The authors report an exceptionally rare patient with findings of a bicuspid aortic valve in conjunction with a mature cystic teratoma in a middle-aged male presenting for symptomatic chest pain. Surgical resection and valve replacement were performed, confirming the rare cardiac tumor. While certainly interesting, this case highlights the importance of maintaining a broad differential diagnosis and the appropriate work-up, treatment and considerations for such rare pathology.
Meticulous transfer of coronary arteries is of crucial importance in transposition of great arteries and determines the success of the switch procedure. This report describes a coronary anatomy consisting of four separate ostia from the two facing sinuses in a six-month-old infant presenting with d-transposition of great arteries and ventricular septal defect. Being a rare coronary arterial pattern not described in previous coding systems, the surgeon would do well to be aware of this possibility while performing the switch procedure.
A 44‑year‑old male patient was referred to our department with unremarkable physical examination and laboratory data due to a mass which was incidentally found in the right atrial during a routine examination.Transthoracic and transesophageal echocardiography revealed a 46×30 mm, well-delimited, non-mobile mass in the superior portion of the right atrium. Besides the intracardiac mass, another low density was detected in adjacent pericardial cavity at cardiac computed tomography ;he extracardiac mass appeared to be caused by invasive growth from the intracardiac mass.An operation was performed through right anterolateral minithoracotomy with the patient under hypothermic cardiopulmonary bypass. During operation, it was found that the surface of the right atrium was covered by an adipose mass (30×40 mm; Fig. 2A). Intracardiac mass also showed yellow adipose tissue (40×50 mm; Fig. 2B). Both parts of the mass infiltrated the myocardium. The mass was resected completely; and right atrium was reconstructed by using bovine pericardium pad. After the operation, the pathology confirmed the both intracardiac and extracardiac tissues as lipoma; transthoracic echocardiogram showed the atrial mass was removed completely and the left ventricular ejection fraction was normal . The patient’s postoperative course was uneventful and he was discharged home after 7 days.
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.
Title: Cardiac surgery and healthcare quality: Is the right question being asked?Authors : Abdullah Nasif, MD1/ Saqib Masroor, MD1 1Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo Medical Center Toledo, OH USAManuscript: Minimally Invasive Mitral Valve Surgery After Previous Sternotomy: A Propensity-Matched Analysis.Disclosure : NoneWord Count : 1381Even though by 2003, Casselman (and many others) had concluded that totally endoscopic mitral valve repair can be performed safely with excellent results and a high degree of patient satisfaction1, less than a quarter of all isolated mitral valve procedures were performed using minimally invasive approach (MIS) by 20162. Conventional sternotomy (ST) remains the approach of choice in the majority of cardiac surgery centers. Since 2011, partial sternotomy has fallen out of favor and right mini thoracotomy (RMT) approach has been the major MIS approach (with or without robotics) for both primary as well as re-operative mitral valve surgery. At experienced centers, the indications for MIS surgery have been expanded to include complex pathologies, reoperative surgery, endocarditis, as well as a hybrid open approach for severely calcified mitral annuli using an open deployment of transcatheter aortic valve3-5.One reason for the slow adoption of MIS has been the lack of randomized prospective trials comparing the conventional sternotomy approach with MIS. Most literature supporting the use of MIS has consisted of retrospective review of series of individual surgeons or centers, which have shown a shorter length of stay, reduced need for transfusions and a quicker recovery2,3. Since these reports came from centers with extensive experience and the fact that initial cohorts of patients undergoing MIS were relatively lower risk patients, these retrospective observational studies were not as convincing in their conclusions, because the two groups of patients were not similar. Only a few propensity-matched analyses comparing MIS vs sternotomy have so far been reported in patients undergoing primary surgery4-6.For re-operative mitral valve surgery, there has been one propensity-matched comparison of 42 pairs of patients undergoing right mini-thoracotomy MIS vs sternotomy from China7. MIS patients had lower transfusions, shorter length of stay and lower costs, while having similar mortality. However, the study had a mean length of stay of 22 days vs 16 days and mortality of 11% vs 7 % for sternotomy and MIS patients, respectively and thus the results cannot be reliably generalized.In this issue of the Journal , Hamandi et al8, reviewed 305 isolated MV reoperations that were performed in a single institution between 2007-2018. Patients who underwent MIS MV reoperation totaled 199, while sternotomy operations were 106. The primary endpoints were operative mortality and 1-year survival with operative complications and length of stay being secondary endpoints. Median age of patients was 69 years with an equal gender distribution. The team performed propensity-matched analysis to compare the two groups.There were 88 well-balanced matched pairs. There was no statistically significant difference in mortality among the matched groups at 30 days (3.4% vs 8.0%, p=0.19) or at 1-year (15.9% vs. 16.5%, p=0.9). Comparing long-term survival rates, no statistically significant difference was found up to 5 years postoperatively. Also, the incidence of post-operative complications such as atrial fibrillation, valve dysfunction or renal failure didn’t show any statistically significant difference. However, intraoperative blood utilization was significantly lower among the MIS cohort (p<0.01). Patient satisfaction was not evaluated as is not possible in a retrospective analysis. Neither was readmission rates and other similar measures which would be important in a value-based care system.The 30-day mortality difference (3.4% vs 8%), while not statistically significant, tended to be lower in MIS patients. 