Transaortic septal myectomy at the time of aortic valve replacement for severe aortic stenosis: a case series of 55 cases.

Introduction: Symptomatic aortic valve stenosis (AS) is associated with asymmetric basal septal hypertrophy (ABSH) in 10% of cases. In this cohort, it has been suggested that rectification of the left ventricular outflow tract obstruction (LVOTO) by concomitant septal myectomy (CSM) can improve the results of aortic valve replacement (AVR). Objective: This study aims to present the technique of AVR with CSM for severe AS with ABSH and to determine the associated early and late post-operative outcomes. Methods: Fifty-five patients were prospectively recruited to undergo AVR with CSM between 2011 and 2021 at two centres. The primary outcomes were mortality within 30 days, incidence of post-operative ventricular septal defects (VSD) and prosthetic valve sizing. The secondary outcomes were in-hospital complications, permanent pacemaker implantation (PPI), survival at 15 months and changes on transthoracic echocardiogram. Results: Post-operative mortality was 1.8% and this figure was unchanged at 15-month follow-up. No patients developed a post-operative VSD. Intra-operatively, it was found that in 94.6% cases the direct valve sizing increased by one, when compared to the measurement made before CSM. The indexed effective orifice area (iEOA) was > 85 cm2/m2 in 96.4% and no patients had an iEOA ≤ 0.75 cm2/m2. Four patients (7.3%) required PPI due to complete atrioventricular block. Conclusion: AVR with CSM is a simple technique that can be utilised in severe AS with ABSH. There does not appear to be an increase in mortality or incidence of iatrogenic VSDs. Importantly, CSM allows for the implantation of a larger aortic valve compared to measurements made before CSM.

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.

Combination of internal (epicardial) and external (transthoracic) defibrillation during heart surgery.

OBJECTIVES: This report describes a modified defibrillation technique during cardiac surgery using a combined internal (epicardial) and external (transthoracic) defibrillation system. METHODS: We routinely used 30 J (J) shock between the epicardial pad placed directly onto the right atrium and the left anterolateral transthoracic pad placed in the left anterolateral chest wall directly to the skin in the area of the cardiac apex under the nipple. RESULTS: Thirty-two patients whom developed ventricular fibrillation (VF) during surgery were managed in theatre using this method. A single 30 J shock was successfully given in 29 patients while the remaining three required an additional shock with the same amount (30 J). CONCLUSIONS: We believe that this technique is safe and complications free. It is easy to perform especially in patients with difficult access such as redo operations.

Quantification of Operational Learning in Minimal Invasive Extracorporeal Circulation.

Minimal invasive extracorporeal circulation (MiECC) has initiated important new efforts within science and technology towards a more physiologic perfusion. In this study, we aim to investigate the learning curve of our center regarding MiECC. We studied a series of 150 consecutive patients who underwent elective coronary artery bypass grafting by the same surgical team during the initial phase of MiECC application. Patients were randomly assigned into two groups. Group A (n = 75) included patients operated on MiECC, while group B (n = 75) included patients operated with conventional cardiopulmonary bypass (cCPB). The primary end-point of the study was to identify whether there is a learning curve when operating on MiECC. The following parameters were unrelated with increasing experience, even though the results favored MiECC use: reduced CPB duration (102.9 ± 25 vs. 122.2 ± 33 min, P <0.001), peak troponin release (0.07 ± 0.02 vs. 0.1 ± 0.04 ng/mL, P < 0.01), peak creatinine levels (0.97 ± 0.24 vs. 1.2 ± 0.3 mg/dL, P < 0.001), duration of mechanical ventilation (14.1 ± 7.2 vs. 36.9 ± 59.8 h, P < 0.01) and ICU stay (2.1 ± 0.7 vs. 4.4 ± 6.4 days, P < 0.01). However, need for intraoperative blood transfusion showed a trend towards a gradual decrease as experience with MiECC system was accumulating (R2 = 0.094, P = 0.007). Subsequently, operational learning applied to postoperative hematocrit and hemoglobin levels (R2 = 0.098, P = 0.006). We identified that advantages of MiECC technology in terms of reduced hemodilution and improved end-organ protection and clinical outcome are evident from the first patient. Optimal results are obtained with 50 cases; this refers mainly to significant reduction in the need for intraoperative blood transfusion. Teamwork from surgeons, anesthesiologists, and perfusionists is of paramount importance in order to maximize the clinical benefits from this technology.

Effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing coronary artery bypass grafting: a randomized pilot study.

