The implementation of automatic fasteners such as the Cor-knot ® device (LSI Solutions, Inc.) has revolutionized the field of minimally invasive valvular surgery. Nonetheless, paravalvular regurgitation, valvular embolization, and early leaflet perforation are all potential complications which may occur. Late manifestations of leaflet perforation (>5-year post-implantation) are rare. Herein, we discuss a patient who underwent remote Trifecta ® (St. Jude, Inc.) surgical aortic valve replacement (SAVR) presenting with symptomatic critical aortic regurgitation secondary to leaflet perforation from automatically fastened metallic Cor-knot ® sutures.
Endocarditis originating from a prior venous cannulation site is undescribed in the current literature. Infections of the heart pose significant morbidity and mortality to patients, therefore prompt recognition, diagnosis, and treatment are critical. Our patient underwent coronary artery bypass grafting (CABG) and developed a postoperative sternal wound infection with methicillin resistant staphylococcus aureus (MRSA). After failing nonoperative management, redo-sternotomy was performed with atrial wall debridement and patch repair. During this procedure, two unexpected small discrete abscess pockets of the right atrial epicardium were discovered. One of the abscess pockets fistulized into the right atrium and was noted to be at his prior venous cannulation site for cardiopulmonary bypass as evidenced by neighboring prolene suture. The patient had an uneventful recovery and was discharged home on postoperative day 7. Transthoracic echo was obtained 6 weeks after his second operation and did not show any recurrence of endocarditis. We present a unique case of persistent cardiac infection with a complicated course and management strategy.
Introduction: There are no guidelines regarding the use of bovine pericardial or porcine valves for aortic valve replacement, and prior studies have yielded conflicting results. The current study sought to compare short- and long-term outcomes in propensity-matched cohorts of patients undergoing isolated AVR with bovine versus porcine valves. Methods: This was a retrospective study utilizing an institutional database of all isolated bioprosthetic surgical aortic valve replacements performed at our center from 2010 to 2020. Patients were stratified according to type of bioprosthetic valve (bovine pericardial or porcine), and 1:1 propensity-score matching was applied. Kaplan-Meier survival estimation and multivariable Cox regression for mortality were performed. Cumulative incidence functions were generated for all-cause readmissions and aortic valve reinterventions. Results: A total of 1,502 patients were identified, 1,090 (72.6%) of whom received a bovine prosthesis and 412 (27.4%) of whom received a porcine prosthesis. Propensity-score matching resulted in 412 risk-adjusted pairs. There were no significant differences in clinical or echocardiographic postoperative outcomes in the matched cohorts. Kaplan-Meier survival estimates were comparable, and, on multivariable Cox regression, valve type was not significantly associated with long-term mortality (HR 1.02, 95% CI: 0.74, 1.40, p=0.924). Additionally, there were no significant differences in competing-risk cumulative incidence estimates for all-cause readmissions (p=0.68) or aortic valve reinterventions (p=0.25) in the matched cohorts. Conclusion: The use of either bovine or porcine bioprosthetic aortic valves yields comparable postoperative outcomes, long-term survival, freedom from reintervention, and freedom from readmission.
Background and aim The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery. Methods This systematic review and network meta-analysis involved cardiac surgical patients (age >18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. Results The primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 hours, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]). Conclusions In this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 hr MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.
Objective: To develop a machine learning-based model for predicting the risk of acute respiratory distress syndrome (ARDS) after cardiac surgery. Methods: Data were collected from 1011 patients who underwent cardiac surgery between February 2018 and September 2019. We developed a predictive model on ARDS by using the random forest algorithm of machine learning. The discrimination of the model was then shown by the area under the curve (AUC) of the receiver operating characteristic curve. Internal validation was performed by using a 5-fold cross-validation technique, so as to evaluate and optimize the predictive model. Model visualization was performed to reveal the most influential features during the model output. Results: Of the 1011 patients included in the study, 53 (5.24%) suffered ARDS episodes during the first postoperative week. This random forest distinguished ARDS patients from non-ARDS patients with an AUC of 0.932 (95% CI=0.896-0.968) in the training set and 0.864 (95% CI=0.718-0.997) In the final test set. The top 10 variables in the random forest were cardiopulmonary bypass time, transfusion red blood cell, age, EUROSCORE II Score, albumin, hemoglobin, operation time, serum creatinine, diabetes, and type of surgery. Conclusion: Our findings suggest that machine learning algorithm is highly effective in predicting ARDS in patients undergoing cardiac surgery. The successful application of the generated random forest may guide clinical decision making and aid in improving the long-term prognosis of patients.
Systemic right ventricular failure after physiologic repair for dextro-transposition of the great arteries can be managed with durable mechanical circulatory support; however, the right ventricular morphology, such as intervening papillary muscles, presents challenges to inflow cannula positioning. Papillary muscle repositioning is an innovative technique to circumvent the obstructive anatomy.
