Spanish Society of Cardiovascular & Endovascular Surgery registry of interventions in patients with congenital heart disease: 2021, and retrospective of the previous decade

The Spanish Society of Cardiovascular & Endovascular Surgery presents the 2012-2021 report of the activity in congenital cardiovascular surgery, based on a voluntary and anonymous registration involving most of Spanish centres. This article is complementary to the 2021 cardiovascular surgery annual report, and they are published together. In 2021, still marked by the aftermath of the COVID-19 pandemic, the decline in our 2020 congenital activity persists, compared with previous years. We included data from the previous 10 years, in order to obtain real information related to our activity with these relatively scarce pathologies. In the last decade, a total of 20,139 congenital heart surgeries were performed, accounting for 9.5% of all major surgery (congenital + acquired) performed in Spain during that period. Of these surgeries, 81.5% of them required extracorporeal circulation and 18.5% not. We highlight the interventions in neonates and adult patients, which mean respectively 18% and 21% of our whole activity and are a real challenge. The most prevalent congenital heart pathologies operated on were: septal defects in cases requiring extracorporeal circulation, and ductus in patients without extracorporeal circulation. The presented data are adjusted to the basic Aristotle score of preoperative surgical risk. The observed mortality of surgeries with extracorporeal circulation was 3.07% (Aristotle: 6.29), and without cardiopulmonary bypass 2.25% (Aristotle: 4.82). Our national registry of surgical activity in congenital heart disease shows good results, allows us to compare ourselves within a national and international framework, design improvement strategies, set objectives and improve the quality of our actions.Copyright © 2023 Sociedad Espanola de Cirugia Cardiovascular y Endovascular

Anaesthetic Management for A Patient Presenting for Caesarean Delivery with A giant Thymoma - A Case Report

Presentation of a thymoma during pregnancy means that safe delivery becomes more challenging. We present a 33-year-old pregnant woman who was diagnosed with a large thymoma causing marked compression of the tracheobronchial tree and right atrium. After various multidisciplinary meetings she presented for elective caesarean section delivery at 31 weeks of gestation. A combined spinal-epidural anaesthesia was performed, along with colloid pre-and co-loading, and vasopressor support. The delivery was uneventful. The possibility of catastrophic complications was foreseen. Therefore, all requirements for the possibility of airway or haemodynamic collapse were planned carefully, including the possibility of emergent cardiopulmonary bypass.Copyright © 2023, College of Anaesthesiologists of Sri Lanka. All rights reserved.

Development of artificial circulation

The importance of developing an artificial means to oxygenate blood and perfuse the body, and their potential benefits to mankind were postulated as early as the 17th century. The modern artificial circulatory devices which are capable of tackling life-threatening conditions are powerful tools in the medical armamentarium. The painstaking research which paved the way for these technologies spanned over a century. The introduction of cardiopulmonary bypass heralded the development and worldwide adoption of open-heart surgery in the last 70 years. The ability to support the failing heart and lungs has averted early deaths for tens of thousands of patients. The recent severe acute respiratory distress syndrome coronavirus 2 pandemic is the latest example of how the use of respiratory extracorporeal membrane oxygenation has been catapulted to unprecedented levels. This chapter takes the reader on a brief journey through some of the key historical developments that underpinned the successes of these medical innovations. © 2023 Elsevier Inc. All rights reserved.

Percutaneous Thrombectomy Using Angiovac System as a Diagnostic and Therapeutic Tool in Managing Right Atrial Mass in a High-Risk Patient

Background Right atrial (RA) masses often pose a dilemma in accurate diagnosis and management. We describe a challenging case of a large mobile RA mass in a febrile cancer patient. Case A 36-year-old female with newly diagnosed breast cancer on chemotherapy for 4 months via Port-A-Cath presented initially with COVID-19 pneumonia but continued to have persistent fever and dyspnea. A CT of the chest ruled out pulmonary embolism but showed an incidental RA mass. Echocardiography confirmed a large (2.7 x 1.6 cm), pedunculated mobile mass in the RA, attached to the free wall near the Eustachian valve (Fig.1). For a suspected thrombus, anticoagulation was initiated and a percutaneous thrombectomy using AngioVac was attempted. The mass was tightly attached to the atrial wall and too large to suction, resulting in only partial extraction of multiple tumor-like masses. Decision-making In addition to catheter-related thrombus and COVID-19 infection-related thrombus in transit, possibilities of myxoma, metastasis and fungal vegetation were considered due to its atypical features. A week later, pathology confirmed the diagnosis of an organized thrombus. Surgery was deferred and instead a repeat AngioVac using a larger aspiration catheter successfully aspirated the entire RA mass without complications. Conclusion Percutaneous aspiration of RA masses can prove to be of both diagnostic and therapeutic use, especially in high-risk patients. It can help avoid invasive surgical intervention in clinical dilemmas. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Cold Agglutinin Detected in the Intraoperative Period: A Case of Coronary Bypass.

