Impact of concomitant replacement of the ascending aorta in patients undergoing aortic valve replacement on operative morbidity and mortality.

OBJECTIVES: The aim of this study was to evaluate the impact of concomitant ascending aortic replacement on operative morbidity and mortality in patients undergoing aortic valve replacement (AVR). METHODS: We retrospectively analysed our institutional database for all patients undergoing elective isolated AVR and AVR with concomitant replacement of the ascending aorta between January 2009 and May 2020. Patients undergoing surgery for infective endocarditis or requiring hypothermic circulatory arrest were excluded. A 3:1 propensity matching was performed for 688 patients to compare isolated AVR (120 patients) with AVR + ascending aortic replacement (40 patients). RESULTS: There were significant differences in median cardiopulmonary bypass (CPB) time [92.5 (75-114) vs 118.5 (104-131) min; P < 0.001], median aortic cross-clamp time [65.0 (51.5-78.5) vs 84.5 (77-94) min; P < 0.001] and median intensive care unit stay [1 (1-3) vs 2 (1-6) days; P < 0.01]. There was no significant difference in the use of intraoperative and postoperative blood products, re-exploration for bleeding, postoperative atrial fibrillation, acute renal failure, incidence of stroke, perioperative myocardial infarction and 30-day mortality. CONCLUSIONS: Concomitant replacement of the ascending aorta significantly prolongs CPB and aortic clamp times but does not increase operative morbidity and mortality. Therefore, replacement of a dilated ascending aorta appears to be the most durable and safest treatment option in patients undergoing AVR with an aneurysmatic ascending aorta.

Lower hemisternotomy: infrequently used but versatile.

BACKGROUND: A lower hemisternotomy is an infrequently used approach in cardiac surgery. This single center report evaluates applicability and clinical outcomes of procedures performed through a lower hemisternotomy. METHODS: The institutional database was reviewed. From 2014 to 2019, 55 consecutive patients had undergone minimally invasive procedures through a lower hemisternotomy (median follow-up 34 months). Demographic as well as outcome data were retrieved from our prospectively maintained institutional database. RESULTS: Performed procedures included mitral and tricuspid repairs, aortic valve replacement as well as coronary artery bypass grafting. The median patient age was 72 years. Out of the 55 patients, 55% were male. Predominantly mitral valve procedures (11 isolated, 30 combined) had been performed. Mitral valve procedures (N.=41) consisted of 36 repairs and 5 replacements. Repair rate for degenerative mitral insufficiency was 97.6%. Median EuroScore II was 3.4% (2.1-6.0). Median cross-clamp time was 67 (44-99) min. Median procedural length was 169 (138-201) min. Reoperation rate for bleeding was 1.8%. Major vascular complications occurred in two patients. Freedom from valve related reoperation was 96.1% during follow-up. Thirty-day mortality and overall mortality during follow-up was 3.6% and 10.9%. CONCLUSIONS: In properly selected cases the lower hemisternotomy allows for a variety of cardiac procedures. It permits central aortic cannulation and a direct vision of intracardiac structures and therefore should be kept in mind as an alternative minimally invasive approach.

Aortic Root Pressurizing Device: Aortic Valve Evaluation During Cardioplegic Arrest.

PURPOSE: The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. DESCRIPTION: This polyoxymethylene or polyether ether ketone-based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. EVALUATION: The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. CONCLUSIONS: The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.

Comparison of the conventional frozen elephant trunk implantation technique with a modified implantation technique in zone 1.

OBJECTIVES: The aim of the study was to compare the conventional frozen elephant trunk implantation technique with a modified implantation technique with an aortic anastomosis in zone 1 and extra-anatomic revascularization of the left subclavian artery during reperfusion. METHODS: Between May 2014 and March 2018, 40 patients (26 male; mean age 60.2 ± 11.2 years) underwent complete aortic arch replacement with the Thoraflex Hybrid prosthesis™ (Vascutek, Inchinnan, Scotland) at our institution. Seventeen patients underwent conventional arch replacement (group 1) and 23 patients the modified procedure (group 2). Indication for arch replacement included all types of acute and chronic diseases. RESULTS: Cardiopulmonary bypass time (213.1 ± 53.5 vs 243.8 ± 67.0 min, P = 0.13) and aortic cross-clamp time (114.4 ± 40.7 vs 117.3 ± 56.6 min, P = 0.86) did not differ significantly between group 1 and 2. There was a trend towards a shorter circulatory arrest time (50.72 ± 9.6 vs 44.7 ± 15.5 min; P = 0.20) in group 2. Perioperative mortality was 10% (5.9% vs 13%; P = 0.62). Stroke occurred in 10% (5.9% vs 13%; P = 0.62) of patients. Spinal cord injury occurred in 7.5% of patients (11.8% vs 4.3% P = 0.57). Due to the a proximal aortic anastomosis, there was a significantly shorter coverage of the descending aorta with the prosthesis ending at vertebral level Th7.5 (6.75-8) in group 1 versus Th6.0 (5.0-6.0) in group 2 (P-value = 0.004). CONCLUSIONS: Implantation of the frozen elephant trunk prosthesis in zone 1 allows for a more proximal aortic anastomosis that could make the procedure more feasible especially in patients with difficult anatomies or in an acute setting.

Persistent Left Superior Vena Cava Draining Into the Left Atrium Found During Bypass Operation.

We report the case of a 72-year-old woman who underwent urgent coronary bypass grafting (CABG). Intraoperatively a persistent left superior vena cava (PLSVC) draining into the left atrium was detected. Because of the resulting right-to-left shunt volume even after complete drainage and collapse of the right atrium, the heart was still ejecting in the absence of significant aortic insufficiency. Thorough examination revealed a PLSVC draining into the left atrium. After ligation of the PLSVC, the CABG could be performed as planned.

The accuracy of the Vigileo/FloTrac continuous cardiac output monitor.

OBJECTIVE: The Vigileo/FloTrac system (software version 1.01; Edwards Lifesciences, Irvine, CA) determines cardiac output, without calibration, by analysis of the arterial pulse wave. To assess the accuracy of the Vigileo/FloTrac system, it was compared with the pulmonary artery catheter bolus thermodilution method as the current standard method. The study design was prospective and observer blinded. SETTING: A single university hospital. PARTICIPANTS: Thirty elective coronary artery bypass graft surgery patients. No special interventions were done to the participants. MEASUREMENTS AND MAIN RESULTS: After approval by the ethics committee and with written informed consent, synchronized measurements using both methods were made at 7 predefined time points, intraoperatively and postoperatively, producing 192 data pairs for evaluation. The statistical evaluation was performed by using the Bland-Altman method of analysis. In addition, a +/-20% and +/-30% deviation from the pulmonary artery catheter were evaluated (20% criteria and 30% criteria). In total, 46% of measurements did not fulfill the 20% criteria; 26% were outside the 30% limits. The Bland-Altman analysis for all time points showed that 95% of all differences between both methods were within a range between -2.2 and +3.1 L/min. Regression analysis revealed low correlation values at all time points. CONCLUSION: The described deviation from the standard must be regarded according to the user's needs. Considering the 30% limits of agreement, the Vigileo system (version 1.01) seems sufficiently accurate; applying the 20% criteria, it is not.