"The non-ischemic repair" as a safe alternative method for repair of anterior post-infarction VSD.

Patient's myocardium with post-infarction ventricular septum defect (VSD) is characterized by severe dysfunction. The "additive ischemia" caused by the operating process of cross-clamp ischemia and reperfusion injury, has a significant aggravation to the myocardium and overall negative impact to patient's outcome. We present a useful, safe and advantageous methodology in order to abolish "the toxic phase" of ischemia-reperfusion which is adopted by most as the "classic repair method" of myocardial protection. This abolition is in our opinion, particularly beneficial in order to reverse postoperatively the Low Cardiac Output Syndrome (LOS) and achieve better short and long term results. By using this method we avoid the aortic occlusion, the use of systematic hypothermia and any cardioplegic arrest. Furthermore, the total cardio-pulmonary bypass (CPB) time is significantly reduced, tissue debridement and stitching is much easier and safer. We think the method is applicable for every anterior and apical case of post-infarction septum rupture. After application of method in 3 patients with anterior post-myocardial infarction VSD, we are convinced that the patient will have a better postoperative haemodynamic condition and therefore a better outcome.

Surgical management of congenital heart disease: evaluation according to the Aristotle score.

OBJECTIVE: The Aristotle basic complexity (ABC) score (1.5-15 points) is the sum of potentials for early mortality, morbidity and anticipated surgical technique difficulty. The Aristotle comprehensive complexity (ACC) score (1.5-25 points) is the sum of ABC score and patient-adjusted complexity score; it comprises six complexity levels. We used the ACC score to evaluate quality in surgical management of congenital heart disease. METHODS: Procedures performed in year 2002 and 2007 were analysed. Proportion of procedures requiring at least 1 week of stay in the intensive care unit was chosen as the marker of morbidity. We adopted threshold duration of 120 min for cardio-pulmonary bypass (CPB) cases and the same duration for operations without CPB as surrogate of surgical technical difficulty. The ACC scores were correlated to mortality, morbidity and technical difficulty. RESULTS: This study included 758 patients who underwent 787 primary procedures. The mean ABC and ACC scores amounted to 7.61+/-2.46 and 9.51+/-3.84. Early mortality was 3.05% (24/787), 95% confidence interval (CI): 1.97-4.51%. Zero at ACC levels 1 and 2, it increased from 1.2% (2/161) for level 3 up to 22.2% (2/9) for level 6. Morbidity index was evaluated at 25.9% (204/787), 95% CI: 22.9-29.1%. 1.9% at level 1, it escalated up to 77.8% at level 6. Index of technique difficulty was estimated at 35.2% (277/787), 95% CI: 31.8-38.6%, ranging from 4.8% for level 1 to 66.7% for level 6. A high correlation was found between the ACC scores and mortality, indices of morbidity and technique difficulty, Spearman's correlation coefficient r being 0.9856, 1 and 0.9429, respectively. Mortality (p=0.037) and morbidity (p=0.041) were lower in year 2007 than in 2002 with ABC (p=0.18) and ACC (p=0.37) surgical performance being not significantly different. CONCLUSIONS: The Aristotle score is still under development. Morbidity evaluation should be ideally based on observed postoperative complications; estimation of surgical technical difficulty chosen in this study may not be generalised. Nevertheless, the actual Aristotle comprehensive complexity score, as evaluated in its three components, accurately determined the outcome of surgical management of congenital heart disease. It appears to be an adequate tool to evaluate quality in paediatric cardiac surgery, over time.

Repair of injured right inferior pulmonary vein during mitral valve replacement.

During mitral valve surgery right pulmonary veins injury, subsequent to excessive traction (for better exposure of the mitral apparatus), is often unavoidable. This is more likely in patients with small left atrium. This common complication may cause severe intraoperative bleeding, while its surgical repair may lead to complications such as late stenosis or obstruction of the pulmonary veins. This injury should be early detected, before left atriotomy closing, and it is suggested to be repaired using a patch so as to avoid any possible late constriction.We describe a case -to our knowledge, the first reported in the literature- of intraoperatively injured right inferior pulmonary vein in a patient who underwent mitral valve replacement. As outlined we propose that the ostium of the right inferior pulmonary vein can be repaired by using autologous pericardial patch, incorporated in the completion of left atriotomy closure.

Survival after sequential mechanical complications of acute myocardial infarction, complicated with heparin-induced thrombocytopenia and multiple organ failure: report of a case.