Cold agglutinin disease(CAD) is an autoimmune disease that occurs against erythrocyte antigens. It is usually idiopathic, but some infections can also be a trigger. CAD becomes active in the peripheral circulation at lower temperatures more easily when exposed to cold, causing hemolysis or agglutination. In this article, the management of a coronary bypass case with CA formation in intraoperative period is presented. A 46-year-old diabetic and hypertensive male patient had COVID-19 2 months ago. Cardiopulmonary bypass(CPB) was initiated with adequate heparinization, and the patient was cooled to 32degreeC. It was noticed that there were clots in the cardioplegia delivery line(+1degreeC). Agglutinations were observed in the autologous blood of the patient whose ACT values were normal. After CPB, the operation was completed without any problems and the patient was discharged on the 5th day with recovery. A diagnosis of CAD was made with the results of peripheral smear and immunologic tests. Determination of antibody concentration and thermal amplitude in the preoperative period in patients with CAD is very important. While preparing such patients for surgery, heating of room, patient, fluids, planning of normothermic CPB, and using warm cardioplegia are required. The relationship between CAD and COVID has started to take place in the literature. The patient we presented had a COVID 2 months ago, cold agglutinin may have been induced by COVID or may have arisen idiopathic. Considering that many people may have had a COVID nowadays, care should be taken especially in the perioperative period of cardiac surgery.Copyright © Telif hakki 2022 Gogus-Kalp-Damar Anestezi ve Yogun Bakim Dernegi Dergisi - Available online at www.gkdaybd.org.

Cold Agglutinin Detected in the Intraoperative Period: A Case of Coronary Bypass.

Cold agglutinin disease(CAD) is an autoimmune disease that occurs against erythrocyte antigens. It is usually idiopathic, but some infections can also be a trigger. CAD becomes active in the peripheral circulation at lower temperatures more easily when exposed to cold, causing hemolysis or agglutination. In this article, the management of a coronary bypass case with CA formation in intraoperative period is presented. A 46-year-old diabetic and hypertensive male patient had COVID-19 2 months ago. Cardiopulmonary bypass(CPB) was initiated with adequate heparinization, and the patient was cooled to 32degreeC. It was noticed that there were clots in the cardioplegia delivery line(+1degreeC). Agglutinations were observed in the autologous blood of the patient whose ACT values were normal. After CPB, the operation was completed without any problems and the patient was discharged on the 5th day with recovery. A diagnosis of CAD was made with the results of peripheral smear and immunologic tests. Determination of antibody concentration and thermal amplitude in the preoperative period in patients with CAD is very important. While preparing such patients for surgery, heating of room, patient, fluids, planning of normothermic CPB, and using warm cardioplegia are required. The relationship between CAD and COVID has started to take place in the literature. The patient we presented had a COVID 2 months ago, cold agglutinin may have been induced by COVID or may have arisen idiopathic. Considering that many people may have had a COVID nowadays, care should be taken especially in the perioperative period of cardiac surgery.Copyright © Telif hakki 2022 Gogus-Kalp-Damar Anestezi ve Yogun Bakim Dernegi Dergisi - Available online at www.gkdaybd.org.

