Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery on minimal invasive extracorporeal circulation; A prospective randomized study.

INTRODUCTION: Individualized heparin and protamine management is increasingly used as a strategy to reduce coagulation activation and bleeding complications. While it is associated with increased heparin requirements during Cardiopulmonary Bypass (CPB), the impact on protamine administration remains controversial. We aim to investigate the effect of heparin level-guided monitoring on protamine dosing during cardiac surgery where low-anticoagulation protocols are implemented. METHODS: This is a prospective, randomized, controlled trial. A total of 132 patients undergoing elective full-spectrum cardiac surgery with Minimal Invasive Extracorporeal Circulation (MiECC) were recruited. All patients were managed by the same anaesthetic, surgical and perfusion team. Patients were randomly allocated in two groups; the individualized heparin-protamine titration (IHPT) group and the conventional heparinization and reversal group by using ACT (cACT) with a 0.75:1, protamine: heparin ratio. Titration was accomplished with the Hepcon HMS Plus (Medtronic, Minneapolis, MN) system. The primary outcome of the study was the total protamine dose used. Secondary outcomes comprised of the total heparin dose, the percentage of patients achieving target ACT, 24-h transfusion requirements, postoperative bleeding, duration of mechanical ventilation, major morbidity and length of hospital stay. Patients in each group were divided in two subgroups according to the target ACT; those operated for coronary artery bypass grafting (CABG) using a target ACT >300 s and the rest (non-CABG) patients operated with a target ACT >400 s, respectively. RESULTS: Protamine requirements were significantly reduced when IHPT was implemented; CABG (118 ± 24 mg vs 163 ± 61 mg; p < 0.001) and non-CABG cases (151 ± 46 mg vs 197 ± 45 mg; p < 0.001). Moreover, heparin requirements were significantly higher in the non-CABG subgroup managed with IHPT (34,539 ± 7658 IU vs 29,893 ± 9037 IU; p = 0.02). In overall, no significant differences were detected with respect to postoperative bleeding, transfusion of RBC or other blood products. CONCLUSIONS: Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery with MiECC implementing reduced anticoagulation strategy. TRIAL REGISTRATION: clinicaltrials.gov; NCT04215588.

Cor triatriatum dexter as an incidental finding due to symptomatic bicuspid aortic valve stenosis.

Cor triatriatum is a rare congenital heart defect in which a thin, fibro-muscular membrane divides the left or right atrium into two chambers resulting in a triatrial heart. Subdivision of the left atrium named cor triatriatum sinister (CTS), is the more common form, whereas the right atrial equivalent called cor triatriatum dexter (CTD) is rarer. They account for up to 0.4% and 0.025% of the burden of congenital heart disease respectively. We present the case of CTD found incidentally with transthoracic echocardiography for a patient who underwent aortic valve replacement for symptomatic bicuspid aortic valve stenosis.

Efficacy of Early and Enhanced Respiratory Physiotherapy and Mobilization after On-Pump Cardiac Surgery: A Prospective Randomized Controlled Trial.

BACKGROUND: This randomized controlled trial aimed to investigate the influence of physical activity and respiratory physiotherapy on zero postoperative day on clinical, hemodynamic and respiratory parameters of patients undergoing cardiac surgeries under extracorporeal circulation. METHODS: 78 patients undergoing coronary artery bypass graft (CABG) or/and valvular heart disease surgeries were randomly assigned into an early and enhanced physiotherapy care group (EEPC group; n = 39) and a conventional physiotherapy care group (CPC group; n = 39). Treatment protocol for the EEPC group included ≤3 Mets of physical activity and respiratory physiotherapy on zero post-operative day and an extra physiotherapy session during the first three post-operative days, whereas the CPC group was treated with usual physiotherapy care after the first post-operative day. The length of hospital and intensive care unit (ICU) stay were set as the primary study outcomes, while pre- and post-intervention measurements were also performed to assess the oxymetric and hemodynamic influence of early mobilization and physiotherapy. RESULTS: Participants' mean age was 51.9 ± 13.8 years. Of them 48 (61.5%) underwent CABG. Baseline and peri-procedural characteristics did not differ between the two groups. The total duration of hospital and ICU stay were significantly higher in the CPC group compared to the EEPC group (8.1 ± 0.4 days versus 8.9 ± 0.6 days and 25.4 ± 3 h versus 23.2 ± 0.6 h, p < 0.001, respectively). Statistically significant differences in pre-intervention oxygen saturation, and post-intervention PO2 and lactate levels were also observed between the two groups (p = 0.022, 0.027 and 0.001, respectively). CONCLUSION: In on-pump cardiac surgery, early and enhanced post-procedural physical activity (≤3 METS) can prevent a prolonged ICU stay and decrease the duration of hospitalization while ameliorating post-operative hemodynamic and oxymetric parameters.

