Giant aneurysm of the circumflex artery.

In this paper, we describe a rare case of a giant aneurysm of the circumflex artery that we managed. A 59-year-old female patient presented in cardiogenic shock after partial aneurysm rupture. Giant aneurysms of the circumflex artery are extremely rare entities. The optimal surgical management dictates meticulous preoperative planning and the operation should be carried out on an elective basis.

Minimally invasive tricuspid valve surgery and concomitant MAZE procedure with closure of LA appendage through an ASD.

Utilization of the ASD as a gateway to reach the left heart in tricuspid valve surgery may facilitate the use of a mini right thoracotomy and single atriotomy approach, avoiding the need for bi-atrial incisions and/or median sternotomy.

Early Basal Cuspal Tear of a Porcine Bioprosthetic Mitral Valve Causing Massive Mitral Regurgitation.

Although porcine mitral bioprostheses provide predictably good long-term outcomes, unexpected leaflet tears leading to abrupt haemodynamic changes may occur. Here, we report on a patient who was presented with acute dyspnea due to a cuspal tear of a porcine bioprosthetic mitral valve causing severe mitral regurgitation. Her condition was subsequently complicated by a systemic infection, probably pneumonia, and was successfully managed with an urgent redo-mitral valve replacement.

FFR-guided versus coronary angiogram-guided CABG: A review and meta-analysis of prospective randomized controlled trials.

BACKGROUND: Fractional flow reserve (FFR) is a well-established method for the evaluation of coronary artery stenosis before percutaneous coronary intervention. However, whether FFR assessment should be routinely used before coronary artery bypass graft surgery (CABG) remains unclear. A meta-analysis of prospectively randomized controlled trials (PRCTs) was carried out to compare the outcomes of FFR-guided CABG vs coronary angiography (CAG)-guided CABG. METHOD: The meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two PRCTs (the FARGO and GRAFFITI trials) were found and included reporting data on 269 patients with 6 and 12 month follow-up. Primary endpoints were rates of overall death, MACCE, target vessel revascularization, and spontaneous myocardial infarction (MI). Secondary endpoints were overall graft patency and patency of arterial and venous grafts. RESULTS: There were no significant differences between the FFR-guided and CAG-guided groups in the rates of overall death, MACCE, target vessel revascularization, spontaneous MI and graft patency. Meta-analysis of FARGO and GRAFFITI PRCTs showed that FFR-guided CABG and CAG-guided CABG produced similar clinical outcomes with similar graft patency rates up to a year postoperatively. CONCLUSION: Currently available PRCTs showes no sufficient evidence to support the use FFR in CABG.

Prospective randomized trial of endoscopic vs open radial artery harvest for CABG: Clinical outcome, patient satisfaction, and midterm RA graft patency.

BACKGROUND AND AIM: Endoscopic radial artery (RA) harvest (ERAH) is an alternative to open RA harvest (ORAH) technique. Our aim was to ascertain clinical outcomes, patent satisfaction, and 1-year angiographic patency rates after ERAH and ORAH. PATIENTS AND METHODS: A total of 50 patients undergoing coronary artery bypass grafting were prospectively randomized to two groups. In the ERAH group (25 patients) the RA was harvested endoscopically and in the ORAH group (25 patients) openly. RESULTS: There were not differences between the groups in preoperative characteristics. Length of skin incision was shorter in ERAH (P < .001) but there were not differences in the length of RA, harvest time, blood flow, and pulsatility index after ERAH and ORAH. Wound healing was uniformly smooth in ERAH and there were two hematomas and one infection in ORAH. Postoperatively, major neuralgias were present in five patients in ORAH and none in ERAH and minor neuralgias in 11 and 3 patients (P = .02) respectively. Twenty-four patients in ERAH and four in ORAH graded their experience as excellent (P < .001). One-year angiographic RA patency was 90% without intergroup difference. Target vessel stenosis less than 90% adversely affected RA patency (P < .0001). CONCLUSIONS: In expert center, ERAH does not appear to have negative impact on the time harvest, the length, and quality of RA conduit, the wound healing, and the occurrence of hand and forearm complications. In addition, provides excellent cosmetic result and patient satisfaction. RA graft patency is gratifying when placed to a target coronary artery vessel with stenosis greater than 90%.

Intraoperative embolism of a right atrial myxoma: a case report.

BACKGROUND: Atrial myxomas are the most common benign cardiac tumours. Clinical manifestations vary from constitutional symptoms, to valvular stenosis and embolic events, and surgical removal is the only suggested treatment. CASE SUMMARY: A 50-year-old female patient was referred to our centre for surgical excision of a reported right atrial mass. A transoesophageal echocardiographic exam revealed two right atrial masses and the surgical plan was total removal of both masses. However, during the operation the surgeons were not able to locate the larger of the two masses and embolization to the pulmonary trunk was considered as the most likely explanation in this setting. A control suction of the right ventricle and the proximal part of the pulmonary arteries was performed to check if the mass had embolized distally but this did not yield any mass. The patient was transferred to the intensive care unit and remained stable for 2 h, until she developed an abrupt cardiogenic shock with signs of right heart failure. An emergent pulmonary computed tomography angiography demonstrated the embolized mass to the left pulmonary artery and the patient was retransferred to the operating room for emergent surgical removal of the mass. The patient showed immediate clinical and haemodynamic improvement after the removal of this mass and had an uneventful further hospitalization. DISCUSSION: Multiple right atrial myxomas are rarely reported and surgical excision requires experience, as in case of embolization immediate removal must be obtained to prevent from right ventricle distress and cardiogenic shock.