Management of Pediatric Pulmonary Hypertension Using Remote Pulmonary Artery Pressure Sensor Monitoring

Background Management of pediatric pulmonary hypertension (PH) may require manipulation of multiple receptor sites to maximize response to medical therapy. Assessment of response typically occurs through imaging, labs, physical exam and recurrent cardiac catheterization, with anesthetic exposure to assess pulmonary artery pressures (PAP) and vascular resistance (PVR). We aimed to assess feasibility, safety and utility of remote PAP monitoring in pediatric PH patients. Methods We reviewed 4 pediatric patients with significant PH, each of whom underwent cardiac catheterization with pulmonary vasoreactivity testing and placement of a CardioMEMS remote PAP monitoring device. Results Four patients (P1-4: ages 5, 6, 8 and 10 years old) underwent CardioMEMS insertion without procedural complication. P1, P2 and P3 presented with unrepaired VSD;ASD with partial anomalous pulmonary venous return;and ASD and PDA, respectively, while P4 had prior repair of atrioventricular canal. Three patients had Down syndrome. All had elevated PAP and PVR. Mean left lower PA branch size was 7 mm. Mean PAP prior to therapy was 70 mm Hg for P1, 82 for P2, 93 for P3 and 30 for P4. All 4 patients required initiation of triple therapy for treatment of PH, with improvement or normalization of PAP by CardioMEMS, which also included surgical or catheter based intervention for 3 patients. Post-repair of P2, he was unable to be separated from cardiopulmonary bypass and was placed on ECMO. Right ventricular cardiac output improved over 2 weeks, with improvement of PAP determined through serial CardioMEMS. He was successfully decannulated, utilizing CardioMEMS in the OR. Two patients also developed COVID respiratory infections at home with CardioMEMS assessments allowing for oxygen and medication titration. Conclusion Remote PAP monitoring is feasible and appears safe in pediatric patients with adequate PA size. It allows for manipulation of medical therapy with real time knowledge of impact on PAP and can augment management during weaning of mechanical cardiac support. It may also augment decision-making in management of PH patients with developmental disabilities in whom traditional assessments may be more challenging.Copyright © 2023 American College of Cardiology Foundation

Consequences of anastomotic leaks after minimally invasive esophagectomy: A single-center experience

Background: Anastomotic leak (AL) after minimally invasive esophagectomy (MIE) is a well-described source of morbidity for patients undergoing surgical treatment of esophageal neoplasm. With improved early recognition and endoscopic management techniques, the long-term impact remains unclear. Method(s): A retrospective review was conducted of patients who underwent MIE for esophageal neoplasm between January 2015 and June 2021 at a single institution. Cohorts were stratified by development of AL and subsequent management. Baseline demographics, perioperative data, and post-operative outcomes were examined. Result(s): During this period, 172 MIEs were performed, with 35 of 172 (20.3%) complicated by an AL. Perioperative factors independently associated with AL were post-operative blood transfusion (leak rate 52.9% versus 16.8%;p = 0.0017), incompleteness of anastomotic rings (75.0% vs 19.1%;p = 0.027), and receiving neoadjuvant therapy (18.5% vs 30.8%;p < 0.0001). Inferior short-term outcomes associated with AL included number of esophageal dilations in the first post-operative year (1.40 vs 0.46, p = 0.0397), discharge disposition to a location other than home (22.9% vs 8.8%, p = 0.012), length of hospital stay (17.7 days vs 9.6 days;p = 0.002), and time until jejunostomy tube removal (134 days vs 79 days;p = 0.0023). There was no significant difference in overall survival between patients with or without an AL at 1 year (79% vs 83%) or 5 years (50% vs 47%) (overall log rank p = 0.758). Conclusion(s): In this large single-center series of MIEs, AL was associated with inferior short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, without an accompanying impact on 1-year or 5-year survival. Key message: In this large, single-center series of minimally invasive esophagectomies, anastomotic leak was associated with worse short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, but was not associated with worse long-term survival. The significant association between neoadjuvant therapy and decreased leak rates is difficult to interpret, given the potential for confounding factors, thus careful attention to modifiable pre- and peri-operative patient factors associated with anastomotic leak is warranted.Copyright © 2022 The Authors

