Outcomes of Concomitant Maze Procedure in Tricuspid Repair for Severe Tricuspid Regurgitation.

BACKGROUND: We aimed to analyze the impact of concomitant Maze procedure on the clinical and rhythm outcomes, and echocardiographic parameters in tricuspid repair for patients with severe tricuspid regurgitation (TR) and persistent atrial fibrillation (AF). METHODS: Patients who had severe TR and persistent AF and underwent tricuspid valve (TV) repair were included in the study. Both primary TR and secondary TR were included in the current study. The study population was stratified according to Maze procedure. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE) at 15 years post-surgery. Propensity-score matching analyses was performed to adjust baseline differences. RESULTS: Three hundred seventy-one patients who underwent tricuspid repair for severe TR and persistent AF from 1994 to 2021 were included, and 198 patients (53.4%) underwent concomitant Maze procedure. The maze group showed 10-year sinus rhythm (SR) restoration rate of 55%. In the matched cohort, the maze group showed a lower cumulative incidence of cardiac death (4.6% vs. 14.4%, P = 0.131), readmission for heart failure (8.1% vs. 22.2%, P = 0.073), and MACCE (21.1% vs. 42.1%, P = 0.029) at 15 years compared to the non-maze group. Left atrial (LA) diameter significantly decreased in the maze group at 5 years (53.3 vs. 59.6 mm, P < 0.001) after surgery compared to preoperative level, and there was a significant difference in the change of LA diameter over time between the two groups (P = 0.013). CONCLUSION: The Maze procedure during TV repair in patients with severe TR and persistent AF showed acceptable SR rates and lower MACCE rates compared to those without the procedure, while also promoting LA reverse remodeling.

Evaluation of a novel collagen hemostatic matrix in a porcine heart and cardiac vessel injury model.

BACKGROUND: Flowable hemostatic agents may be more advantageous than nonflowable hemostats, as they have capability to cover irregular wound surfaces, fill deep lesions, and easily remove excess materials with irrigation. In this study, we evaluated the hemostatic efficacy of the collagen hemostatic matrix (CHM) compared to FloSeal® via incisions in the heart and cardiac vessels in a porcine model. METHODS: In each of the two female pigs, a total of two incisions were made in seven locations: right atrium (RA), right ventricle (RV), and cardiac vessels, such as the innominate vein (IV), superior vena cava (SVC), pulmonary artery (PA), coronary artery (CA), and aorta. Hemostatic agents were applied directly to the bleeding wounds. In certain location, one incision was treated with the CHM and the other with FloSeal®, and the time to hemostasis and the degree of bleeding of the two agents were assessed and compared. One week after surgery, the animals were sacrificed, and specimens were collected for histologic evaluation. RESULTS: Bleeding from the vessels with relatively low pressure (the IV, SVC, and RA) was controlled within 1-2 minutes using both a CHM and FloSeal®. Bleeding from the vessels with high blood pressure (the RV, PA, CA, and aorta) was controlled within 3-10 minutes with the CHM. However, hemostasis in the PA and CA was not achieved with FloSeal®. Histological analysis revealed that the use of both the CHM and FloSeal® resulted in foreign body reactions of similar severity. CONCLUSIONS: The hemostatic effect and safety of the CHM may be similar to that of FloSeal®. Further clinical studies must be conducted to validate our results.

Impact of Arteriovenous Fistula for Hemodialysis on Clinical Outcomes of Coronary Artery Bypass.

BACKGROUND: This study compared clinical outcomes between the use of in situ and free internal thoracic artery grafts in patients with upper extremity arteriovenous fistula who underwent coronary artery bypass. METHODS: We reviewed 85 hemodialysis-dependent patients with upper extremity arteriovenous fistula who underwent coronary artery bypass with internal thoracic artery grafts. The patients were categorized into 2 groups; 48 (56%) with in situ graft ipsilateral to the arteriovenous fistula (group I) and 37 (44%) with free grafts anastomosed to the ascending aorta (group F). The follow-up period was 32.0 ± 38.1 months. RESULTS: The estimated overall survival rates at 3, 5, and 10 years were 89.5%, 81.6%, and 53%, respectively, for all discharged patients. There was no significant difference in in-hospital mortality, all-cause mortality, and freedom from major adverse cardiac events between the groups, although cardiac-related deaths occurred only in group I (n = 5). Ipsilateral in situ grafts were associated with hemodialysis-induced chest pain (odds ratio, 5.528; 95% confidence interval, 1.079 to 28.333; p = 0.040). The incidence of dialysis-induced chest pain in patients with in situ noncomposite, in situ composite, and free grafts was 45.5%, 19.4%, and 5.7%, respectively (p = 0.009). CONCLUSIONS: Mortality was not influenced by using the internal thoracic artery as an ipsilateral in situ graft in patients with upper extremity arteriovenous fistula. However, there was a risk of increased incidence of hemodialysis-induced chest pain that is most likely related to coronary steal. A free internal thoracic artery graft would be an alternative option in these patients.

Non-intubated video-assisted thoracoscopic lung biopsy for interstitial lung disease: a single-center experience.

BACKGROUND: The mortality and morbidity associated with video-assisted thoracoscopic (VATS) lung biopsy for interstitial lung disease (ILD) are not negligible. We evaluated whether non-intubated VATS lung biopsy, which avoids intubation and general anesthesia, can be safely performed in ILD subjects. METHODS: This retrospective study compared the incidence of complications and surgical mortality between 25 consecutive intubated subjects and 10 non-intubated subjects (a total of 35 consecutive subjects) at a single institution. RESULTS: No major surgical complications or deaths were reported in either group, and non-intubated VATS biopsies were safely performed in subjects with relatively low carbon monoxide diffusing capacity (P=0.08) or poor American Society of Anesthesiologists physical status scores (ASA) (P=0.02). CONCLUSIONS: These preliminary results suggest that non-intubated VATS lung biopsy is a safe and feasible option in patients with ILD.