4 patients in the MIS group converted to sternotomy due to adhesions. It is not clear from the manuscript, if the mortality in the MIS group was in some way related to the conversions or not. But based on our experience over the years and from the analysis of this manuscript, we recommend an early conversion to sternotomy if one is dealing with difficult adhesions, rather than risking a long tedious operation and possibly emergently converting to sternotomy. It is also important to note that 75% of patients were discharged home, however readmission rate is unknown. With the advent of value-based purchasing, readmission rates should also be looked at. Overall, the authors should be congratulated on their excellent management of this subset of patients and for taking the time share their experience with us.Propensity score matching is commonly used in evaluation research to estimate average treatment effects.9 The main benefit in using this statistical method is to remove confounding bias from observational cohorts. It attempts to reduce the effects of confounders by matching already treated subjects with control subjects who exhibit a similar propensity for treatment based on preexisting covariates that influence treatment selection. However, it is limited in that it requires the removal of data and works primarily on binary treatments. In this study, by including standardized mean difference (SMD), the authors were able to balance the covariates in this propensity-matched analysis.Other than being a single-center retrospective study, this study suffered from other short-comings of a propensity match study, such as the loss of study power due to the decreased sample size after performing propensity matching. Also, “the surgeon effect” was noted. Since the MIS MV reoperative surgeries were performed by the same surgeons who performed the sternotomy cases, the results may not be generalizable.The question being addressed by this manuscript (and by most other similar comparisons of one therapy vs another) is, “Is MIS better than sternotomy?”Unfortunately, that question cannot be satisfactorily addressed with this or similar studies. Healthcare quality has evolved since its inception in 1999 with the Institute of Medicine report, titled “To Err is human”. In the subsequent report “Crossing the Quality Chasm”11, a high-quality care is defined as beingsafe, effective, patient-centered, timely, efficient and equitable. Our healthcare delivery system is changing, and so should our research methodologies. Our analyses should go deeper than scratching the surface with mortality and morbidity data. Most studies, including this one by Hamandi et al, do not even address “effectiveness” adequately in the context of healthcare quality. Having similar mortality and morbidity means that both approaches are equally ‘safe ’. We have little information about other measures of safety, such as readmissions, central line associated blood borne infections. We have not evaluated whether the two approaches were patient centered (Did the patient participate in choosing the approach?), efficient (Cost of care) or equitable.As cardiac surgeons dealing with life and death from up close, we are not used to viewing healthcare from the rather distant 6-pronged quality viewpoint mentioned above. But this is important for a very important reason which I explain below.Individual surgeons and patients may not have the power to bring about a meaningful change in the way we do business everyday. But just like state pension funds pressured oil companies into facing climate change10, big stakeholders like insurance companies and other payers may be able to convince the cardiac surgeons to face the future. For that to happen, quality metrics such as readmission rates, cost of care and patient satisfaction must be looked at and reported, because that is how these stakeholders assess quality. According to some studies7 MIS approach is better in terms of cost and patient satisfaction. Such comprehensive analyses of quality will go a long way in answering a slightly different question than the one posed earlier; “Does MIS offer better quality than sternotomy?”If we want to influence healthcare delivery and have a passion for quality, then our research methodology must reflect the high standards, that we have set for our clinical work. We should also develop new measures of quality besides morbidity and mortality. We have to look at those metrics that have traditionally been ignored by surgeons, but are important for the payers and the hospitals that rely on these payers for their success. As far a minimally invasive vs sternotomy approach is concerned, that question is not going to last for long. Not because one side would have won or the other lost, but because for those that have not yet boarded the train of minimally invasive mitral valve surgery, that train may have already left the station, moving at full speed ahead towards the “percutaneous station”. It is not a matter of if , but when , sternotomy would not be the standard of care for mitral valve surgery. Today’s vascular surgeons save open repair of abdominal aortic aneurysm for a very small subset of patients. There is no reason to believe that tomorrow’s mitral valve surgeons will consider open sternotomy any differently for mitral valve surgery.