What is the role of sutureless aortic valves in today's armamentarium?

INTRODUCTION: Sutureless and rapid-deployment aortic bioprostheses represent an emerging and promising technology for the treatment of aortic valve stenosis. Unlike traditional aortic bioprostheses, these devices are not hand-sewn, thus allowing a significant reduction in operative times, while facilitating minimally invasive surgery and complex cardiac interventions. Sutureless aortic valve replacement represents a less invasive treatment option and an excellent alternative to conventional aortic valve replacement in elderly and higher risk patients. Areas covered: This review summarizes the current literature on sutureless and rapid-deployment aortic bioprostheses, focusing on their hemodynamic and clinical performance. Moreover, we highlight clinical caveats associated with these devices and report the current recommendations for their use, as advocated by experts in the field. Expert commentary: Finally, we summarize our group's technical modification with regards to positioning of these bioprostheses and propose some technical aspects which could decrease post-procedural permanent pacemaker requirement.

A new hemostatic agent: initial life-saving experience with Celox (chitosan) in cardiothoracic surgery.

Celox (MedTrade Products Ltd, Cheshire, UK) is a proprietary preparation of chitosan, indicated for moderate to severe hemorrhage and currently used for hemostasis in the emergency and military settings. We describe its lifesaving use in 2 patients undergoing cardiothoracic surgery in which conventional techniques had failed.

How I do it: transapical cannulation for acute type-A aortic dissection.

Aortic dissection is the most frequently diagnosed lethal disease of the aorta. Half of all patients with acute type-A aortic dissection die within 48 hours of presentation. There is still debate as to the optimal site of arterial cannulation for establishing cardiopulmonary bypass in patients with type-A aortic dissection. Femoral artery cannulation with retrograde perfusion is the most common method but because of the risk of malperfusion of vital organs and atheroembolism related to it different sites such as the axillary artery, the innominate artery and the aortic arch are used. Cannulation of these sites is not without risks of atheroembolism, neurovascular complications and can be time consuming. Another yet to be popularised option is the transapical aortic cannulation (TAC) described in this article. TAC consists of the insertion of the arterial cannula through the apex of the left ventricle and the aortic valve to lie in the sinus of Valsalva. Trans-oesophageal guidance is necessary to ensure correct placement of the cannula. TAC is an excellent method of establishing cardiopulmonary bypass as it is quick, provides a more physiological method of delivering antegrade arterial flow and is the only method to assure perfusion of the true lumen.

Management of superior vena cava obstruction syndrome due to thrombosis of a Contegra conduit used to re-establish the innominate vein-to-right atrium continuity.

Following intraoperative superior vena cava injury, venous drainage of the head, neck and upper extremities can be re-established with bovine jugular vein (Contegra) conduits. Inadequate anticoagulation, however, may lead to conduit thrombosis and superior vena cava obstruction syndrome. This can be successfully treated with percutaneous dilatation and stenting of the failed conduit.

Does systemic leukocyte filtration affect perioperative hemorrhage in cardiac surgery? A systematic review and meta-analysis.

Cardiopulmonary bypass causes a systemic inflammatory reaction. Activation of leukocytes is an important part of this process, and is known to directly contribute to the development of postoperative coagulopathy, and thus hemorrhage. The removal of leukocytes from the cardiopulmonary bypass circulation, using specialized filters, has been proposed as one method for attenuating this inflammatory response. However, there is no consensus on its effectiveness. We used meta-analytical techniques to systematically assess the literature reporting on the potential effect of systemic leukofiltration on perioperative hemorrhage. Random effects modeling was used to calculate overall estimate, and heterogeneity was assessed. Systemic leukofiltration made no significant impact on chest tube drainage in the first 24 hours (weighted mean difference [WMD], x23.9 ml; 95% confidence interval [CI], x95.48-47.61; p = 0.51) or on the total packed red cell transfusion requirements of each patient (WMD, 7.84 ml; 95% CI, x80.13-95.81; p = 0.86). The studies performed in this area thus far are highly heterogeneous, due in part to relatively poor-quality design and inadequate matching of their study groups. Although further high-quality trials on systemic leukofiltration may be appropriate, other strategies to reduce the coagulopathy associated with cardiopulmonary bypass should be sought and evaluated.

The effect of preoperative atrial fibrillation on survival following mitral valve repair for degenerative mitral regurgitation.