Use of nafamostat mesilate for anticoagulation during extracorporeal membrane oxygenation: A systematic review.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) represents an advanced option for supporting refractory respiratory and/or cardiac failure. Systemic anticoagulation with unfractionated heparin (UFH) is routinely used. However, patients with bleeding risk and/or heparin-related side effects may necessitate alternative strategies: among these, nafamostat mesilate (NM) has been reported. METHODS: We conducted a systematic literature search (PubMed and EMBASE, updated 12/08/2021), including all studies reporting NM anticoagulation for ECMO. We focused on reasons for starting NM, its dose and the anticoagulation monitoring approach, the incidence of bleeding/thrombosis complications, the NM-related side effects, ECMO weaning, and mortality. RESULTS: The search revealed 11 relevant findings, all with retrospective design. Of these, three large studies reported a control group receiving UFH, the other were case series (n = 3) or case reports (n = 5). The main reason reported for NM use was an ongoing or high risk of bleeding. The NM dose varied largely as did the anticoagulation monitoring approach. The average NM dose ranged from 0.46 to 0.67 mg/kg/h, but two groups of authors reported larger doses when monitoring anticoagulation with ACT. Conflicting findings were found on bleeding and thrombosis. The only NM-related side effect was hyperkalemia (n = 2 studies) with an incidence of 15%-18% in patients anticoagulated with NM. Weaning and survival varied across studies. CONCLUSION: Anticoagulation with NM in ECMO has not been prospectively studied. While several centers have experience with this approach in high-risk patients, prospective studies are warranted to establish the optimal space of this approach in ECMO.

Strategies to mitigate inflammation in management of complex congenital heart disease complicated by "multisystem inflammatory syndrome in children".

A 6-month-old boy, a case of Shone's complex, presented in decompensated state was found to have severe mitral stenosis along with multisystem inflammatory syndrome in children (MISC) warranting urgent surgical intervention. Various modalities including cytokine-adsorbing hemofilter were used to target inflammation. Postoperatively, the child recovered from low cardiac output accompanied by decrease in the levels of inflammatory markers, inopressors, and ventilatory requirements. Open heart surgery in itself is a proinflammatory process and is best avoided during the active inflammatory phase of MISC. In the rare and unavoidable circumstance exemplified by this index case, multipronged strategy targeting inflammation as described can be successfully implemented.

Left Ventricular Apical Thrombus after Covid-19 Infection Associated with Pediatric Stroke

INTRODUCTION: Stroke is rare in the pediatric population but is often associated with significant morbidity and mortality prompting evaluation for a wide range of pathologic processes. Neurologic manifestations of COVID-19 infection include meningoencephalitis, acute demyelinating encephalomyelitis, Guillain barre and stroke. Throughout the literature, patients seen with neurologic disease had severe COVID-19 infection and/or the multi-system inflammatory syndrome (MIS-C). Only a small proportion of patients had neurologic manifestations as the presenting feature with confusion and seizures being most common. DESCRIPTION: We report the case of a 12-year-old male who presented with left sided weakness and confused speech. This occurred following a 3-day illness with reported fever, malaise, and headache with photophobia resolved. On admission he was afebrile with a left facial droop, grade 4 power in the left hemibody and ankle clonus. Labs revealed an elevated WBC (16.4 x 103 cell/mm3) and CRP (7.3mg/dl), a negative respiratory viral panel and COVID-19 PCR test but positive COVID-19 antibody 315 s/co ratio and increased fibrinogen (523mg/dl) and d-dimers (2.69 mcg/ml). CSF had no WBCs and a negative meningitisencephalitis panel. Computed tomography of the brain was normal but an MRI brain with angiography and venography showed multiple infarcts consistent with embolic strokes. An echocardiogram revealed a mobile mass at the left ventricular apex measuring 2.5 x 1.6 cm suggestive of a large clot in the presence of normal biventricular function, and no wall motion abnormalities. Due to the risk of re-embolization with devastating neuro-cardiac effects, he underwent left ventriculotomy and clot removal with cardiopulmonary bypass and was continued on therapeutic anticoagulation. Alternative etiologies such as thrombophilia, infective endocarditis or an intracardiac tumor were ruled out. DISCUSSION: Intracardiac thrombosis has been reported in adults and children with COVID-19 but often along with pneumonia, dilated cardiomyopathy and myocardial infarction or acute MIS-C and intracardiac devices. Delayed thrombosis in the absence of MIS-C or cardiac dysfunction is not as frequently seen and brings to light the prolonged prothrombotic state post COVID infection.

