBC, and not transfusing a PRBC with a potassium level above 15 mmol/L, they accomplished to suggest a safe and easy way for preventing transfusion associated hyperkalemia.
The gold standard for the treatment of pure aortic insufficiency (PAI) is surgical valve repair or replacement.1 With the newest transcatheter heart valve technologies and the accumulating years of experience of heart teams with the current transcatheter aortic valve replacement (TAVR) prostheses, implanters have push the envelope with off-label use of those valves designed and approved for aortic stenosis, in patients with pure aortic insufficiency especially those at higher risks or for compassionate use.3 However, new prostheses are currently under investigation in clinical use and evidences are provided on the safety and efficacy of those latter. It will be discussed in this commentary, the actual clinical evidences and the use of transcatheter heart valves, in and off label, for the treatment of pure aortic insufficiency.
Patients with a bicuspid aortic valve (BAV) are at increased risk of valvular regurgitation compared to their counterparts with a tri-leaflet aortic valve. There is now increasing emphasis to offer BAV repair to mitigate the risks of prosthesis-related complications, including thromboembolism, haemorrhage and endocarditis, as well as structural valve deterioration and future re-operation with conventional valve replacement, particularly in younger populations. Furthermore, over the preceding two decades, our greater understanding of the functional anatomy of the BAV, pathophysiological mechanisms of BAV insufficiency and the development of a functional classification of aortic regurgitation have significantly contributed to the evolution of aortic valve reconstructive surgery. In this commentary, we discuss a recent article from the Journal of Cardiac Surgery comparing external annuloplasty and subcommissural annuloplasty as techniques for BAV repair.
Background: The success of coronary artery bypass grafting surgery (CABG) is dependent on long-term graft patency, which is negatively related to early wall thickening. Avoiding high-pressure distension testing for leaks and preserving the surrounding pedicle of fat and adventitia during vein harvesting may reduce wall thickening. Methods: A single-centre, factorial randomised controlled trial was carried out to compare the impact of testing for leaks under high versus low pressure and harvesting the vein with versus without the pedicle in patients undergoing CABG. The primary outcomes were graft wall thickness, as indicator of medial-intimal hyperplasia, and lumen diameter assessed using intravascular ultrasound after 12 months. Results: 96 eligible participants were recruited. With conventional harvest, low-pressure testing tended to yield a thinner vessel wall compared to high-pressure (mean difference MD (low minus high) -0.059mm, 95%CI -0.12, +0.0039, p=0.066). With high pressure testing, veins harvested with the pedicle fat tended to have a thinner vessel wall than those harvested conventionally (MD (pedicle minus conventional) -0.057mm, 95%CI -0.12, +0.0037, p=0.066, test for interaction p=0.07). Lumen diameter was similar across groups (harvest comparison p=0.81; pressure comparison p=0.24). Low pressure testing was associated with fewer hospital admissions in the 12 months following surgery (p=0.0008). Harvesting the vein with the pedicle fat was associated with more complications during the index admission (p=0.0041). Conclusions: Conventional saphenous vein graft preparation with low pressure distension and harvesting the vein with a surrounding pedicle yielded similar graft wall thickness after 12 months, but low pressure was associated with fewer adverse events.
Background. Unroofed coronary sinus syndrome (UCSS) is rare and often associated with Left superior vena cava (LSVC). We report our experience in 159 patients with UCSS during a 20-year period in terms of clinical features, diagnosis, associated anomalies, surgical procedures and late outcomes. Methods. Between May 1998 and May 2019, 159 patients with UCSS were treated surgically and followed up. UCSS was confirmed by preoperative echocardiography or CT scan in 97 patients and by the surgeons during surgery in 62. LSVC directly drained into the left atrium (LA) was found in 100 cases. In these patients, 8 cases of LSVC were ligated, 59 cases were reconstructed the intracardiac tunnel to drain LSVC to right atrium (RA), and the extracardiac procedure was constructed to lead the LSVC draining to RA in 2. The associated cardiac lesions were corrected concomitantly. Results There were 5 hospital deaths. We followed up 143 early survivors, and there was no death. Except for one case of avulsion of the patch in which LSVC was drained by internal tunnel, there were no serious complications in other follow-up patients. Conclusion. UCSS is often misdiagnosed in the preoperative evaluation of congenital heart diseases. Preoperative transthoracic echocardiography (TTE) is still the most important method in the diagnosis of UCSS. When associated with LSVC, UCSS should be considered as a possible additional finding．We performed different surgical approaches to deal with the different types of UCSS with LSVC with a good result.
Several studies have already shown that coronary angiography and PCI can be safely performed after CABG. It is of paramount importance that early graft failure is recognized in a timely manner and that an appropriate treatment is delivered immediately in order to reduce the extent of myocardial damage and improve clinical outcome. Therefore, urgent angiography allows both identification of the underlying cause of early graft failure and immediate treatment according to the findings. So far, recent evidence shows that PCI to native coronary arteries is associated with higher procedural success rate and less complications leading to the better clinical outcome.
