Severe aortic insufficiency-induced cardiogenic shock treated with left atrial VA-ECMO and emergent valve-in-valve TAVR.

Conventional venoarterial extracorporeal membrane oxygenation (VA-ECMO) places a functional afterload burden on the left ventricle. In the setting of acute severe aortic insufficiency-induced cardiogenic shock, the utility of VA-ECMO in combination with a failing valve may result in catastrophic haemodynamic consequences. This challenge is compounded when the culprit is a failing surgical bioprosthetic valve. We present a case of severe rapid-onset bioprosthetic aortic insufficiency-induced cardiogenic shock successfully resuscitated with left atrial VA-ECMO promptly followed by emergent percutaneous valve-in-valve transaortic valve replacement. We discuss the logistics, implications, and associated haemodynamic manifestations in utilizing this strategy for such disease processes.

Even Mended Hearts Can Break: Takotsubo After Transcatheter Mitral Valve Replacement.

Transcatheter mitral valve replacement represents an innovative interventional technique for implanting a new mitral prosthesis without surgery. Although technical success is high, post-procedural issues and complications may occur. This report emphasizes the importance of considering alternative cardiac pathologies that may be seen post valvular interventions. (Level of Difficulty: Beginner.).

Elective Thoracoscopic Maze with Venoarterial Extracorporeal Life Support.

This case report describes the intraoperative use of extracorporeal life support (ECLS) for an elective thoracoscopic maze procedure in which the patient could not tolerate one-lung ventilation because of hypoxia. Potential pitfalls associated with the anesthetic management of elective intraoperative ECLS include managing native cardiac ejection and ECLS flows to provide optimal oxygenation and cardiac output. Particular attention must be paid to cardiac and respiratory physiology when ECLS is used in a patient with normal cardiac function.

Outcomes in the current surgical era following operative repair of acute Type A aortic dissection in the elderly: a single-institutional experience.

OBJECTIVES: We reviewed our single-centre experience with emergent operative repair of Stanford Type A aortic dissections, with particular attention to outcomes in the elderly. METHODS: Consecutive adult patients undergoing emergent operative repair of acute Type A aortic dissections between February 2004 and December 2011 at a single institution were identified. Patients were stratified into elderly (≥ 70 years) and control cohorts (<70 years). Kaplan-Meier analysis was used to evaluate survival. RESULTS: A total of 117 patients undergoing emergent repair of Type A aortic dissection were identified during the study period, including 31 (26.5%) elderly and 86 (73.5%) control patients. The mean age in the elderly cohort was 78.0 ± 4.7 years, with 41.9% (13 of 31) being 80 years or older. The elderly and control groups were well matched with regard to preoperative comorbidities (each P>0.05) and the presence of malperfusion at presentation (elderly: 19.4 vs controls: 27.9%, P = 0.35). The most common site of tear involved the proximal ascending aorta (elderly: 83.9 vs controls: 84.9%), with fewer cases affecting the aortic arch (12.9 vs 14.0%; P = 0.75). Operative data, including cardiopulmonary bypass and aortic cross-clamp time, concomitant aortic valve procedures and arch replacement were also similar between cohorts. Fewer elderly patients underwent hypothermic circulatory arrest (67.7 vs 90.7%, P = 0.002). Overall survival to discharge was 87.2% (n = 102), with no difference in the elderly (83.9%; n = 26) vs controls (88.4%; n = 76; P = 0.52). The 30-day (elderly: 82.8 vs controls: 86.2%), 90-day (elderly: 79.0 vs controls: 84.8%) and 1-year (elderly: 75.4 vs controls: 84.8%) survivals were also comparable. CONCLUSIONS: Excellent operative outcomes can be achieved in elderly patients undergoing emergent repair of Type A aortic dissections. Advanced patient age should therefore not serve as an absolute contraindication to operative repair in this high-risk cohort.

Does preoperative hyponatremia potentiate the effects of left ventricular dysfunction on mortality after cardiac surgery?