Cold agglutinin detected in the intraoperative period: a case of coronary bypass

Cold agglutinin disease(CAD) is an autoimmune disease that occurs against erythrocyte antigens. It is usually idiopathic, but some infections can also be a trigger. CAD becomes active in the peripheral circulation at lower temperatures more easily when exposed to cold, causing hemolysis or agglutination. In this article, the management of a coronary bypass case with CA formation in intraoperative period is presented. A 46-year-old diabetic and hypertensive male patient had COVID-19 2 months ago. Cardiopulmonary bypass(CPB) was initiated with adequate heparinization, and the patient was cooled to 32°C. It was noticed that there were clots in the cardioplegia delivery line(+1°C). Agglutinations were observed in the autologous blood of the patient whose ACT values were normal. After CPB, the operation was completed without any problems and the patient was discharged on the 5th day with recovery. A diagnosis of CAD was made with the results of peripheral smear and immunologic tests. Determination of antibody concentration and thermal amplitude in the preoperative period in patients with CAD is very important. While preparing such patients for surgery, heating of room, patient, fluids, planning of normothermic CPB, and using warm cardioplegia are required. The relationship between CAD and COVID has started to take place in the literature. The patient we presented had a COVID 2 months ago, cold agglutinin may have been induced by COVID or may have arisen idiopathic. Considering that many people may have had a COVID nowadays, care should be taken especially in the perioperative period of cardiac surgery. (English) [ FROM AUTHOR]

Incidentally discovered cold hemagglutinins within autologous blood bag and cardioplegia line in a patient with a recent history of COVID-19 undergoing coronary artery surgery.

INTRODUCTION: Cold agglutinin disease (CAD) is a rare autoimmune disorder characterized by destruction (hemolysis) of erythrocytes. In CAD, autoantibodies that cause agglutination at temperature of optimum +3-+4 ℃ degree cause symptoms. It is known that CAD often occurs after viral infections. Also, it has been reported in case reports that COVID-19 disease can cause CAD. CASE REPORT: 46-year-old male patient with a history of diabetes mellitus and hypertension presented to outpatient clinic in our department to have CABG surgery. He recovered from COVID-19 disease 1.5 months ago. Cardiopulmonary bypass was initiated and the cross-clamp was placed and antegrade Delnido cardioplegia solution was started to be given at +4 ℃. It was observed that the cardioplegia line was agglutinated. On the other hand, it was seen that the autologous blood taken by the anesthesiologist was also agglutinated and formed air bubbles and became unusable. X-clamp was removed and the heart rhythm recovered. The patient was consulted to hematology during postoperative intensive care follow-ups. The cold agglutinin test performed at of +4 ℃ was reported as positive. In this case, we associated the CAD with covid-19 for three main reasons. First one, the patient's complaints about CAD started after COVID-19 disease. Secondly, in the national health archive, the patient's pre-COVID-19 blood tests were completely normal but it was seen that LDH increased and RBC-HCT incompatibility started after COVID-19. As the third, when we search the literature, we have seen the COVID-19 related CAD in many case reports published by hematologists. CONCLUSION: With the rare cold agglutinin disease, it seems that we will encounter it more often after the COVID-19 pandemic. Except for deep hypothermia, the most important problem is seen during cardioplegia administration. Therefore, non-blood cardioplegia can be lifesaving.

Aortic thrombosis presenting as myocardial infarction in a child

Background: Ascending aortic thrombus is rare in children without history of trauma, hypercoagulable condition or vascular disease and carries a high mortality risk necessitating rapid identification and management. Aim(s): We aim to present the clinical course for a rare pediatric case. Method(s): We reviewed the medical record for a child with recurrent life-threatening thrombi. Result(s): A 12-year old previously healthy male presented with chest pain. ECG revealed ST segment elevation. Echocardiography revealed an ejection fraction of 25% and a mobile mass (10 x 20 mm) in the ascending aorta. COVID testing was negative. Troponin-I was elevated. He was emergently placed on cardiopulmonary bypass where a large organized thrombus was removed. The left anterior descending coronary artery was occluded. He underwent intracoronary tPA, aspiration thrombectomy and balloon angioplasty. Hypercoagulable and autoimmune work-up revealed elevated factor 8 activity, von willebrand factor (vWF) activity and thrombocytosis with increased function by viscoelastic testing (ROTEM). Myocarditis, cardiogenetics and genetic testing for thrombophilia were negative. He was discharged on heart failure therapy, triple anti-platelet therapy (aspirin, clopidogrel, dipyridamole) and apixiban. He underwent a heart transplant 5 months later. Three weeks post-transplantion, he was incidentally found to have a large left atrial thrombus. At this time, he was only on aspirin. Factor 8 activity at time of transplant and second thrombus discovery was >400%. vWF activity and platelet count were also elevated. ROTEM revealed elevated platelet and fibrinogen activity. He underwent left atrial thrombectomy and was restarted on triple antiplatelet therapy and apixiban. He has not had recurrence on this regimen for 8 months. Conclusion(s): Thrombocytosis and elevated pro-inflammatory coagulation factors may predispose to development of potentially fatal thrombi. Besides inflammation, etiology may be unknown, particularly in apparently healthy children, prompting additional research into potentially genetic conditions in these complex pathways to further elucidate patients at risk.