Total arch repair (TAR) has become a mainstay of the surgical management of complex pathologies of the ascending aorta and aortic arch, in particular acute Type A aortic dissections (ATAAD). TAR with devices such as the frozen elephant trunk (FET) have been shown to dramatically improve clinical outcomes in such cases. However, TAR with FET remains an immensely challenging procedure, and the risk of debilitating postoperative complications remains high. Spinal cord ischaemia (SCI) and stroke are two particularly tragic adverse outcomes of TAR with FET; it is unsurprising therefore that much research has been done to determine both the underlying cause thereof, and strategies to mitigate this risk. Mousavizadeh and colleagues produced a fascinating systematic review and meta-analysis investigating the relationship between the duration of hypothermic circulatory arrest (HCA) and the risk of developing complications including SCI and stroke. Their data seem to suggest HCA duration is a key factor in causing SCI and stroke following TAR with FET for ATAAD. However, other factors such as stent sizing and landing zone also contribute. Further prospective research into this relationship is recommended to fully elucidate what truly is to blame for these postoperative neurological complications.
Background COVID‐19 is usually mild, but patients can present with pneumonia, acute respiratory distress syndrome (ARDS) and circulatory shock. Although the symptoms of the disease are predominantly respiratory, involvement of the cardiovascular system is common. Patients with heart failure (HF) are particularly vulnerable when suffering from COVID‐19. Aim of the Review To examine the challenges faced by healthcare organisations, and mechanical circulatory support management strategies available to patients with heart failure, during the COVID-19 pandemic. Results Extracorporeal membrane oxygenation (ECMO) can be lifesaving in patients with severe forms of ARDS, or refractory cardio-circulatory compromise. The Impella RP can provide right ventricular circulatory support for patients who develop right side ventricular failure or decompensation caused by COVID-19 complications, including pulmonary embolus. HT are reserved for only those patients with a high short-term mortality. LVAD as a bridge to transplant may be a viable strategy to get at-risk patients home quickly. Elective LVAD implantations have been reduced and only patients classified as INTERMACS profile 1 and 2 are being considered for LVAD implantation. Delayed recognition of LVAD‐related complications, misdiagnosis of COVID‐19, and impaired social and psychological well‐being for patients and families may ensue. Remote patient care with virtual or telephone contacts is becoming the norm. Conclusions HF incidence, prevalence, and undertreatment will grow as a result of new COVID-19-related heart disease. ECMO should be reserved for highly selected cases of COVID-19 with a reasonable probability of recovery. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs.
Background: Valve-sparing aortic root replacement such as the re-implantation (David) procedure is becoming increasingly popular. Despite the fact that the procedure is technically more complex, long-term studies demonstrated that excellent clinical outcomes in selected patients with durable repair are achievable. Benefits of minimal access cardiac surgery have stimulated enthusiasm in the use of this approach for valve-sparing aortic root replacement. Methods: We have reviewed available literature on the topic of valve-sparing aortic root replacement (David procedure) via minimally invasive approach through upper hemisternotomy in an attempt to assess current trends and to recognize potential advantages of this technique. Patient selection and preoperative work-up play important role in performing minimally invasive David procedure safely. Surgical technique is similar to the standard David procedure, with several exceptions, and is performed via upper hemisternotomy. Results and Conclusion: Evidence from non-randomized observational and comparative studies demonstrated excellent clinical outcomes of minimally invasive David procedure in selected patients with comparable perioperative mortality to the conventional technique. To date, elective David procedure with a minimal access technique has been performed in low- and intermediate-risk patients. We believe that minimally invasive David procedure could be particularly useful in young patients (Marfan syndrome, bicuspid AV) as it allows faster recovery with improved cosmesis. A decision to perform minimally invasive David procedure should be individualized to each patient and based on the experience of the team. Further large prospective randomized studies with long-term follow-up are still needed to confirm durability of minimal access technique.
Background Porcine aortic roots (PAR) have been reported in the literature with acceptable short and long-term outcomes for the treatment of aortic root aneurysms. However, their efficacy in type A aortic dissection (TAAD) is yet to be defined. Methods Using data from a locally collated aortic dissection registry, we compared the outcomes in patients undergoing aortic root replacement for TAAD using either of two surgical options: i) PAR or ii) composite valve grafts (CVG). A retrospective analysis was conducted for all procedures in the period 2005-2018. Results A total of 252 patients underwent procedures for TAAD in the time period. Sixty-five patients had aortic root replacements (PAR n=30, CVG n=35). Between group comparisons identified a younger CVG group (50.5 vs 64.5, p<0.05) although all other covariates were comparable. Operative parameters were comparable between the two groups. The use of PAR did not significantly impact operative mortality (OR 0.93, 95% CI 0.22-3.61, p=0.992), stroke (OR 2.91, 0.25 – 34.09, p=0.395), re-operation (OR 0.91, 95% CI 0.22 – 3.62, p=0.882) or length of stay (coef 2.33, -8.23 – 12.90, p=0.659) compared to CVG. Five-year survival was similar between both groups (PAR 59% vs CVG 69%, p=0.153) and re-operation was negligible. Echocardiography revealed significantly lower aortic valve gradients in the PAR group (8.69 vs 15.45 mmHg, p<0.0001), and smaller left ventricular dimensions both at 6 weeks and 1 year follow up (p<0.05). Conclusions This study highlights the comparable short and mid-term outcomes of PAR in cases of TAAD, in comparison to established therapy.
