Thoracoscopic Sympathectomy for Long QT Syndrome. Literature Review and Case Study.

BACKGROUND: Multiple case studies have suggested that video-assisted thoracoscopic sympathectomy (VATS) reduces the occurrence and frequency of symptoms in long QT syndrome (LQTS) [1,2,3]. To date there has not been a literature review to report on the short-term and long-term outcomes of this procedure. Our primary aims are to review the literature findings on the clinical outcomes of VATS sympathectomy for long QT and present a local centre case report on the outcomes of T2-T5 sympathectomy. METHODS: Relevant articles were identified by a systematic search of PubMed, Cochrane and Scopus databases, from November 1985 to October 2015. A total of 520 patients from 21 publications were included for analysis and discussion in three main areas: presenting symptoms and indication for surgery, perioperative complications, and patient quality of life following surgery. Our case study reviews a 49-year-old female with recently diagnosed long QT syndrome and intolerance to beta blocker therapy successfully managed with T2-T5 thoracic sympathectomy. RESULTS: The most common presenting indication for operative management of long QT syndrome was syncope (208/520 patients) and tachyarrhythmia (207/520 patients). T1-T5 left sympathectomy was performed in 15/21 published reports (332/520 patients) with partial stellate removal or in its entirety. Follow-up of patients ranged from 1 month to 11 years. Four patients died in the postoperative period, from fatal arrhythmias. The most common postoperative findings were no symptoms (64/520 patients); tachyarrhythmia (55/520 patients), syncope (45/520 patients), and Horner's syndrome (13/520 patients with 27 patients reporting associated symptoms). Thirteen cases reported on the QTc changes post sympathectomy and 9/13 cases involving 220/520 patients showed marked QTc reduction following surgery. Mean preoperative QTc was 558ms and median 559ms. Mean postoperative QTc was 476ms and median 466ms. Our patient showed a marked reduction in QTc following surgery, with no evidence of arrhythmias and reduced beta blocker dependence. CONCLUSIONS: Surgical management of LQTS has historically involved a left cervicothoracic stellectomy removing stellate ganglia and typically part of the left thoracic sympathetic chain resulting in reduction in symptoms but increasing the risk of Horner's syndrome and intermittent temperature changes [4,5]. Surgical resection of the thoracic ganglia alone for management of LQTS is scarce in the literature. Short-term follow-up in our case study following a T2-T5 sympathectomy revealed reduction in symptoms, no requirement for beta blocker therapy and reduced QTc interval. Further follow-up using greater patient numbers will further support T2-T5 sympathectomy as an option for surgical management of LQTS.

Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes.

Objective: Reoperative mitral valve surgery is increasingly required and can be associated with significant morbidity and mortality. The beating heart minimally invasive mitral valve surgery has a proposed benefit in avoiding the risks of repeat sternotomy, with reducing the need for adhesiolysis and cardioplegia reperfusion injury. We describe our experience with such a technique in patients with previous sternotomy. Methods: A retrospective study was performed and all patients undergoing surgery of mitral valve through a right limited thoracotomy without application of an aortic cross-clamp (beating heart) as a redo cardiac surgery between January 2006 and January 2015 were included (n=25). Perioperative data as well as the operative technique are presented. Results: Six patients (24%) had two previous sternotomies and one (4%) had three previous sternotomies. Mitral valve repair was performed in 11 patients (44%). No patient required conversion to median sternotomy. Inotropic support beyond 4 hours after operation was required in seven patients (28%). Ventilation time was less than 12 hours in 14 patients (56%) with another six patients (24%) extubated within 24 hours after surgery. Postoperative course was complicated with cerebrovascular accident in two patients (8%). In-hospital mortality was 4% (n=1). There was no 30-day mortality after discharge. Conclusions: Reoperative mitral valve surgery can be safely performed through a limited right thoracotomy approach on a beating heart while on full cardiopulmonary bypass. The technique can be associated with potentially shorter operation, shorter cardiopulmonary bypass and a less complicated recovery.

Long Term Outcomes Following Freestyle Stentless Aortic Bioprosthesis Implantation: An Australian Experience.