BACKGROUND: Ventricular wall rupture and acute mitral regurgitation due to papillary muscle rupture post-acute myocardial infarction are rare and dramatic mechanical complications. The operative mortality of both complications remains extremely high but this is the only treatment which has greatly improved the prognosis. CASE PRESENTATION: We describe the course of a patient, who survived after left ventricular free wall rupture two days post-acute myocardial infarction. He underwent left ventricular rupture repair plus two coronary artery bypass grafting. On the fifth postoperative day he developed papillary muscle rupture and acute mitral valve regurgitation. He was reoperated as an emergency case for mitral valve replacement. The patient sustained numerous complications, such as renal failure, heparin-induced thrombocytopenia, sepsis, acute respiratory distress syndrome, and multiple organ failure. He was on continuous venous-venous hemofiltration for one week and underwent a tracheostomy on the ninth postoperative day. He remained on a ventilator for three weeks. The patient survived, was discharged home after six weeks, and remains in very good condition on follow-up so far. CONCLUSION: The operative mortality of both complications remains high but this is the only treatment which improves the prognosis. Surviving both events is rare and few cases have been reported in the literature. This case highlights the necessity of careful echocardiographic examination in any patient presented with post-myocardial infarction new onset of hemodynamic instability. Identification of a single site of rupture does not eliminate the possibility of additional ruptures in the papillary muscle and intraventricular septum, and transesophageal echocardiography should be used to search for these entities. Although repair of each of these complications carries a high mortality, failure to address them will almost certainly result in death. Using standard surgical techniques, including preoperative intraaortic balloon pump insertion and careful postoperative management, successful outcome is possible.

Is blood cardioplegia superior to crystalloid cardioplegia?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether blood cardioplegia is clinically superior to crystalloid cardioplegia for myocardial protection. Altogether 501 papers were identified. We selected 22 papers that represented the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This is a difficult topic to review, as the techniques studied in the many trials performed vary widely. Factors which may vary include warm or cold blood cardioplegia, antegrade and retrograde administration, systemic hypothermia or normothermia, topical heart cooling, high and low potassium solutions, 'hot shots', warm induction, volume of cardioplegia, patient factors and bypass times. However, three papers stand out. The meta-analysis of 34 randomised trials by Prof Fremes (2006) found a significantly lower incidence of low output syndrome (LOS) and CK-MB release with blood cardioplegia. He found no differences in myocardial infarction or mortality. This meta-analysis was confounded, however, by the fact that he was unable to extract data on LOS and CK-MB from the two largest trials which contributed over half the patients in his paper and are significantly larger than all other studies. The first paper by Ovrum (2006) randomised 1440 patients to antegrade cold blood or crystalloid and found no clinical differences, and the second paper by Martin (1994) of 1001 patients compared warm blood to cold crystalloid but the study had to be stopped due to a high incidence of neurological events in the warm blood group. We reviewed a further 18 randomised trials reporting over 50 patients. Of these, 10 reported some statistically significant clinical outcomes in favour of blood cardioplegia and five reported statistically significant differences in enzyme release in favour of blood cardioplegia. A recent survey of UK practice found that 56% of surgeons use cold blood cardioplegia, 14% use warm blood cardioplegia, 14% use crystalloid cardioplegia, 21% use retrograde infusion and 16% do not use any cardioplegia. The papers presented in our review support most of these practices!

What is the patency of the gastroepiploic artery when used for coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was to investigate the patency of the gastroepiploic artery when used for coronary artery bypass grafting. Altogether 304 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concluded that the right gastroepiploic artery has been found to have a good short- and long-term patency when anastomosed to the right coronary artery. Long-term patency is 80-90% at 5 years and around 62% at 10 years. Abdominal complications are low but they do occur. Anastomoses of the gastroepiploic artery to the left anterior descending artery perform much more poorly and should be avoided if possible. The long-term patency of the gastroepiploic artery seems to be similar to that of the saphenous vein.

Is a stentless aortic valve superior to conventional bioprosthetic valves for aortic valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether a stentless valve is superior to conventional stented valves when tissue aortic valve replacement is performed. Altogether more than 515 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that stentless valves allow a larger effective orifice area valve to be implanted with a lower mean and peak aortic gradient postoperatively. At six months several studies and a meta-analysis have shown superior left ventricular mass regression in the stentless valve groups. However, by 12 months the stented valve groups catch up in terms of mass regression and this significance disappears. So the 'eminent speaker from the floor', was right with his statement, that there have been no definitively proven benefits for stentless valves.

What is the patency of the short saphenous vein when used for coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was what the patency of the short saphenous vein is, when used for coronary artery bypass grafting. Altogether 347 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that small reports give a two-year patency of 77% and a six-year patency of 65% and duplex studies show that the short saphenous vein may be from 2.8 mm to 4.2 mm in diameter. However, caution should be applied when considering these patency rates as they are derived from individual studies of <40 patients. The lesser saphenous vein may be considered as an alternative to brachial or cephalic vein in patients with unsuitable long saphenous vein, and unsuitable mammary, radial or gastroepiploic arteries.