OBJECTIVE: Left ventricular dysfunction and preoperative hyponatremia are associated with adverse outcomes after cardiac surgery. However, the interactions between them are unknown. Thus, we evaluated the interaction of low left ventricular ejection fraction (<40%) and preoperative hyponatremia (Na <135 mEq/L) with morbidity and mortality after cardiac surgery. METHODS: The interaction of hyponatremia and ejection fraction with hospital complications, length of stay, and mortality was analyzed using logistic and Cox regression analysis in 2247 patients who underwent cardiac surgery between 2005 and 2008 at The Ohio State University Wexner Medical Center. RESULTS: Of the patients, 68.5% had normal ejection fraction. Hyponatremia was present in 18% of patients with normal ejection fraction and 35% of patients with low ejection fraction. Hyponatremic patients had higher rates of New York Heart Association class III and IV, more comorbidities, and higher Society of Thoracic Surgeons score and European System for Cardiac Operative Risk Evaluation irrespectively of their ejection fraction. The correlation between preoperative sodium and ejection fraction was weak (r(2) = 0.04). Hyponatremia increased the rate of postoperative complications and hospital stay, and decreased 1- and 3-year survivals in patients with both normal and low ejection fraction. Hyponatremia was independently associated with longer hospital stay for normal ejection fraction (multiplier, 1.18; confidence interval, 1.09-1.27; P < .001) and low ejection fraction (multiplier, 1.10; confidence interval, 1.0-1.21; P = .05), increased need for dialysis for normal ejection fraction (odds ratio, 2.16; confidence interval, 1.08-4.32; P = .03), and increased risk of mortality for normal ejection fraction (hazard ratio, 1.56; confidence interval, 1.20-2.05; P = .001), but not for patients with low ejection fraction (hazard ratio, 1.21; confidence interval, 0.89-1.65; P = .21). CONCLUSIONS: Hyponatremia is more common in patients with low ejection fraction. Although preoperative hyponatremia is independently associated with adverse outcomes in patients with normal ejection fraction, an association with adverse outcomes in patients with low ejection fraction was not demonstrated.

Postoperative hyponatremia predicts an increase in mortality and in-hospital complications after cardiac surgery.

BACKGROUND: The association between postoperative hyponatremia (Na < 135 mEq/L) and outcomes after cardiac surgery has not been established. We studied the prevalence of postoperative hyponatremia and its effects on outcomes after cardiac surgery. STUDY DESIGN: We studied 4,850 patients who underwent cardiac surgery from 2002 to 2008. We used multivariable logistic and Cox regression analysis to study the association between postoperative hyponatremia and mortality, length of hospital stay (LOS), and complications. RESULTS: Postoperative hyponatremia was present in 59%. Hyponatremic patients were older (mean ± SD, 62 ± 13 vs 61 ± 14 years, p = 0.001), had lower left ventricle ejection fraction (mean ± SD, 44% ± 16% vs 48% ± 13%, p < 0.001), higher mean pulmonary artery pressures (mean ± SD, 30 ± 11 vs 27 ± 9 mmHg, p < 0.001), lower glomerular filtration rate (mean ± SD, 72 ± 29 vs 74 ± 27 mg/min/1.73 m(2), p = 0.01), higher EuroSCORE (median, 15% vs 6%, p < 0.001), higher New York Heart Association class IV (31% vs 26%, p = 0.002), prevalence of COPD (23% vs 14%, p < 0.001), and peripheral vascular disease (16% vs 12%, p < 0.001). Hyponatremia increased overall (24% vs 18.2%, p < 0.001) and late mortality (18.6% vs 13.9%, p < 0.001) and length of stay (LOS; 11 vs 7 days, p < 0.001). Mortality increased with the severity of the hyponatremia. After adjusting for baseline and procedure variables, postoperative hyponatremia was associated with increase in mortality (hazard ratio 1.22, 95% CI 1.06-1.4, p = 0.004), LOS (multiplier 1.34, 95% CI 1.22-1.49, p < 0.001), infectious (odds ratio [OR] 2.32, 95% CI 1.48-3.62, p < 0.001), pulmonary (OR 1.82, 95% CI 1.49-2.21, p < 0.001), and renal failure complications (OR 2.46, 95% CI 1.58-3.81, p < 0.001) and need for dialysis (OR 3.66, 95% CI 1.72-7.79, p = 0.001). CONCLUSIONS: Hyponatremia is common after cardiac surgery and is an independent predictor of increased mortality, length of hospital stay, and postoperative complications.

Preoperative hyponatremia predicts outcomes after cardiac surgery.