OBJECTIVES: Perioperative low cardiac output syndrome occurs in 3-14% of patients undergoing isolated coronary artery bypass grafting (CABG), leading to significant increase in major morbidity and mortality. Considering the unique pharmacological and pharmacokinetic properties of levosimendan, we conducted a prospective, double-blind, randomized pilot study to evaluate the effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing CABG. METHODS: Thirty-two patients undergoing CABG with low left ventricular ejection fraction (LVEF ≤ 40%) were randomized to receive either a continuous infusion of levosimendan at a dose of 0.1 µg/kg/min for 24 h without a loading dose or a placebo. The primary outcome of the study was the change in the LVEF assessed with transthoracic echocardiography on the seventh postoperative day. Secondary outcomes included the physiological and clinical effects of levosimendan. RESULTS: All patients tolerated preoperative infusion of levosimendan well. The LVEF improved in both groups; this increase was statistically significant in the levosimendan group (from 35.8 ± 5% preoperatively to 42.8 ± 7.8%, P = 0.001) compared with the control group (from 37.5 ± 3.4% preoperatively to 41.2 ± 8.3%, P = 0.1). The cardiac index, SvO2, pulmonary capillary wedge pressure and right ventricular stroke work index showed a similar trend, which was optimized in patients treated with levosimendan. Moreover, an increase in extravascular lung water was noticed in this group during the first 24 h after surgery. CONCLUSIONS: This pilot study shows that prophylactic levosimendan infusion is safe and effective in increasing the LVEF postoperatively in patients with impaired cardiac function undergoing coronary surgery. This finding may be translated to 'optimizing' patients' status before surgery.

Massive chest wall resection and reconstruction for malignant disease.

OBJECTIVE: Malignant chest wall tumors are rare neoplasms. Resection with wide-free margins is an important prognostic factor, and massive chest wall resection and reconstruction are often necessary. A recent case series of 20 consecutive patients is reported in order to find any possible correlation between tumor histology, extent of resection, type of reconstruction, and adjuvant treatment with short- and long-term outcomes. METHODS: Twenty patients were submitted to chest wall resection and reconstruction for malignant chest wall neoplasms between 2006 and 2014. The mean age (ten males) was 59±4 years. The size and histology of the tumor, the technique of reconstruction, and the short- and long-term follow-up records were noted. RESULTS: The median maximum diameter of tumors was 10 cm (5.4-32 cm). Subtotal sternal resection was performed in nine cases, and the resection of multiple ribs was performed in eleven cases. The median area of chest wall defect was 108 cm(2) (60-340 cm(2)). Histology revealed soft tissue, bone, and cartilage sarcomas in 16 cases (80%), most of them chondrosarcomas. The rest of the tumors was metastatic tumors in two cases and localized malignant pleural mesothelioma and non-Hodgkin lymphoma in one case. The chest wall defect was reconstructed by using the "sandwich technique" (propylene mesh/methyl methacrylate/propylene mesh) in nine cases of large anterior defects or by using a 2 mm polytetrafluoroethylene (e-PTFE) mesh in nine cases of lateral or posterior defects. Support from a plastic surgeon was necessary to cover the full-thickness chest wall defects in seven cases. Adjuvant oncologic treatment was administered in 13 patients. Local recurrences were observed in five cases where surgical reintervention was finally necessary in two cases. Recurrences were associated with larger tumors, histology of malignant fibrous histiocytoma, and initial incomplete resection or misdiagnosis made by nonthoracic surgeons. Three patients died during the study period because of recurrent disease or complications of treatment for recurrent disease. CONCLUSION: Chest wall tumors are in their majority mesenchymal neoplasms, which often require major chest wall resection for their eradication. Long-term survival is expected in low-grade tumors where a radical resection is achieved, while big tumors and histology of malignant fibrous histiocytoma are connected with the increase rate of recurrence.

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.

Magnetic connectors for coronary surgery: what do we know a decade later?

In 2001, a novel sutureless magnetic anastomotic device (MVP) for coronary anastomosis was introduced in Europe for both on-pump and off-pump procedures. The device has been implanted in more than 150 patients with encouraging short-term but less favorable mid-term results. However, to date long-term patency outcomes of those recipients have not been investigated. This is the first report on an excellent angiographic performance of this automated magnetic device ten years after left internal thoracic artery to left anterior descending grafting in a man who underwent coronary angiography prior to thymectomy.

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.

Early reoperation performed for the management of complications in patients undergoing general thoracic surgical procedures.