Effect of Cytokine Adsorption on Mortality: A Meta-Analysis

Background: Cytokine adsorption using the CytoSorb device had been proposed to be beneficial in various clinical settings including sepsis, ARDS, hyperinflammatory syndromes, cardiac surgery or recovery after cardiac arrest. The aim of this analysis was to provide evidence for the efficacy of the CytoSorb device with regard to mortality in these settings. Method(s): We searched Medline, Cochrane Library database and used the database provided by CytosorbentsTM. Central Register of Controlled Trials and clinicaltrials. gov for randomized, controlled studies (01.1.2010-28.2.22). We considered randomized controlled trials and observational studies with a control group. The longest reported mortality (30 days-, hospital- or ICU-mortality) was defined as primary endpoint. For analyzing the data we computed risk ratios and 95%-confidence intervals and used DerSimonian and Lairds random effects model (R 4.1). We analysed all studies together and separated in the subgroups sepsis, cardiac surgery, SARS-CoV-2 infection, recovery from cardiac arrest, other severe illness. The meta-analysis was registered in advance (PROSPERO: CRD42022290334). Result(s): Of initial 1249 publications, 37 trials were found eligible, in total including 1256 patients treated with CytoSorb and 1230 controls. Concerning the primary endpoint mortality Cytosorb did not show a positive effect in all studies together 1.10 [0.92;1.33] RR [95%-CI], in sepsis 1.03 [0.81;1.31], CPB surgery 0.85 [0.51;1.44], severe illness 1.05 [0.79;1.39], SARS-CoV-2 1.58 [0.50;4.94], and recovery from cardiac arrest 1.22 [1.02;1.46] (figure). Likewise we did not find significant difference in ICU length of stay, lactate levels, or norepinephrine after treatment. Conclusion(s): To date there is no evidence for a positive effect of the CytoSorb adsorber on mortality across a bunch of indications that justifies its widespread use in intensive care medicine. (Table Presented).

Outcomes of COVID-19 infection occurring in the recovery period of the open-heart surgery.

Background: In this study, we aimed to examine the effect of novel coronavirus 2019 disease (COVID-19) on the healing process of patients undergoing open-heart surgery. Methods: Between October 2020 and May 2021, a total of in 22 patients (14 males, 8 females; mean age: 60±15 years; range, 18 to 82 years) who developed COVID-19 within the first 30 days after open-heart surgery were retrospectively analyzed. Since the study was conducted in the pre-vaccination period, all of the patients were unvaccinated. Demographic, operative, and laboratory data of the patients were analyzed, and morbidity and mortality rates were evaluated. Results: Postoperative COVID-19 infection occurred in 22 of 1,171 patients who underwent open-heart surgery. Pneumonia developed in 14 (64%) patients and mechanical ventilation support was required in 50% (n=7) of them. Mortality was seen in eight (36%) patients. Only procalcitonin level (p=0.003) and age (p=0.005) had significant effects on survival. Conclusion: Postoperative COVID-19 infection is associated with high pneumonia and mortality rates in unvaccinated patients. Protocols that can prevent false polymerase chain reaction negativity and early contamination can be life-saving.

Delayed Surgical Management of Acute Type A Aortic Dissection in a Patient with Recent COVID-19 Infection and Post-COVID-19 Bronchopneumonia-Case Report and Review of Literature.

Ever since it was first described in 1760, acute type A aortic dissection has created difficulties in its management. The recent COVID-19 pandemic revealed that extrapulmonary manifestations of this condition may occur, and recent reports suggested that aortic dissection may be amongst them since it shares a common physiopathology, that is, hyper-inflammatory syndrome. Cardiac surgery with cardiopulmonary bypass in the setting of COVID-19-positive patients carries a high risk of postoperative respiratory failure. While the vast majority accept that management of type A aortic dissection requires urgent surgery and central aortic therapy, there are some reports that advocate for delaying surgery. In this situation, the risk of aortic rupture must be balanced with the possible benefits of delaying urgent surgery. We present a case of acute type A dissection with COVID-19-associated bronchopneumonia successfully managed after delaying surgery for 6 days.