OBJECTIVE: To study the effect of preoperative hyponatremia (Na <135 mEq/L) on outcomes after cardiac surgery. METHODS: From 2002 to 2008, 4370 patients had cardiac surgery at our institution (CABG in 2238, valve in 597, CABG valve in 537, other in 998). The institution electronic medical records, STS database, and Social Security death index data were analyzed. The association of hyponatremia with mortality, hospital length of stay (LOS), and complications was analyzed using regression analysis. RESULTS: Prevalence of hyponatremia was 21%. Patients with preoperative hyponatremia had lower left ventricular ejection fraction (39% ± 17% versus 46% ± 14%, P < 0.001) and glomerular filtration rate (69 ± 32 mg/min/1.73 m(2)versus 74 ± 27 mg/min/1.73 m(2), P < 0.001) and higher median EuroSCORE (19% versus 9%, P < 0.001), NYHA class 3-4 (77% versus 65%, P < 0.001), prevalence of chronic obstructive pulmonary disease (25% versus 18%, P < 0.001), and arteriopathy (20% versus 13%, P < 0.001). Hyponatremia was associated with increased early mortality (9% versus 4%, P < 0.001), late mortality (24% versus 16%, P < 0.001), and LOS (13 versus 8 d, P < 0.001). Mortality increased with the severity of hyponatremia. After adjusting for baseline and operative variables, hyponatremia was associated with increased hazard of mortality (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.14-1.52, P < 0.001), risk of early mortality (odds ratio [OR] 1.52, 95% CI 1.09-2.12, P < 0.001), late mortality (HR 1.37, 95% CI 1.16-1.62, P < 0.001), LOS (multiplier 1.26, 95% CI 1.15-1.39, P < 0.001), operative complications (OR 1.30, 95% CI 1.00-1.69, P = 0.051), and dialysis (OR 1.64, 95% CI 1.11-2.44, P = 0.013). CONCLUSIONS: Preoperative hyponatremia is common, especially in high-risk patients. It is an independent risk factor for mortality, prolonged hospitalization, and complications after cardiac surgery.

Interim results of the 5-box thoracoscopic maze procedure.

BACKGROUND: In accordance with the Cox-Maze paradigm, successful treatment of atrial fibrillation (AF) requires (1) complete posterior left atrial isolation, (2) elimination of corridors for perimitral reentry, (3) elimination of cardiac venous (superior vena cava and coronary sinus) arrhythmogenic foci, (4) complete autonomic denervation, and (5) occlusion or removal of the left atrial appendage. Using a totally thoracoscopic approach, isolation of all left atrial arrhythmogenic substrate is achieved through the creation of 5 discrete but contiguous compartments, thereby enabling unambiguous verification with bidirectional block. Since no previous closed-chest procedure incorporates all these end points, an update on patient outcomes is reported. METHODS: One hundred seventy-nine consecutive patients with antiarrhythmic drug-resistant AF (3 paroxysmal, 5 persistent, 171 longstanding persistent cases), known preoperatively for 5.7 (range 0.5 to 25) years, underwent the 5-box thoracoscopic Maze procedure. Only 1 patient suffered a serious procedural complication (sternotomy for pulmonary artery injury). Postoperative rhythm surveillance consisted of 1 week of continuous ambulatory monitoring at 3, 6, 13, and 24 months. Failure was defined as any tachyarrhythmia exceeding 30 seconds beyond the 3-month anniversary. RESULTS: Freedom from AF was observed in 137 of 142 patients at 3 months, 115 of 119 patients at 6 months, 75 of 78 patients at 13 months, and 24 of 25 patients at 24 months. Two patients remain in sinus rhythm on low-dose antiarrhythmia therapy. Warfarin is discontinued only after the first monitoring session confirms rhythm stability. CONCLUSIONS: Replication of the left atrial Cox-Maze lesion set through a totally thoracoscopic approach isolates virtually all arrhythmogenic substrate. Meticulous verification of compartment integrity allows for outcomes equivalent to the Cox-Maze benchmark.

Shortness of breath: pulmonary embolism, ischemic heart failure, or both? The role of concomitant surgery.

We present a case of a patient who underwent successful concomitant surgical management of his massive pulmonary embolism and severe multivessel coronary disease. His presentation with shortness of breath prompted a comprehensive evaluation, which revealed both problems. This experience emphasizes the importance of considering both problems, because treating one but not the other could be catastrophic.

Anterior wall viability and low ejection fraction predict functional improvement after CABG.