The hemispherical aortic annuloplasty reconstructive technology (HAART) is an internal geometric annuloplasty ring designed to restore a natural elliptical shape to the aortic annulus as part of aortic valve repair. We present 4D flow hemodynamic analysis before and after implementation of the HAART ring in patients undergoing ascending aortic replacement. HAART patients displayed similar or improved flow profiles when compared to a patient undergoing ascending aortic replacement alone.
Background: While prior data have suggested worse outcomes in women after acute type A aortic dissection (ATAAD) repair when compared to men, results have been inconsistent across studies over time. This study sought to evaluate the impact of sex on short- and long-term outcomes after ATAAD repair. Methods: This was a retrospective study utilizing an institutional database of ATAAD repairs from 2007 to 2021. Patients were stratified according to sex. Kaplan-Meier survival estimation and multivariable Cox regression were performed. Supplementary analysis using propensity score matching was also performed. Results: Of the 601 patients who underwent ATAAD repair, 361 were males (60.1%) and 240 (39.9%) were females. Females were significantly older, more likely to have hypertension, and more likely to have chronic lung disease. Females were also significantly more likely than males to undergo hemiarch replacement, while males were significantly more likely than females to undergo total arch replacement and frozen elephant trunk. Operative mortality was 9.4% among males and 13.8% among females, though this was not a statistically significant difference (p=0.098). Postoperative complications were comparable between groups. Kaplan-Meier survival estimates were similar for men and women, and, on multivariable Cox regression, sex was not significantly associated with long-term survival (HR 1.00, 95% CI: 0.73, 1.37, p=0.986). Outcomes remained comparable after supplementary propensity score matched analysis. Conclusion: ATAAD repair can be performed with comparable short-term and long-term outcomes in both men and women.
Background VIV-TAVR is established and provides good initial clinical and hemodynamic outcomes. Lacking long-term durability data baffle the expand to lower risk patients. For those purposes, the present study adds a hemodynamic 3-years follow-up. Methods A total of 77 patients underwent VIV-TAVR for failing aortic bioprosthesis during a 7-years period. Predominant mode of failure was stenosis in 87.0%. Patients had a mean age of 79.4±5.8 years and a mean logistic EuroSCORE of 30.8±15.7%. The STS-PROM averaged 5.79±2.63%. Clinical results and hemodynamic outcomes are reported for 30-days, 1-, 2- and 3-years. Completeness of follow-up was 100% with 44 patients at risk after 3-years. Follow-up ranged up to 7.1 years. Results Majority of the surgical valves were stented (94.8%) with a mean labeled size of 23.1±2.3mm and true-ID of 20.4±2.6mm. A true-ID ≤21mm had 58.4% of the patients. Self-expanding valves were implanted in 68.8% (mean labeled size 24.1±1.8mm) and balloon-expanded in 31.2% (mean size 24.1±1.8mm). No patient died intraoperatively. Hospital mortality was 1.3% and three-years survival 57.1%. All patients experienced an initial significant dPmean-reduction to 16.8±7.1mmHg. After 3-years mean dPmean raised to 26.0±12.2mmHg. This observation was independent from true-ID or type of TAVR-prosthesis. Patients with a true-ID ≤21mm had a higher initial (18.3±5.3mmHg vs. 14.9±7.1mmHg; p=0.005) and dPmean after 1-year (29.2±8.2mmHg vs. 13.0±6.7mmHg; p=0.004). There were no significant differences in survival. Conclusions VIV-TAVR is safe and effective in the early period. In surgical valves with a true-ID≤21mm inferior hemodynamic and survival outcomes must be expected. Nonetheless, also patients with larger true-ID’s showed steadily increasing transvalvular gradients. This raises concern about durability.
A 77-year-old woman underwent mitral valve replacement and tricuspid annuloplasty for severe mitral stenosis and tricuspid regurgitation with pulmonary hypertension. Two months later, the patient was readmitted because of marked edema. A new harsh pansystolic murmur was auscultated, and echocardiography revealed a jet from the left ventricle to the right atrium but no perivalvular leakage was detected at the mitral valve position. At operation, an 6mm defect adjacent to the tricuspid annulus in the interatrial septum and detachment of the anterior edge of the tricuspid ring were detected. The defect was closed using a pericardial patch. An inadequate stitch at the anteroseptal commissure in the previous operation led to left ventricular-right atrial communication.
Surgical pulmonary artery thrombectomy is a well-established emergency treatment for massive pulmonary embolism (PE) in which fibrinolysis or thrombolysis cannot happen. However, surgery for massive PE that requires peripheral pulmonary artery thrombus removal remains challenging. We established a simple and secure pulmonary artery thrombectomy method using cardiopulmonary bypass and cardiac arrest. In this procedure, the surgical assistant arm, typically used for coronary artery bypass grafting, is used to obtain a feasible working space during thrombectomy. We present seven consecutive massive PE cases treated with the present surgical method and successfully weaned from cardiopulmonary bypass or extracorporeal membrane oxygenation postoperatively. This procedure can be used to prevent right ventricular failure after surgery as surgeons can remove the thrombus up to the second branch of the pulmonary artery with direct vision.