Acute obstruction of a mechanical aortic valve in a young woman: case report and review of the literature.

UNLABELLED: Acute aortic valve obstruction is a medical and surgical emergency necessitating intensive care unit admission. The differential diagnosis includes thrombosis, pannus formation or vegetations. The diagnosis should be obtained as soon as possible, with possible orientation towards the cause. Different diagnostic modalities exist nowadays. Notably, the transesophageal echocardiography (TEE) offers a diagnosis and a guide for management. Surgical treatment remains of choice despite growing evidence about a benefit of combined thrombolytic and anticoagulation line of management. LEARNING POINTS: Acute management and resuscitation of acute valvular obstruction.Differential diagnosis and role of echo in the diagnosis.Management options.

Repair of post-intubation tracheoesophageal fistulae through the left pre-sternocleidomastoid approach: a recent case series of 13 patients.

OBJECTIVE: Post-intubation tracheoesophageal fistula (TEF) is a late complication of tracheotomy, while membranous trachea laceration during percutaneous dilational tracheostomy is implicated in the generation of early post-tracheotomy TEF. Surgical repair is the only viable option for these patients and the technique of repair depends on a variety of factors. METHODS: Totally 13 patients (mean age: 54.1±12.6 years; male: 8) with post-intubation TEF were managed between 2007 and 2013. The diagnosis was always made through esophagoscopy followed by endoscopic gastrostomy and bronchoscopy for repositioning of the tracheal tube just above the carina. Repair of the fistula was made in all patients through a left pre-sternocleidomastoid incision followed by dissection of the fistulous tract, suturing of esophagus and trachea and interposition of the whole pedicled left sternocleidomastoid muscle (SCMM) between the two suture lines. RESULTS: Five out of the 13 procedures were performed in mechanically ventilated patients; 3 of them died from septic complications during the postoperative period while fistula recurred in 1 of those 3 patients due to extensive inflammation of the tracheal wall. The rest 8 patients underwent fistula repair after weaning from mechanical ventilation and the results of repair were excellent. The additional procedure of temporary T-tube insertion was obviated in one patient to manage extensive tracheomalacia. CONCLUSIONS: The left pre-sternocleidomastoid incision is an excellent access for the repair of a post-intubation TEF without tracheal resection. The interposition of the whole left pedicled SCMM between the suture lines of trachea and esophagus avoids fistula recurrence and offers the best chance for cure.

Who might benefit from early aspirin after coronary artery surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early administration of aspirin might optimize vein graft patency. More than 250 papers were found using the reported search, of which 4 new papers in addition to the previous 7 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. Early postoperative aspirin administered within 6 h following coronary artery bypass grafting (CABG) has been shown to be optimal for prevention of vein graft occlusion. Early aspirin has significant benefit in reducing vein graft occlusion, mortality, myocardial infarction, stroke, renal failure and bowel infarction. The efficacy of early postoperative aspirin on vein graft patency diminishes the later it is administered. It has optimal benefit at 6 h, some benefit at 24 h and no benefit after 48 h post CABG. ACC/AHA, EACTS and ACCP have issued guidelines recommending administration of early aspirin or an alternative (clopidogrel, ticlopidine and indobufen) at 6 h or soon after bleeding has settled as the standard of care for optimization of vein graft patency. The ACCP guideline has also suggested that optimal prevention of cardiovascular complication should have higher value than prevention of postoperative bleeding. Several randomized, controlled studies, including a meta-analysis, have shown that early administration of aspirin following CABG is not associated with increased blood loss or transfusion requirement. Postoperative bleeding has been identified as a significant reason for non administration of early aspirin in a prospective study. It is essential to define/quantify the postoperative blood loss that precludes administration of early aspirin. This will enhance prompt administration in some cases and guide judgement, especially in patients with high-risk factors for vein graft thrombosis. Administration at 6 h is the optimal time to give aspirin as long as bleeding has settled.

Successful surgical in situ treatment of prosthetic graft infection by staged procedure after Bentall operation and total aortic arch replacement.

We report a case of a 29-year-old Marfan patient who developed prosthetic graft infection 10 months after Bentall operation and successive replacement of the remaining ascending aorta and the entire aortic arch for acute aortic dissection. Instead of an aggressive high-risk aortic redo procedure with removal and replacement of the infected prosthetic graft we elected a staged graft-sparing surgical approach. After 18 months of close follow-up the patient is in good condition and free from infectious sequela. This case and our review of the literature suggest that open extensive disinfection followed by tissue flap coverage is highly effective in controlling thoracic aortic prosthetic graft infection and may be considered as first-line treatment in such high-risk aortic arch redo patients.