BACKGROUND: Absence of myocardial hyperenhancement on cardiac magnetic resonance imaging (CMR) predicts functional improvement after coronary artery bypass graft surgery (CABG). However, not all patients with absence of hyperenhancement improve their left ventricular ejection fraction (LVEF) after CABG. We sought to identify other characteristics associated with improvement in LVEF after CABG. METHODS: Preoperative CMR was obtained in 95 patients who underwent CABG from 2003 to 2007 at The Ohio State University Medical Center. Follow-up LVEF was assessed by echocardiogram between 3 wk and 2 y postoperatively (mean: 7±0.5 mo). Improvement in LVEF was defined as a postoperative increase in LVEF≥10%. CMR and clinical factors were analyzed for predictors of functional improvement. RESULTS: Mean age was 61±1 y with 79 males. LVEF improved from 28%±2% preoperatively, to 38%±2% postoperatively (P<0.0001). Forty-three patients improved their LVEF. Patients who improved their LVEF had a lower preoperative LVEF (P=0.0001) and higher anterior wall viability (P=0.03). Preoperative LVEF (odds ratio 0.89, 95% CI 0.83-0.95, P=0.001) and left ventricular end systolic volume index (odds ratio 0.97, 95% CI 0.95-0.99, P=0.015) were predictors of improvement in LVEF by multivariable logistic regression analysis. CONCLUSIONS: Recruitment of viable non functioning myocardium of the anterior wall is responsible for the improvement in ejection fraction. Low LVEF, non-remodeled left ventricle, and anterior wall viability predict improvement in ejection fraction after CABG. These criteria may help clinicians select patients who would benefit from surgical revascularization.

The five-box thoracoscopic maze procedure.

PURPOSE: Comprehensive treatment of atrial fibrillation requires both compartmentalization of the posterior left atrium and connecting ablations to the mitral annulus to interrupt perimitral macro reentry and to isolate the arrhythmogenic left atrial substrate. We present a new procedure that compartmentalizes virtually all arrhythmogenic anatomy etiologic in atrial fibrillation, enabling simple verification by demonstration of bidirectional block. DESCRIPTION: Through a totally thoracoscopic approach, complete dissection of the transverse sinus and exposure of the left atrial floor enables the creation of contiguous compartments connecting to the anterior mitral trigone and isolating the posterior left atrium. The result is a comprehensive electrophysiologic replication of the Cox Maze left atrial lesion pattern. EVALUATION: Each compartment is verified in real time using bidirectional block with a probe placed on the untreated atrium inside the compartment. CONCLUSIONS: Interruption of perimitral macro reentry in two perpendicularly oriented planes in a totally thoracoscopic procedure results in an operation with efficacy approximating the Cox Maze benchmark.

Factitious disorders and cardiothoracic surgery: the ongoing multidisciplinary challenges of a complex case.

Chronic factitious disorder, Munchausen's syndrome, can be challenging to manage-particularly when complaints and symptoms suggest medical or surgical emergencies. We present a patient whose problems have spanned many years and a great distance. Hopefully, with a greater awareness of this disease, as this patient continues to seek health care in many different hospitals, the implications of timely access to information, good histories and physical exams, and an index of suspicion can assist in potentially avoiding unnecessary, expensive, and invasive evaluations.

Long-term mechanical support for complex left ventricular postinfarct pseudoaneurysms.

Left ventricular free wall rupture can be a catastrophic problem. Although small lacerations can be managed with various techniques of primary closure, larger and more complex defects can be difficult to treat. We present and discuss 2 cases of chronic, complex ventricular pseudoaneurysms managed successfully with long-term mechanical support.

Toward a definitive, totally thoracoscopic procedure for atrial fibrillation.

PURPOSE: Evolution of anti-arrhythmia surgery beyond the Cox maze III has been hampered by the difficulty in implementing a complete lesion set in a truly minimally invasive approach. In this study, we introduce a true port-access procedure that addresses both autonomic and anatomic sources of atrial fibrillation, with real-time verification of all technical endpoints. DESCRIPTION: A total of 32 patients with persistent or longstanding persistent atrial fibrillation underwent the totally thoracoscopic anti-arrhythmia procedure incorporating pulmonary vein isolation, mapping of epicardial autonomics, extended linear ablations across critical segments of atrial substrate, and ligation of the left atrial appendage. All aspects of the procedure were confirmed with intraoperative electrophysiologic testing. EVALUATION: With 1 week of continuous rhythm surveillance at 3, 6, and 13 months postoperatively in all patients, 21 of 24 patients with 6-month follow-up are in sinus rhythm with no anti-arrhythmia medications. CONCLUSIONS: An anti-arrhythmia operation that is highly effective in patients with advanced forms of atrial fibrillation can be safely performed through a totally port-access approach.

