A Valved Expanded Polytetrafluoroethylene Conduit can Acquire Endothelium After Implantation.

We demonstrate histopathology, neointimal proliferation, and neo-endothelialization in an explanted valved expanded polytetrafluoroethylene (ePTFE) conduit 40 months postimplantation that was void of calcification and inflammation, confirmed by CD-31 positivity on immunohistochemistry. Grossly, there was no distortion with preserved leaflets and lack of calcification. Good biocompatibility, nonreactivity, and low antigenicity, combined with neointimal and endothelial layer generation within the conduit might explain the low infection rates and minimal thrombogenicity. These findings support the use of handmade, valved ePTFE conduits as an economically viable option as a right ventricle to pulmonary artery conduit.

Preparatory stage of interventional extracardiac Fontan.

The extracardiac Fontan can be completed as an interventional procedure when the preparatory stage for Fontan completion is performed at the time of the bidirectional Glenn operation. In this video tutorial, we present the technique for the preparatory stage of an interventional extracardiac Fontan. The interventional aspect offers the advantage of avoiding a redo sternotomy, which involves the risk of cardiac injury, injury to the mediastinal collaterals due to the single-ventricle physiology, the acquired deranged coagulation that may incur morbidity associated with sternal re-entry, and the problems pertinent to cardiopulmonary bypass and/or cardioplegic arrest in this subset of patients.

Completion of an interventional extracardiac Fontan.

The extracardiac Fontan can be completed via transcatheter perforation of the pericardial membrane created during the preparatory stage, thus establishing continuity between the inferior vena cava and the pulmonary artery. This step is followed by deployment of a covered stent to isolate the systemic and pulmonary circuits. The procedure avoids the morbidity associated with cardiac reoperation and is a safe option for patients who present late with prohibitive pulmonary artery pressures in whom primary Fontan completion may not be feasible.

Cerebral embolic shower secondary to BioGlue use in triple valve surgery.

Hemostasis is a crucial step in cardiac surgery which determines postoperative outcomes. Tissue sealants and glues are necessary to achieve hemostasis in situations where conventional methods are unsuccessful. BioGlue, a commonly used topical hemostatic agent, has been reported to cause systemic embolic complications. We report a case of cerebral embolic shower following the use of BioGlue for posterior aortic suture line bleeding in a 49-year-old lady who underwent triple valve surgery. This report brings to light a rare but devastating complication of BioGlue usage in the present era of complex aortic surgeries. We also postulate a mechanism for BioGlue embolization.

Oversized donor heart transplantation-clinical experience with an underestimated problem.

PURPOSE: Heart transplantation is the definitive treatment for end-stage heart failure. With respect to donor-recipient size matching, the problems with undersized heart transplantation have been widely discussed, but there is a paucity of information on oversized transplants due to the presumed advantage of large hearts. We intend to share our center's experience with oversized heart transplantation and its associated problems which would help to expand the knowledge on oversized cardiac allografts. METHODS: Patients who underwent isolated heart transplantation at our hospital between March 1, 2008, and March 1, 2020, were included. For adults, a donor-recipient predicted heart mass percentage difference exceeding 30% and for children, a donor-recipient weight ratio < 0.8 and > 2.0 was considered a mismatch. We collected data from the in-patient medical records and analyzed the in-hospital outcomes and survival post-transplant among various other parameters. RESULTS: Out of the 43 patients included in this study, 32 (74.4%) patients received a matched heart and 11 (25.6%) patients received oversized hearts. None of the patients received an undersized heart. The in-hospital mortality rate of oversized transplants was 18.2% whereas that of matched transplants was 9.4% (p = 0.432). The post-operative characteristics and 1-year survival were comparable between the groups. We encountered problems specific to oversizing in 5 of the 11 patients (45.4%) which are discussed. CONCLUSION: With the liberalization of donor criteria to overcome organ shortage, oversized heart transplantation poses certain unique challenges, which when efficiently managed offers acceptable outcomes.

Bilateral pneumothoraces secondary to an isolated midline zone 1 cervical stab injury.

Penetrating neck trauma, though rare, carries a high morbidity and mortality risk if not recognized promptly, due to the presence of vital neurovascular and airway elements within a closed compartment. We describe the unique presentation of a high zone 1 anterior midline cervical stab injury with bilateral large pneumothoraces and extensive pneumomediastinum. Understanding the respiratory mechanics and a high clinical suspicion will help to recognize such complications of tracheobronchial injuries and their timely management is key to salvage of these patients.

Surgical management of hydatid cyst of the interventricular septum.

Cardiac hydatidosis constitutes about 0.5-2% of all hydatid diseases. The interventricular septum is involved in 4% of cardiac hydatidosis cases. We demonstrate the surgical management of a large (76 x 66 mm) septal hydatid cyst in a 20-year-old man. The hydatid cyst was approached through a right ventriculotomy under cardiopulmonary bypass. The germinative membrane was removed in toto. The cavity was then obliterated to prevent recurrence of the cyst. The patient had an uneventful postoperative recovery. Histopathological examination confirmed the diagnosis of hydatid cyst. The patient remains asymptomatic with echocardiographic and magnetic resonance imaging evidence of freedom from disease at the 3-month follow-up.