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.
Left ventricular free wall rupture (LVFWR) is a most rare but often lethal mechanical complication of acute myocardial infarction (AMI). The mortality rate for LVFWR is described from 75% to 90% and it is the cause for 20% of in-hospital deaths after AMI. Death results essentially from the limited time available for emergent intervention after onset of symptoms. Emergency surgery is indicated and normally the rupture site is easily identified, but it may not be apparent macroscopically, corresponding to transmyocardial or subepicardial dissection with an external rupture far from the infarction site, or already thrombosed and contained. Repair of the ventricular wall is usually achieved either by suturing the edges of the tear or closing it with patches of artificial material or biological tissues, usually using some kind of biological glue. However, several cases of successful conservative management have been described. In this Editorial, I comment on the metanalysis conducted by Matteucci et al, published in this issue of the Journal, including 11 non-randomized studies and enrolling a total of 363 patients, which brings a great deal of new knowledge that can help not only in the prevention but also in the management of this dreadful complication of AMI.
Introduction Atrial fibrillation (AF) is frequent after any cardiac surgery, but evidence suggests it may have no significant impact on survival if sinus rhythm (SR) is effectively restored early after the onset of the arrhythmia. In contrast, management of preoperative AF is often overlooked during or after cardiac surgery despite several proposed protocols. This study sought to evaluate the impact of preoperative AF on mortality in patients undergoing isolated surgical aortic valve replacement (AVR). Methods We performed a retrospective, single-centre study involving 2,628 consecutive patients undergoing elective, primary isolated surgical AVR from 2008 to 2018. A total of 268/ 2,628 patients (10.1%) exhibited AF before surgery. The effect of preoperative AF on mortality was evaluated with univariate and multivariate analyses. Results Short-term mortality was 0.8% and was not different between preoperative AF and SR cohorts. Preoperative AF was highly predictive of long-term mortality (median follow-up of 4 years [Q1-Q3 2-7]; HR: 2.24, 95% CI: 1.79-2.79, P<0.001), and remained strongly and independently predictive after adjustment for other risk factors (HR: 1.54, 95% CI: 1.21-1.96, P<0.001) compared with preoperative SR. In propensity score-matched analysis, the adjusted mortality risk was higher in the AF cohort (OR: 1.47, 95% CI: 1.04-1.99, P=0.03) compared with the SR cohort. Conclusions Preoperative AF was independently predictive of long-term mortality in patients undergoing isolated surgical AVR. It remains to be seen whether concomitant surgery or other preoperative measures to correct AF may impact 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.
1. Stable isotopes represent a unique approach to provide insights into the ecology of organisms. δ13C and δ15N have specifically be used to obtain information on the trophic ecology and food web interactions. Trophic discrimination factors (TDF, Δ13C and Δ15N) describe the isotopic fractionation occurring from diet to consumer tissue and these factors are critical for obtaining precise estimates within any application of δ13C and δ15N values. It is widely acknowledged that metabolism influences TDF, being responsible for different TDF between tissues of variable metabolic activity (e.g. liver vs. muscle tissue) or species body size (small vs. large). However, the connection between the variation of metabolism occurring within a single species during its ontogeny and TDF has rarely been considered. 2. Here, we conducted a 9-month feeding experiment to report Δ13C and Δ15N of muscle and liver tissue for several weight classes of Eurasian perch (Perca fluviatilis), a widespread teleost often studied using stable isotopes, but without established TDF for feeding on a natural diet. In addition, we assessed the relationship between the standard metabolic rate (SMR) and TDF by measuring their oxygen consumption of the individuals. 3. Our results showed a significant negative relationship of SMR with Δ13C, and a significant positive relationship of SMR with Δ15N of muscle tissue, but not with TDF of liver tissue. SMR varies inversely with size, which translated into a significantly different TDF of muscle tissue between size classes. 4. In summary, our results emphasize the role of metabolism in shaping specific TDF (i.e. Δ13C and Δ15N of muscle tissue), and especially highlight the substantial differences between individuals of different ontogenetic stages within a species. Our findings thus have direct implications for the use of stable isotope data and the applications of stable isotopes in food web studies.