Congenital superior vena cava (SVC) stenosis is a very rare anomaly especially in pediatric population. Co-existence with obstructed supracardiac total anomalous pulmonary venous connection (TAPVC) has never been reported. Clinical examination should prompt detailed and focused evaluation for this treatable etiology. SVC stenosis, although causing SVC syndrome, may decrease the severity of pulmonary venous hypertension by limiting the amount of blood in obstructed common chamber. Pericardial patch augmentation can cure SVC stenosis, and may allow for growth potential as well. We describe a case of congenital SVC stenosis in a case of obstructed supra-cardiac TAPVC in a 3 month old infant, managed successfully.
Abstract Lockdown, quarantine, self-isolation, personal protection equipment, social distancing have become words of daily usage ever since the world health organisation declared COVID-19 as a pandemic. The impact of COVID 19 extends over the medical field, economy, education and politics. Though the knowledge of the virus is evolving, we are yet to find a solution. India, country with the 2nd largest population, went into a phase of lockdown from 25th March 2020 to 31st May 2020. There was phased measure to “Unlock” starting from1st June 2020. This has affected the clinical practise and training of the resident. The challenges faced during this unprecedented time are multi-faceted which includes overcrowding, health care system, educational background. Indian Association of Cardiovascular-Thoracic Surgeons kept continuing the educational program through a series of “Masterclass”.
Background and aim of the study. To report early clinical outcomes of the frozen elephant trunk technique (FET) for the treatment of complex aortic diseases after transition from conventional elephant trunk. Methods. A single-center, retrospective study of patients who underwent hybrid aortic arch and FET repair for aortic arch and/or proximal descending aortic aneurysms, acute and chronic Stanford type A aortic dissection with arch and/or proximal descending involvement, Stanford type B acute and chronic aortic dissections with retrograde aortic arch involvement. Results. Between December 2017 and May 2020, 70 consecutive patients (62.7±10.6 years, 59 male) were treated: 41 (58.6%) for acute conditions and 29 (41.4%) for chronic. Technical success was 100%. In-hospital mortality was 14.2% (n=12, 17.1% emergency vs. 10.3% chronic, P=NS); 2 (2.9%) major strokes; 1 (1.4%) spinal cord injury. Follow-up was 12.5 months (IQR 3.7—22.3. Overall survival at 3, 6, 12 and 24 months was 90% (95% CI, 83.2—97.3), 85.6% (95% CI, 77.7—94.3), 79.1% (95% CI, 69.9—89.5), 75.6% (95% CI, 65.8—86.9) and 73.5 (95% CI, 63.3—85.3). There were no aortic re-interventions and no dSINE; 5 patients with residual type B dissection underwent TEVAR completion. Conclusions. In a real-world setting, FET demonstrated a rapid learning curve and good clinical outcomes, even in acute type A aortic dissections. Techniques to perfect the procedure and to reduce remaining risks, and consensus on considerations such as standardized cerebral protection need to be reported.
This program director survey attempts to determine how coronavirus 2019 (COVID-19) pandemic is impacting current training in cardiothoracic surgery. A transition to virtual didactic sessions may prove beneficial with increasing attendance. On the other hand, decreasing live simulation and case volumes may jeopardize achieving competency in surgical skills.
Background: Subxiphoid incisional hernias are one of the complications following a median sternotomy, a surgical procedure to provide access to the mediastinum. Incidence has been reported between 1-4%, although the true incidence is not well known due to its asymptomatic nature. Method: A comprehensive search was performed on multiple sites. Keywords included “incisional hernia OR Subxiphoid hernia” AND “Median sternotomy OR Cardiac Surgery OR Coronary artery bypass graft OR Transplant OR Valve replacement”. Articles up to 1st of August 2020 were included in this study. Results: 8 articles were included in the study, with a total number of 132 patient identified. The incidence ranged from 0.81% to 3.44%. There was a mixture of repair method and follow up period reported. Recurrence post-repair ranged from 10% to 43%. Conclusion: Subxiphoid incisional hernias remains challenging to manage. We have discussed the incidence, risk factors, preventions, and management of subxiphoid incisional hernias including both the open and laparoscopic technique.