BACKGROUND: The Freestyle stentless bioprosthesis (FSB) has been demonstrated to be a durable prosthesis in the aortic position. We present data following Freestyle implantation for up to 10 years post-operatively and compare this with previously published results. METHODS: A retrospective cohort analysis of 237 patients following FSB implantation occurred at five Australian hospitals. Follow-up data included clinical and echocardiographic outcomes. RESULTS: The cohort was 81.4% male with age 63.2±13.0 years and was followed for a mean of 2.4±2.3 years (range 0-10.9 years, total 569 patient-years). The FSB was implanted as a full aortic root replacement in 87.8% patients. The 30-day all cause mortality was 4.2% (2.0% for elective surgery). Cumulative survival at one, five and 10 years was 91.7±1.9%, 82.8±3.8% and 56.5±10.5%, respectively. Freedom from re-intervention at one, five and 10 years was 99.5±0.5%, 91.6±3.7% and 72.3±10.5%, respectively. At latest echocardiographic review (mean 2.3±2.1 years post-operatively), 92.6% had trivial or no aortic regurgitation. Predictors of post-operative mortality included active endocarditis, acute aortic dissection and peripheral vascular disease. CONCLUSIONS: We report acceptable short and long term outcomes following FSB implantation in a cohort of comparatively younger patients with thoracic aortic disease. The durability of this bioprosthesis in the younger population remains to be confirmed.

Prevention of Sternal Wound Infections by use of a Surgical Incision Management System: First Reported Australian Case Series.

BACKGROUND: Sternal wound infections are considered a costly and potentially devastating consequence of the median sternotomy in cardiothoracic surgery. Surgical incision management employs the technique of applying a closed, negative pressure vacuum dressing to a closed wound. Several studies have demonstrated a reduction in sternal wound infections using this system. METHODS: A retrospective audit of cases receiving surgical incision management demonstrated a statistically significant reduction in sternal wound infections against a predicted rate. RESULTS: Of the 62 patients identified, only one was complicated by a sternal wound infection with the greatest reduction seen in the high-risk infection group. CONCLUSIONS: Although smaller in size, the results compared well to trials conducted in larger European and US centres. Although not advocating surgical incision management for routine use, it should be considered on patients considered high-risk for sternal wound infection, such as diabetics, the elderly and the obese.

Successful Giant Thymic Cyst Removal: Case Report and Review of the Literature.

Giant thymic cysts are a rare clinical entity evolving from smaller benign thymic cysts over many years. Benign thymic cysts account for approximately 3% of all mediastinal masses. There is a paucity of literature regarding benign thymic cyst management, especially when dealing with giant cysts. This can lead to potential confusion amongst clinicians on how to best treat these patients. We report the successful diagnosis and treatment of a 76 year-old female with a giant, benign thymic cyst. This cyst was discovered incidentally and after consultation of the literature it was found management strategies regarding this condition are scarce. After careful consideration of surgical principles, patient preference and potential complications of a conservative approach, the successful surgical removal of a 1.8 kg cyst took place. The patient improved symptomatically with improved exercise tolerance and lung function tests. This case demonstrates the benefits of giant thymic cyst removal thus confirming diagnosis, reducing potential serious complications and improving patient quality of life.

Minimally invasive mitral valve procedures: the current state.

Since its early days, cardiac surgery has typically involved large incisions with complete access to the heart and the great vessels. After the popularization of the minimally invasive techniques in general surgery, cardiac surgeons began to experiment with minimal access techniques in the early 1990s. Although the goals of minimally invasive cardiac surgery (MICS) are fairly well established as decreased pain, shorter hospital stay, accelerated recuperation, improved cosmesis, and cost effectiveness, a strict definition of minimally invasive cardiac surgery has been more elusive. Minimally invasive cardiac surgery started with mitral valve procedures and then gradually expanded towards other valve procedures, coronary artery bypass grafting, and various types of simple congenital heart procedures. In this paper, the authors attempt to focus on the evolution, techniques, results, and the future perspective of minimally invasive mitral valve surgery (MIMVS).

Redo mitral valve operation via right minithoracotomy--"no touch" technique.

Five patients who had had previous cardiac operations underwent minimally invasive beating heart mitral valve operations via a right minithoracotomy between November 2006 and February 2009. The mean age was 64 ± 10 years and 4 were female. Under general anesthesia with single-lumen ventilation, cardiopulmonary bypass was established using the right femoral artery and vein. Through right minithoracotomy, the left atrium was opened without dissection of pericardial adhesion. The aorta was not cannulated or clamped, using a so-called "No Touch" technique. Four patients had mitral valve replacement and one had mitral ring annuloplasty with the heart beating. Mean cardiopulmonary bypass time was 118 ± 38 minutes. There was no early mortality or confirmed stroke. One patient who underwent mitral ring annuloplasty for ischemic mitral regurgitation died 3 months after surgery due to renal failure. At follow-up, New York Heart Association functional class had improved in 3 patients. In conclusion, in our initial series, minimally invasive beating heart redo mitral valve surgery through right minithoracotomy was safely performed with no early mortality.