Lung Transplantation for COVID Acute Respiratory Distress Syndrome: A Pediatric and Adult Case Series

Purpose: Lung transplantation (LTx) has been shown to be a viable treatment for irreversible lung disease caused by COVID-19. Given the limited data on the subject, our purpose was to examine the process and outcomes of LTx for COVID Acute Respiratory Distress Syndrome (ARDS) in a retrospective single center cohort study which includes one pediatric patient. Method(s): This case series is a retrospective review of our patients diagnosed with COVID ARDS who underwent LTx for that diagnosis. All LTx in this cohort occurred between September 9, 2020 and August 26, 2021. We report on candidate selection, pre-LTx patient care, intra-operative procedure, and post-transplant recovery. Result(s): A total of ten patients that underwent LTx for COVID ARDS were identified. The average age of the cohort was 44.9 years (range of 16-60 years) and the mean Lung Allocation Score (LAS) 85.4 +/- 9.65. LTx occurred on average 96.5 +/- 32.9 days following onset of COVID symptoms. Seven patients (70%) in the cohort were bridged to LTx on extracorporeal membrane oxygenation (ECMO) for an average of 72.1 +/- 25.9 days. Six patients (60%) required mechanical ventilation prior to LTx. Intra-operatively, seven patients received life support via ECMO, 2 via off-pump, and 1 via cardio-pulmonary bypass (CPB). Seven patients required intraoperative packed red blood cells (mean 5.4 +/- 2.5). Following transplant, 60% of patients received ECMO for a mean duration of 2.0 +/- 0.9 days;90% of the cohort received ventilatory support. At 72 hours following surgery, cohort graft viability surpassed in center averages for non COVID LTx recipients;50% of patients had no primary graft dysfunction (PGD) (grade 0) and 50% had PDG grade 1. Discharges occurred 29.0 +/- 11.7 days following LTx and no episodes of acute rejection were noted in this time frame. As of publication there is 100% patient and allograft survival. Conclusion(s): While substantial center resources and expertise are required, LTx for COVID ARDS can be safely performed with a high rate of success. Careful candidate selection, donor selection, and institutional support were all critical elements that contributed to the 100% success rate observed in this cohort, which includes the youngest reported patient to undergo LTx for COVID ARDS.

Initiating a pediatric cardiac surgery program in europe during the COVID-19 pandemic: Methods, challenges and outcomes

Background and Aim: Before 2020, no pediatric cardiac surgery pro-gram was available at our institution, despite being a university hospital providing tertiary care for 6 million inhabitants. Our goal is to describe the preparation and the first year of expe-rience of our pediatric cardiac surgery program, which will even-tually cater for 300 patients annually. Method(s): The project was supported by European funds (INTERREG program). Medical and nursing staff training was performed via a transborder collaboration. Significant investments were necessary to reach the required standards for the facilities (operating rooms, pediatric intensive care beds) and equipment (cardiopulmonary bypass and ECMO machines, ultrasound sys-tems etc.). A multidisciplinary team was built over 3 years. The pediatric ECMO program was started a year prior to the surgical program. In parallel, a program dedicated to the study and care of neurological impact of congenital heart diseases and interventions was set up. Importantly, a progressive upscale was devised: only children with a weight gt;5 kg requiring non-complex surgeries were operated on during the first year. Result(s): The first year of experience was marked by challenges caused by the successive COVID-19 waves, such as restricted access to the operating room and a subsequent slow-down in the progression of the schedule. Fifty-nine patients constituted the cohort of the first year (October 2020-October 2021). In addition to low-risk procedures (left-to-right shunts closures etc.), cases included 6 tetralogy of Fallot repairs, 1 Ross procedure and 2 bilateral cavopulmonary connections. There were no early or late deaths. Median age was 6.3 years old (1.8-9.8) and median weight was 18.5 kg (10.0-32.0). Fourteen patients (23.7%) were operated on with a weight lt;10 kg. Bypass cases represented 72.9% (43 patients) of all cases. Median cardiopulmonary bypass and cross-clamping times were 88 (52-153) and 51 (26-98) minutes respectively. Median intensive care and hospital stays were 3 (2.0-6.7) and 6 days (5-11) respectively. Conclusion(s): Despite COVID-19-related difficulties, our pediatric cardiac surgery program achieved excellent outcomes in selected patients. Institutional support, meticulous planning, team cohesion and perseverance are keys for successful initiation of a program requiring such high technicality.