Placement of long-term implantable ventricular assist devices without the use of cardiopulmonary bypass.

BACKGROUND: Implantation of ventricular assist devices for cardiac support is normally performed using cardiopulmonary bypass. Post-operative complications could be minimized by the placement of these devices without the use of cardiopulmonary bypass. METHODS: We hypothesize that left ventricular assist devices (LVADs), in selected patients, can be implanted safely off-pump. RESULTS: In 25 patients, LVADs were implanted off-pump (mean age 50 years; 64% male, 36% female; average left ventricular ejection fraction 15%). Pre-operatively 68% of patients were on inotropes, 25% had an intra-aortic ballon pump, and 44% had a previous sternotomy. Blood utilization intra- and post-operatively was relatively minimal with 1 re-exploration for bleeding. There were 3 deaths. CONCLUSIONS: We describe a technique for successful placement of a left ventricular assist device without the use of cardiopulmonary bypass.

Ascending aortic dissection: look again before you leap.

Advances in imaging technology can provide a potentially more accurate, precise, and timely diagnosis. However, false-positive results, particularly when acute aortic pathology is being considered, can lead to unnecessary interventions. We present a case of a computed tomography scan that was false-positive for aortic dissection and highlight the importance of confirmatory studies.

Intestinal ischemia complicating ascending aortic dissection: first things first.

Typically acute dissections of the ascending aorta are considered operative emergencies with delays in treatment potentially resulting in considerable morbidity and mortality. However, occasionally associated unstable or poorly defined problems (such as neurologic impairment or end-organ ischemia) may warrant further investigation and possible treatment to facilitate safe aortic repair. We present a case of acute ascending aortic dissection associated with an intra-abdominal vascular and enteric catastrophe that was successfully managed prior to aortic repair.

Transaortic delivery of the transmitral lesion in a complete maze procedure.

A 68-year-old hypertensive diabetic woman with chronic atrial fibrillation presented with progressive congestive symptomatology. She was diagnosed with severe aortic stenosis, moderate mitral regurgitation, and critical right coronary artery stenosis. In addition to coronary revascularization and bioprosthetic aortic valve replacement, she underwent a mitral valve repair and a complete cryoMaze procedure through a transaortic approach. This technique obviates a separate left atriotomy for the mitral repair and Maze procedure. It affords excellent exposure, while reducing cross clamp and cardiopulmonary bypass time as well as avoiding the potential sequelae of bleeding and traction injuries resulting from a left atriotomy.

Vacuum-assisted apical suction devices induce passive electrical changes consistent with myocardial ischemia during off-pump coronary artery bypass graft surgery.

OBJECTIVE: Off-pump coronary artery bypass graft surgery is common therapy to completely revascularize diseased hearts. In order to graft posterior arteries in this procedure, the heart must be lifted from the chest cavity and manipulated to expose the surgical field using an apical suction device. This suction device may cause unwanted myocardial ischemia. METHODS: In this observational study, we measured myocardial electrical impedance, a parameter that responds to myocardial ischemia, as well as ST-segment changes during off-pump coronary artery bypass graft surgery in 12 patients with two-vessel coronary artery disease undergoing revascularisation of the left anterior descending and the posterior descending coronary arteries. During the posterior descending artery revascularisation phase of the procedure the apical suction device was oriented over the electrodes used to measure myocardial electrical impedance, thus allowing us the opportunity to assess myocardial ischemia in this region of the heart. RESULTS: In these 12 patients, myocardial electrical impedance progressively increased under the suction device during posterior coronary artery revascularisation, suggesting that myocardial ischemia developed in this region of the myocardium. ST-segment changes were negligible while the heart was vertically displaced (and the suction device attached), but increased immediately when the heart was returned to the neutral anatomical position. CONCLUSION: Our data suggest that the apical suction device may cause ischemia while the heart is vertically displaced and electrically disconnected from the body. Under these conditions, ST-segment changes may not detect myocardial ischemia. Myocardial electrical impedance has the potential to reliably detect intraoperative myocardial ischemia under these circumstances.