Ruptured saphenous vein graft aneurysm.

Ruptured saphenous vein graft (SVG) aneurysm is a rare source of significant morbidity and mortality. SVG is a common technique of coronary artery bypass grafting (CABG), but vein graft aneurysm and ruptured SVG aneurysm have not received the required attention as only few case reports exist. We present the case of a 50-year old man with ruptured vein graft aneurysm who had significant postoperative complications following surgery, and outline some preventive/management strategies.

Serum levels of matrix metalloproteinases -1,-2,-3 and -9 in thoracic aortic diseases and acute myocardial ischemia.

BACKGROUND: Matrix metalloproteinases (MMPs) constitute a family of zinc-dependent proteases (endopeptidases) whose catalytic action is the degradation of the extracellular matrix components. In addition, they play the major role in the degradation of collagen and in the process of tissue remodeling. The present clinical study investigated blood serum levels of metalloproteinases- 1, -2, -3 and -9 in patients with acute and chronic aortic dissection, thoracic aortic aneurysm and acute myocardial ischemia compared to healthy individuals. METHODS: The blood serum levels of MMP-1, -2, -3 and -9 were calculated in 31 patients with acute aortic dissection, 18 patients with chronic aortic dissection, 18 patients with aortic aneurysm and in 13 patients with acute myocardial ischemia, as well as in 15 healthy individuals who served as the control group. Serum MMP levels were measured by using an ELISA technique. RESULTS: There were significantly higher levels of MMP-3 in patients with acute myocardial ischemia as compared to acute aortic dissection (17.33 +/- 2.03 ng/ml versus 12.92 +/- 1.01 ng/ml, p < 0.05). Significantly lower levels of MMP-1 were found in healthy controls compared to all groups of patients (1.1 +/- 0.38 ng/ml versus 2.97 +/- 0.68 in acute aortic dissection, 3.09 +/- 0.98 in chronic dissection, 3.16 +/- 0.51 in thoracic aortic aneurysm and 4.58 +/- 1.04 in acute myocardial ischemia, p < 0.05). Higher levels of MMP-1 and MMP-3 were detected on males. There was a positive correlation with increasing age (r = 0.38, p < 0.05). In patients operated for acute type A aortic dissection, the levels of MMP-1, MMP-3 and MMP-9 increased immediately after surgery, while the levels of MMP-2 decrease. At 24 hours postoperatively, levels of MMP -1, -2 and -9 are almost equal to the preoperative ones. CONCLUSION: Measurement of serum MMP levels in thoracic aortic disease and acute myocardial ischemia is a simple and relatively rapid laboratory test that could be used as a biochemical indicator of aortic disease or acute myocardial ischemia, when evaluated in combination with imaging techniques.

A rare tumoral combination, synchronous lung adenocarcinoma and mantle cell lymphoma of the pleura.

BACKGROUND: Coexistence of adenocarcinoma and mantle cell lymphoma in the same or different anatomical sites is extremely rare. We present a case of incidental discovery of primary lung adenocarcinoma and mantle cell lymphoma involving the pleura, during an axillary thoracotomy performed for a benign condition. CASE PRESENTATION: A 73-year old male underwent bullectomy and apical pleurectomy for persistent pneumothorax. A bulla of the lung apex was resected en bloc with a scar-like lesion of the lung, which was located in proximity with the bulla origin, by a wide wedge resection. Histologic examination of the stripped-off parietal pleura and of the bullectomy specimen revealed the synchronous occurrence of two distinct neoplasms, a lymphoma infiltrating the pleura and a primary, early lung adenocarcinoma. Immunohistochemical and fluorescence in situ hybridization assays were performed. The morphologic, immunophenotypic and genetic findings supported the diagnosis of primary lung adenocarcinoma (papillary subtype) coexisting with a non-Hodgkin, B-cell lineage, mantle cell lymphoma involving both, visceral and parietal pleura and without mediastinal lymph node involvement. The neoplastic lymphoid cells showed the characteristic immunophenotype of mantle cell lymphoma and the translocation t(11;14). The patient received 6 cycles of chemotherapy, while pulmonary function tests precluded further pulmonary parenchyma resection (lobectomy) for his adenocarcinoma. The patient is alive and without clinical and radiological findings of local recurrence or distant relapse from both tumors 14 months later. CONCLUSION: This is the first reported case of a rare tumoral combination involving simultaneously lung and pleura, emphasizing at the incidental discovery of the two coexisting neoplasms during a procedure performed for a benign condition. Any tissue specimen resected during operations performed for non-tumoral conditions should be routinely sent for pathologic examination.