Delayed recurrent spontaneous pneumothorax post-recovery from COVID-19 infection.

Pneumothorax, as a consequence of coronavirus disease 2019 (COVID-19) infection, has become an established entity but the delayed occurrence of pneumothorax, after recovery from the illness, is less commonly reported. We present a case of delayed recurrent spontaneous pneumothorax, presenting 4 weeks after recovery from COVID-19 in a previously healthy middle-aged gentleman, for which uniportal video-assisted thoracoscopic surgery (VATS) pleurectomy was performed, but the cause of pneumothorax could not be ascertained. This report brings to light, the importance of continued surveillance of COVID-19 survivors, the unpredictability of the disease process, and the challenges of thoracic surgery in this unique subset of patients.

Need of the hour: Structural heart intervention training for trainee surgeons in India.

Cardiothoracic surgery is on the verge of undergoing a major metamorphosis from being a conventional surgical branch to a technologically powered specialty with plenty of emphasis on learning the minimally invasive techniques, and a step forward is the advent of interventional techniques to treat most of the major cardiac ailments. Though the world of interventions has been traditionally dominated by the physicians, it is time we surgeons get ourselves actively involved in learning and performing these interventional procedures to stay relevant. This is not an attempt to disrupt the physician-surgeon harmony but to nurture a symbiotic relationship between the two specialties for advancement in cardiac science and technological growth, ultimately to benefit the patient. In this article, we discuss the Indian and the global scenario of the role of surgeons in the interventional arena and various training modalities available for surgeons to learn the art of cardiac interventions. We tried to understand the impediments in implementing interventional training for surgeons and also propose certain amendments to the way the future cardiothoracic surgeons are trained.

Veno-arterial extracorporeal membrane oxygenation: Special reference for use in 'post-cardiotomy cardiogenic shock' - A review with an Indian perspective.

The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve 'milieu intérieur'. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.

Anatomic classification of the right aortic arch.

The term right aortic arch is used for an aorta that arches over the right bronchus. Right aortic arch was classified into two types by Felson et al, based on branching patterns, with a proposed embryological explanation, and into three types by Shuford et al. Other anatomical variants of right aortic arch were described later, including isolated left brachiocephalic artery and aberrant left brachiocephalic artery. We have classified right aortic arch anatomy into 10 variants, supported by radiological evidence, and with reference to possible embryology. This classification will help in understanding the morphological basis for the formation of different types of right aortic arch and the course of the recurrent laryngeal nerve in such cases.

The aortic arch in tetralogy of Fallot: types of branching and clinical implications.

INTRODUCTION: Tetralogy of Fallot is the most common form of cyanotic CHD, with an incidence of 421 cases per million live births, constituting around 10% of CHD. Variations in aortic arch anatomy associated with tetralogy of Fallot, other than the incidence of right aortic arch (13-34%), are not frequently reported. A comprehensive analysis of a large number of tetralogy of Fallot cases is required to arrive at a compendious description of aortic arch anatomy. MATERIALS AND METHODS: All patients with a diagnosis of tetralogy of Fallot who had CT or MRI either pre or post procedures between 1 January 2010 and 31 December 2019 at our hospital were included in the study. Using radiology consultants' reports and analysis of individual images, we identified the various morphological patterns of aortic arches prevalent in these patients. RESULT: Out of 2684 patients who met the inclusion criteria, 1983 patients had left aortic arch (73.9%), 688 patients had right aortic arch (25.7%), four patients had cervical aortic arch (0.15%), eight patients had double aortic arch (0.3%), one patient had an aorto-pulmonary window (0.04%), and none of the patients had interrupted aortic arch. Sub-classification and clinical implications of the arch variations are described. CONCLUSION: Up to 10% of tetralogy of Fallot patients may have significant anatomical variations of aortic arch that would necessitate changes or additional steps in their surgical or interventional procedures.

Handmade trileaflet valved ePTFE right ventricle to pulmonary artery conduit - How do we do it?

Right ventricle to pulmonary artery conduits such as homografts and pre-manufactured synthetic conduits are widely employed in the present era of complex congenital cardiac surgeries for disorders involving right ventricle - pulmonary artery discontinuity and major coronary artery crossing the right ventricular outflow tract. The key drawback of homograft conduits is the need for reoperation to replace them as a result of degeneration over time or in cases where a child has outgrown the conduit and cost is a major drawback to using commercially available conduits. The advantages of expanded polytetrafluoroethylene are its long-term durability in terms of conduit calcification/degeneration and valve stenosis/regurgitation and its cost-effectiveness.  In this video presentation, we demonstrate the preparation and intraoperative usage of a handmade, trileaflet, valved polytetrafluoroethylene conduit in a case of double outlet right ventricle with valvular and subvalvular pulmonary stenosis and the left anterior descending artery crossing the right ventricular outflow tract. Our experience with this handmade conduit is close to 120 cases and we have seen excellent postoperative recovery and results. Our medium-term follow-up echocardiographic evidence shows conduit patency and preserved valve function.