OBJECTIVE: To detect the rate and predisposing factors for the development of postoperative complications requiring re-operation for their control in the immediate postoperative period. METHODS: During the time period 2009-2012, 719 patients (male: 71.62%, mean age: 54±19 years) who underwent a wide range of general thoracic surgery procedures, were retrospectively collected. Data of patients who underwent early re-operation for the management of postoperative complications were assessed for identification of the responsible causative factors. RESULTS: Overall, 33/719 patients (4.6%) underwent early re-operation to control postoperative complications. Early re-operation was obviated by the need to control bleeding or to drain clotted hemothoraces in nine cases (27.3%), to manage a prolonged air leak in six cases (18.2%), to drain a post-thoracotomy empyema in five cases (15.2%), to revise the thoracotomy incision or an ischemic musculocutaneous flap in five cases (15.2%), to manage a bronchopleural fistula in four cases (12.1%), to manage persistent atelectasis of the remaining lung in two cases (6.1%), to cease a chyle leak in one case (3%) and to plicate the right hemidiaphragm in another one case (3%). The factors responsible for the development of complications requiring reopening of the chest for their management were technical in 17 cases (51.5%), initial surgery for lung or pleural infections in 9 (27.3%), the recent antiplatelet drug administration in 4 (12.1%) and advanced lung emphysema in 3 (9.1%). Mortality of re-operations was 6.1% (2/33) and it was associated with the need to proceed with completion pneumonectomy in the two cases with persistent atelectasis of the remaining lung and permanent parenchymal damage. The majority of complications requiring reoperation were observed after lung parenchyma resection (17 out of the 228 procedures/7.4%) or pleurectomy (7 out of the 106 procedures/6.5%). Reoperations after video-assisted thoracic surgery (VATS) were uncommon (2 out of the 99 procedures/2%). CONCLUSIONS: The rate of complications requiring reoperation after general thoracic surgery procedures is low and it is mainly related to technical issues from the initial surgery, the recent administration of antiplatelet drugs, the presence of advanced emphysema and surgery for infectious diseases. The need to proceed with completion pneumonectomy has serious risk for fatal outcome.

Treatment of infected thoracic aortic prosthetic grafts with the in situ preservation strategy: a review of its history, surgical technique, and results.

For cardiothoracic surgeons prosthetic graft infection still represents a difficult diagnostic and treatment problem to manage. An aggressive surgical strategy involving removal and in situ replacement of all the prosthetic material combined with extensive removal of the surrounding mediastinal tissue remains technically challenging in any case. Mortality and morbidity rates following such a major and risky surgical procedure are high due to the nature of the aggressive surgical approach and multi-organ failure typically caused by sepsis. However, removal of the infected prosthetic graft in patients who had an operation to reconstruct the ascending aorta and/or the aortic arch is not always possible or necessary for selected patients according to current alternative treatment options. Rather than following the traditional surgical concept of aggressive graft replacement nowadays a more conservative surgical approach with in situ preservation and coverage of the prosthetic graft by vascular tissue flaps can result in a good outcome. In this article, we review the relevant literature on this specific topic, particularly in terms of graft-sparing surgery for infected ascending/arch prosthetic grafts with special emphasis on staged treatment and the use of omentum transposition.

Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study.

OBJECTIVE: A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. DESIGN: Prospective randomized study. SETTING: All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. PARTICIPANTS: One hundred twenty patients were assigned randomly into 2 groups (60 in each group). INTERVENTIONS: Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. MEASUREMENTS AND MAIN RESULTS: Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. CONCLUSIONS: MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting.

Coronary ostium topography: an implication for transcatheter aortic valve implantation?

OBJECTIVES: Shorter distances from coronary ostia to the calcified aortic valve may result in occlusion with potential infarction during transcatheter aortic valve implantation. We hypothesized that preoperative CT-scan measurements might predict coronary occlusion. METHODS: Distances from the coronary ostia to the calcified aortic valve were measured during open heart aortic valve replacement in 60 consecutive patients. Distances were compared to preoperative CT-scan measurements evaluating distance of the coronary ostia as well (n = 15). RESULTS: The distances of the lower lip of the left and the right coronary artery ostia measured from the aortic annulus were 14.7 ± 3.9 mm and 13.4 ± 4.0 mm, respectively. The left, right and noncoronary cusp heights were 13.9 ± 2.5 mm, 12.8 ± 3.0 mm and 13.3 ± 3.1 mm, respectively. Coronary ostia topography indicated variations from the middle to the noncoronary commissure in 40% for the left and 63% for the right coronary ostium. CT-scan based measurements resulted in a distance of 12.8 ± 3.5 mm for the left and 13.9 ± 4.0 mm for the right coronary ostium, compared to 14.2 ± 4.2 mm and 13.5 ± 4.3 mm measured intraoperatively. A mild correlation between both measurements could be observed (r = 0.374, P = 0.188, left and r = 0.46, P = 0.09, n = 15). CONCLUSIONS: CT-scan-based measurements differed from the intraoperative measurements, however preoperative CT-scan evaluation may be a useful tool to identify patients with short distance of coronaries.