Perioperative Outcomes of Repeated Open Surgery on the Thoracic Aorta.

BACKGROUND: Repeated thoracic aorta repair is increasingly common. With the increase in hybrid procedures, determination of the best treatment strategy requires evaluation of the clinical outcomes of classic open surgery. METHODS: We retrospectively reviewed 119 patients (84 men and 35 women, aged 51.0 ± 16.7 years) with a history of open repair involving the thoracic aorta above the diaphragm. The patients underwent an average of 1.3 ± 0.8 surgeries (range: 1-8) on the thoracic aorta before the final operation. Clinical outcomes were evaluated on the basis of the need for emergency surgery, indications for surgery, pathologic causes, and other operative variables. RESULTS: Hospital mortality was 6.7% (n = 8). Postoperative bleeding occurred in 16% (n = 19). On multivariable analysis, emergency surgery (odds ratio [OR], 19.005; P = .003; 95% confidence interval [CI], 2.710-133.305) and cardiopulmonary bypass (CPB) time (OR, 1.562 per 30 minutes; P = .007; 95% CI, 1.126-2.165) were predictors of hospital death. Emergency surgery (OR, 4.105; P = .029; 95% CI, 1.157-14.567) and CPB time (OR, 1.189 per 30 minutes; P = .035; 95% CI, 1.012-1.396) were also associated with postoperative bleeding, in addition to surgery for an infectious cause (OR, 10.824; P = .010; 95% CI, 1.755-66.770). Estimated survival at 1, 5, and 7 years was 86.6%, 80.5%, and 78.2%, respectively. CONCLUSION: Despite the variety of preoperative conditions and operations performed, repeated open surgery for thoracic aorta repair can be performed with acceptable early and late outcomes.

Successful Treatment of a Giant Emphysematous Bulla with an Endobronchial Valve in a Patient with Contralateral Lung Cancer.

Patients with severe emphysema have a higher risk of developing lung cancer, and their surgical risk increases when emphysema is accompanied by a giant bulla. Here, we describe a patient who had an emphysematous giant bulla in the right upper lobe that was treated with an endobronchial valve placement. Subsequently, a cancerous lesion on the contralateral lung was successfully removed by lobectomy.

Impact of ablation duration on rhythm outcome after concomitant maze procedure using cryoablation in patients with persistent atrial fibrillation.

BACKGROUND: The aim of this study was to evaluate the impact of ablation duration during a maze procedure using a nitrous oxide-based cryosurgical system. METHODS: From May 2001 to December 2006, 256 consecutive patients who underwent a concomitant maze procedure using nitrous oxide-based cryoablation for chronic atrial fibrillation (AF) during cardiac surgery were enrolled. The ablation duration for each lesion was between 120 s at -60 °C in 140 patients (control group) and 160 s in 116 patients (long duration group). RESULTS: One in-hospital death occurred, and a permanent pacemaker was implanted in one patient (0.4%). At discharge, absence of AF was noted in 84.5% of the long duration group and in 87.1% of the control group. During follow up, patients in the long duration group achieved and maintained the absence of AF at a higher rate than the control patients (96% vs. 84% at 24 months, respectively: P = 0.008). Multivariable analysis identified long AF duration as the only independent predictor of AF recurrence. At late follow up, left atrial mechanical activity was less frequent in the control group than in the long duration group. The mean left atrial volume index was lower in the long duration group than in the control group. CONCLUSION: The modified cryomaze procedure is safe and effective. Ablation time plays an important role in achieving and maintaining the absence of AF. Long cryoablation duration is recommended for optimal cryomaze results.

The Absence of Atrial Contraction as a Predictor of Permanent Pacemaker Implantation after Maze Procedure with Cryoablation.

BACKGROUND: The absence of atrial contraction (AC) after the maze procedure has been reported to cause subsequent annular dilatation and to increase the risk of embolic stroke. We hypothesized that the lack of AC could increase the risk of permanent pacemaker (PPM) implantation in patients undergoing the maze procedure. METHODS: In 376 consecutive patients who had undergone a cryo-maze procedure and combined valve operation, recovery of AC was assessed at baseline and at immediate (≤2 weeks), early (≤1 year, 4.6±3.8 months), and late (>1 year, 3.5±1.1 years) postoperative stages. RESULTS: With a median follow-up of 53 months, 10 patients underwent PPM implantation. Seven PPM implants were for sinus node dysfunction (pauses of 9.6±2.4 seconds), one was for marked sinus bradycardia, and two were for advanced/complete atrioventricular block. The median (interquartile range) time to PPM implantation was 13.8 (0.5-68.2) months. Our time-varying covariate Cox models showed that the absence of AC was a risk factor for PPM implantation (hazard ratio, 11.92; 95% confidence interval, 2.52 to 56.45; p=0.002). CONCLUSION: The absence of AC may be associated with a subsequent risk of PPM implantation.

Right Aortic Arch with a Retroesophageal Left Subclavian Artery and an Anomalous Origin of the Pulmonary Artery from the Aorta.

We report the case of a newborn with a rare anatomic variation: a right aortic arch with a retroesophageal left subclavian artery and an anomalous origin of the pulmonary artery from the aorta. This variation was diagnosed using echocardiography and computed tomography, and we treated the condition surgically.