A CASE OF LUNG TRANSPLANT WITH RECENTLY INFECTED SARS-COV-2 DONOR LUNGS

SESSION TITLE: Lung Transplantation Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: A shortage of lungs persists despite the addition of increased-risk donors to the transplantation pool. Waitlist mortality increased from 14.7 to 16.1 deaths per 100 waitlist years from 2019 to 2020. (1) Novel strategies are needed to further expand the donor pool. We report a case of intentional transplant of recently infected acute respiratory virus syndrome 2 (SARS-CoV-2) donor lungs to a patient with end-stage Idiopathic Pulmonary Fibrosis (IPF). CASE PRESENTATION: A 67 year old man with IPF, former tobacco and alcohol abuse, hypertension and gastroesophageal reflux disease underwent a sequential bilateral lung transplant on cardiopulmonary bypass. His post-operative course was complicated by Pseudomonas Aeruginosa pneumonia and bilateral pleural effusions status-post bilateral chest tube placement. He was extubated 4 days after surgery and had his chest tubes removed within 1 week. He discharged on room air 17 days after transplant and appeared well at his 3 week post-operative clinic visit. The donor lungs came from a 28 year old woman with chronic hepatitis C and recent asymptomatic SARS-CoV-2 infection. She tested positive for SARS-CoV-2 on reverse transcriptase polymerase chain reaction (RT-PCR) nasopharyngeal (NP) swabs at 12 and 7 days prior to surgery. She had negative SARS-CoV-2 results on lower respiratory tract testing via bronchioalveolar lavage (BAL) at 7 and 2 days prior to surgery. Recipient RT-PCR NP testing was negative on post-operative days 3, 10, and 17. Two subsequent BAL samples were negative in the first week post-operation. The recipient consented to transplant and was aware of the donor's recent SARS-CoV-2 and chronic hepatitis C infections. Infectious disease did not recommend any SARS-CoV-2 anti-viral therapy or post-exposure prophylaxis. Hepatology prescribed treatment for donor derived hepatitis C viremia on discharge. DISCUSSION: Emerging pathogens present a challenge in minimizing donor-derived diseases. The utilization of lungs, including patients with recent SARS-CoV-2 infection, should be considered carefully. Institutional guidelines vary in donor exclusion criteria based on history of prior SARS-CoV-2 infection, severity of prior infection, timing of last SARS-CoV-2 result, and type of screening test. (2,3) We report a case of intentional lung transplant with asymptomatic SARS-CoV-2 infection on NP swab 1 week prior to transplant and negative lower respiratory tract testing 2 days prior to transplant. Our recipient patient has remained SARS-CoV-2 free at 3 weeks post-operation on serial testing. We propose that the timing of recent donor infection, even within 10 days of positive results, is less important as infectious status based on lower respiratory tract testing at the time of transplant. CONCLUSIONS: We demonstrate that donor lung donation following very recent asymptomatic SARS-CoV-2 infection can be done safely with good short-term outcomes. Reference #1: (1) 2020 Annual Data Report. Scientific Registry of Transplant Recipients https://srtr.transplant.hrsa.gov/annual_reports/2020/Lung.aspx Accessed [03/23/22] Reference #2: (2) Querrey, M, Kurihara, C, Manerikar, A, et al. Lung donation following SARS-CoV-2 infection. Am J Transplant. 2021;21: 4073– 4078. https://doi.org/10.1111/ajt.16777 Accessed [03/23/22] Reference #3: (3) Summary of Current Evidence and Information– Donor SARS-CoV-2 Testing & Organ Recovery from Donors with a History of COVID-19. Version Release Date: January 21, 2022. US Department of Health & Human Services. Organ Procurement and Transplantation Network https://optn.transplant.hrsa.gov/media/kkhnlwah/sars-cov-2-summary-of-evidence.pdf Accessed [03/23/22] DISCLOSURES: No relevant relationships by Thomas Meehan No relevant relationships by Jagadish Patil No relevant relationships by Huddleston Stephen