Objectives: To date, there is no consensus on optimal speed for rotational atherectomy (RA) in patients with coronary heart disease (CHD). Here, we aimed to investigate interventional outcomes of RA at different rotational speeds and analyze its clinical effect in the patients with CHD. Methods: A total of 372 CHD patients were retrospectively analyzed between February 2017 and December 2021. The patients received RA at different rotational speeds. The patients were divided into four groups based on the maximum RA speed: group 1 (˂150,000rpm, 76 cases), group 2 (150,000rpm, 156 cases), group 3 (160,000rpm, 90 cases) and group 4 (≥170,000rpm, 50 cases). The perioperative endpoints included hypotension, vasospasm, dissection, slow flow, perforation, bradyarrhythmia, burr entrapment, rotawire fracture during RA as well as the incidence of heart failure, stent thrombosis, and cardiac death during hospitalization. Six-months incidence of major cardiovascular and cerebrovascular events (MACCE) such as a composite of myocardial infarction (MI), stent thrombosis, target vessel revascularization (TVR), cardiogenic death, all-cause death or stroke were the long-term primary endpoints. On the other hand, long-term secondary endpoint was chronic heart failure. Results: Our analysis showed that patients in group 4 had a higher incidence of slow flow during the RA operation (P=0.025). There was no significant difference in other complications among the four groups. Besides, there was no significant difference in six-month MACCE among the four groups (P=0.452). After adjusting for confounding factors, increase in rotational speed led to a higher probability of slow flow (P for non-linearity = 0.131; adjusted model) and MACCE (P for non-linearity = 0.183; adjusted model). Logistic regression analysis showed that rotational speed was a predictor of slow flow during RA operation (OR=1.24, 95%CI:1.05~1.47, P=0.013), as well as six-month incidence of MI (OR=2.22, 95%CI:1.04~4.71,p=0.038). Moreover, the analysis demonstrated that a rotational speed of ˂150,000rpm was a predictor of vasospasm during RA operation (OR=3.62, 95% CI:1.21~10.8, P=0.021). Conclusion: Our findings showed that CHD patients treated with RA at a rotational speed of ≥170,000rpm had a higher risk of slow flow. In contrast, a rotational speed of ˂150,000rpm was shown to be an independent risk factor for spasm during RA in CHD patients. Moreover, rotational speed is an independent risk factor for slow flow and six-month MI in CHD patients. There was no significant difference in six-month outcomes in comparison to elective CHD patients with different rotational speeds, and the probability of MACCE was intensified with increase in rotational speed.
Based on Carpentier’s classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morpho-functional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets, but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.
For donation after circulatory death, procurement is performed after the heart has arrested. This technique has been employed and adopted by clinicians to overcome the shortage of available hearts for transplant. Warm ischemia time plays a pivotal role in the survival outcome of the heart recipients. We describe a fast and safe technique to flush the heart during recovery from circulatory death donors in order to shorten the warm ischemia time.
Background: Heart transplant from controlled donation after circulatory death (cDCD) is an emerging strategy that is rapidly expanding and may help increase the heart donor pool. Materials and Methods: The use of thoracoabdominal normothermic regional perfusion (TANRP) with extracorporeal membrane oxygenation device has allowed to perform cardiac transplantation after cDCD. Several experiences have been carried out in recent years, however the maximum cold ischemia time is still unknown. We present a successful case of heart transplantation using a graft from cDCD from another hospital with 201 minutes of cold ischemia time, the longest published in Europe. Discussion and conclusion: Heart transplant from cDCD could be a good alternative to brain dead donation. This experience suggests than nonlocal cardiac donation in controlled asystole could tolerate long periods of cold ischemia time and break the main barriers in cardiac donation after circulatory death.
Pump thrombosis is a rare and infrequent complication of HeartMate III left ventricular assist device (LVAD). While there are reports of pump thrombosis in the postoperative period, to our knowledge, there have been no prior reports on pump thrombosis in the intraoperative period. Here we present a case of a 24-year-old female who required HeartMate III LVAD implantation for progressive heart failure and the intraoperative period was complicated with pump thrombosis (PT). Managing PT in the intraoperative period is challenging and time-sensitive because of its rare occurrence and paucity of recommendations in diagnosing the PT.
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.
81-year-old man with a history of Bio-Bentall surgery presented to the emergency department with fever, chills and back pain. Initial physical examination was inconclusive apart from sudden onset of delirium, and investigation showed elevated WBCs, anemia, and neutrophilia. Further studies revealed gram-positive cocci on the initial blood culture, which was then confirmed to be MSSA bacteremia. Subsequently, a TEE showed a peri-aortic abscess, Moderate AR and severe AS with no evidence of endocarditis. Antibiotics were started and urgent abscess drainage was planned. In a hybrid operative setting, a multidisciplinary team of cardiology, and cardiac surgery managed the periaortic graft abscess drainage through a median sternotomy and TAVR. Post-operatively, the complications included bradycardia, and RHF. Six-week course of IV Rifampin, Probenecid and Cefazolin was initiated, and patient was to remain on lifelong Cefadroxil.