Background: Pediatric Emergency Care Applied Research Network (PECARN) is a useful Clinical Decision Support Tool (CDST) to identify traumatic brain injuries and reduce the use of head CT scans among pediatric patients. The present Meta-analysis aims to evaluate the diagnostic accuracy of the PECARN rule from 2009 to 2020 in children with a very low risk of blunt head trauma. Methods: A detailed search was conducted from the databases of Medline (via PubMed), Cinahl (via Ebsco), Scopus, Web of Sciences, from 2009 till the end of December 2020 using the keywords like decrease use of CT scan, blunt head trauma (BHT) combined with accuracy, Pediatric Emergency Care Applied Research Network (PECARN) OR Clinical Decision Support Tool (CDST). Studies showing the diagnostic accuracy of the PECARN rule in children younger than 18 years of age with minor BHT were included. Results: 13 studies were included in the present analysis. Pooled sensitivity of 0.08, (95% confidence interval of 0.074 - 0.087), pooled specificity of 0.20 ( 95% CI of 0.196 - 0.213) and diagnostic odds ratio of 0.004 (95% CI of 0.000-0.1666) was in <2 years of age. The overall sensitivity of 0.07, specificity of 0.66, and diagnostic odds ratio of 0.54 (95% CI of 0.10 -2.78) was seen in ≥2 years of age. Overall sensitivity of 0.13 (95% CI 0.12-0.14), specificity of 0.81 (95% CI 0.80-0.82) and diagnostic odds ratio of 0.79 (95% CI of 0.08 -7.71) was in 0-18 years of age. Conclusion: The present analysis indicates the PECARN decision tool as an accurate CDST in low-risk minor blunt head trauma cases in children below two years of age and can become a useful tool in reducing Head CT’s scan overuse in pediatric emergency departments.
Mini-Commentary on Manuscript # BJOG-20-2493A Biomarker for Amniotic Fluid Embolism: The Search ContinuesWord count: 495Research into the pregnancy associated cytokine storm-like condition historically known as amniotic fluid embolism (AFE) has been hampered by a lack of unique diagnostic criteria. In its classic form, the clinical presentation of this condition is unmistakable. In less classic presentations, each of the clinical hallmarks of AFE (depressed ventricular function, lung injury and coagulopathy) may, in isolation, be seen in other obstetric conditions. Indeed, much of the confusion arising from previously published case series purporting to describe women with AFE appears to be the result of the inclusion of patients with other conditions. (Clark SL et al Obstet Gynecol 2014:123: 337-48) Identification of a reliable, objective biomarker specific to AFE is badly needed.It is against this background that the work of Bouvet et al is especially welcome. These investigators examined the use of insulin-like growth factor binding protein -1, a protein found in high concentration in amniotic fluid, as a potential biomarker of AFE in women suspected to have this condition. Unfortunately, the results were negative, leading the authors to question the usefulness of this assay.Although the results were negative, the major importance of this study may be as an example of how to properly conduct a search for AFE biomarkers. These authors avoided several pitfalls that have invalidated most previous biomarker publications. First, they used 2 objective, internationally recognized clinical criteria sets for identifying women with AFE. Their finding that only about half of women suspected to have AFE actually had the condition based on either of the identified criteria sets emphasizes the importance of insisting on inclusion criteria more stringent than “someone thought the patient had AFE,” so common in current literature. Secondly, in their use of women with suspected AFE these investigators avoided another common pitfall in biomarker research, namely the use of normal pregnant women, rather than critically ill women as controls. Presumably the women without AFE had some other form of critical illness. This distinction is particularly important in investigating the potential of various inflammatory mediators as specific markers for AFE.Finally, the authors’ data support 2 additional important conclusions beyond the original intent of the paper. The finding that 100% of AFE patients identified by the SMFM criteria also met the UK diagnostic criteria serve as additional validation of the ability of the former criteria to reliably identify a group of women who, for research purposes, do have the disease, while excluding some others with less typical forms of AFE. (Clark et al, Am J Obstet Gynecol 2016:408-12.) Secondly, the authors’ findings of no difference in levels of ILGFBP-1 in women with and without clinical AFE, despite high levels of this protein in amniotic fluid, supports the current belief that amniotic fluid per se is unrelated to the condition known as amniotic fluid embolism.It is generally accepted by the scientific community that AFE is unpreventable. It is hoped that additional quality research such as that of Bouvet et al may someday change this unfortunate fact.