Minimally invasive mitral valve replacement in a patient with previous omphalocele repair and severe scoliosis.

Mitral valve surgery in a patient with severe chest deformity and poor respiratory function can be associated with a high risk due to difficult access and postoperative respiratory failure. A 45-year-old man with scoliosis and respiratory dysfunction who had undergone previous omphalocele repairs presented with severe mitral regurgitation. Mitral valve replacement via right mini-thoracotomy was successfully performed. The minimally invasive approach was considered useful in this patient with anatomical difficulty and respiratory dysfunction.

Early results of minimally invasive mitral valve surgery: initial series in a public hospital in Australia.

PURPOSE: This study analyzes the initial experience with minimally invasive mitral valve surgery through a right minithoracotomy in a public teaching hospital in Australia and evaluates early surgical outcomes. METHODS: A retrospective review of patients who underwent minimally invasive mitral valve surgery between November 2006 and March 2009 was performed. RESULTS: A total of 60 patients included 47 (78%) patients who had mitral valve plasty and 13 (22%) who had mitral valve replacement. The mean age was 61 ± 15 years; 33 (55%) patients were male; and 6 (10%) had had previous cardiac operations. The mean cardiopulmonary bypass and aortic cross-clamp times were 140 ± 46 and 93 ± 35 min, respectively. All patients who underwent mitral valve plasty left the operation room with no more than trivial residual mitral regurgitation. There was no operative mortality. Reoperation for bleeding and stroke occurred in 2 patients each. The mean intensive care unit and hospital stays were 3.1 ± 5.8 and 10.6 ± 8.9 days, respectively. Among the 47 patients with mitral valve plasty, 46 (98%) had mild or less mitral regurgitation on transthoracic echocardiography at discharge. There was one late death. No reoperation for the mitral valve has been observed so far. An echocardiography report was obtained for 34 of the 47 who had had mitral valve plasty at 12.1 ± 7.9 months postoperatively, and 27 (79%) of them had mild or less mitral regurgitation. CONCLUSION: Minimally invasive mitral valve surgery through a right minithoracotomy was safely performed with no early mortality.

Recurrent rupture of an infected aortic arch.

Severe bacterial aortitis without an aneurysmal component is a rare but life-threatening problem that requires aggressive treatment to eliminate the infection and prevent recurrence. Herein, we present the case of a 58-year-old man who underwent patch repair of a nonaneurysmal aorta that had ruptured due to Staphylococcus aureus infection. Postoperatively, he experienced a recurrent rupture that required reoperation. We successfully performed wide-margin débridement followed by aortic arch replacement with a prosthetic vascular graft and omental flap.

Mitral paravalvular abscess with left ventriculo-atrial fistula in a patient on dialysis.

BACKGROUND: Infective endocarditis in hemodialysis patients is challenging but is becoming more common recently. CASE REPORT: A 64-year-old man with end-stage renal disease on hemodialysis presented with infective endocarditis of mitral valve and coronary artery disease after commencing training for home hemodialysis. During a course of antibiotic treatment the patient developed left ventriculo-atrial fistula due to mitral paravalvular abscess. Abscess debridement followed by reconstruction of the mitral annulus with fresh autologous pericardial patch and mitral valve replacement using a mechanical prosthesis with concomitant coronary artery bypass grafting was performed successfully. CONCLUSION: Timely diagnosis, proper antibiotic treatment and early surgical intervention including aggressive debridement should improve the outcome of this high-risk disease.

Chylous pericardial effusion after aortic valve replacement.

Chylous pericardial effusion after open-heart surgery is a rare complication. We report a case of chylous pericardial effusion following aortic valve replacement, which presented as cardiac tamponade, and its subsequent management.

Right pleuropericardial release: a useful technique in off-pump coronary surgery.

We describe the use of right pleurotomy combined with right pericardial release during off-pump coronary surgery. The maneuver releases the compression exerted on the right cardiac chambers during cardiac verticalization and improves hemodynamic stability during exposure of the posterior or lateral coronary vessels.