OBJECTIVE: There is conflicting evidence with regard to the impact of preoperative atrial fibrillation (AF) on the post mitral valve (MV) repair on the early and late outcome. METHODS: A total of 349 patients undergoing various MV repair procedures for degenerative mitral regurgitation (MR) between 1997 and 2003 were studied. Preoperatively, 152 (44%) of these patients were in AF and 197 (56%) patients were in sinus rhythm (SR). The clinical features and the outcome in these two cohorts of patients were compared. RESULTS: The patients in the AF group were older than their counterparts in the SR group (66+/-7 vs 62+/-9 years) (p=0.01), had a higher mean NYHA class score (2.4+/-0.6 vs 2.2+/-0.7) (p=0.04) and were more likely to have impaired left ventricular function (60% vs 36%) (p<0.0001). A similar proportion of patients in the AF (38%) and SR (30%) groups had additional cardiac surgical procedures (p=0.12). Operative mortality was 3.9% in AF group versus 0.5% in SR group (p=0.04), and operative morbidity was 27% versus 17%, respectively (p=0.03). At latest follow up, 4% of patients that were in SR preoperatively developed AF; conversely, 2% of the patients in the AF group converted to SR. The rates of recurrent grade II or III MR (4% vs 5%) (p=0.8) and MV re-operation (2.6% vs 2.5%) (p=1.0) were similar in the AF and SR groups. Kaplan-Meier survival at 7 years was 75+/-6% versus 90+/-3% (p=0.005). On Cox proportional hazards regression model, impaired LV function [(p=0.02), hazard ratio 0.25 (95% confidence intervals (C.I.) 0.078-0.84)] and AF [(p=0.03), hazard ratio 2.70 (95% C.I. 1.09-6.68)] were significant adverse predictors of survival. CONCLUSIONS: This study shows that in patients undergoing MV repair for degenerative MR, preoperative AF has a major negative impact on the early and late survival.

The effects of various leukocyte filtration strategies in cardiac surgery.

It is known that cardiopulmonary bypass causes an inflammatory reaction with an associated morbidity and mortality. Several anti-inflammatory strategies have been implemented to reduce this response, including leukocyte removal from the circulation using specialised filters. The aim of this study is to systematically review the available evidence on leukocyte filtration in cardiac surgery, focusing on its effect on systemic inflammation and whether this has influenced clinical outcomes. Five electronic databases were systematically searched for studies reporting the effect of leukocyte filtration at any point within the cardiopulmonary bypass circuit in humans. Reference lists of all identified studies were checked for any missing publications. Two authors independently extracted the data from the included studies. Whilst systemic leukodepleting filters do not appear to consistently lower leukocyte counts, they may preferentially remove activated leukocytes. Small improvements in early post-operative lung function in patients receiving systemic leukodepletion have been reported, but this does not lead to reduced hospital stay or decreased mortality. There is substantial evidence that cardioplegic leukocyte filtration attenuates the reperfusion injury at a cellular level, but this has not been translated into clinical improvements. Finally, whilst various strategies involving multiple leukocyte filters, or the incorporation of pharmacological agents into leukocyte-depleting protocols have been evaluated, the current available results are not conclusive. Our study suggests that there is not enough high quality or consistent evidence to draw guidelines regarding the use of leukocyte-depleting filters within routine cardiac surgical practice.

Tube-graft inversion for the construction of an "open" distal anastomosis during ascending aortic replacement: a new technique.

For the construction of a distal "open" anastomosis during ascending aortic replacement, a tube-graft is placed opposite to the transected aorta. We describe an alternative technique. The tube-graft is inverted and positioned within the aortic arch in a way that brings the entire circumference of the distal end of the tube-graft next to the circumference of the transected aorta. An end-to-end anastomosis is then fashioned with a running suture, the needle of which goes through the aorta and the tube-graft in a single pass. This technique permits easy, accurate, and fast suture placement, producing a hemostatic distal anastomosis within a short circulatory arrest time.

Early failure of surgical angioplasty with tissue glue: a word of caution.

A 43-year-old woman with critical stenosis of the left main stem was managed with saphenous vein angioplasty using BioGlue. She developed severe myocardial ischemia postoperatively, probably due to external compression exerted on the patch by the adhesive material, and required emergency coronary artery bypass grafting.

Leukocytes-depleting filters preferentially remove activated leukocytes and reduce the expression of surface adhesion molecules during the simulated extracorporeal circulation of human blood.

The effect of leukocyte-depleting filters on the total and activated leukocyte counts and the expression of surface adhesion molecules CD11b, CD18, and CD62L during the in vitro extracorporeal circulation of human blood was studied. A 200 ml blood sample was taken from 10 patients undergoing CABG surgery. The blood was circulated for 60 minutes within an experimental extracorporeal circuit. A leukocyte-depleting filter was attached in five circuits (filtered group). In five other circuits, no filter was used (controls). Total leukocyte counts were determined manually. Activated leukocytes were identified using nitroblue tetrazolium staining. The expression of CD11b, CD18, and CD62L was measured with flow cytometry. At 60 minutes, total leukocyte counts were reduced by 49% from the baseline values in the filtered group and 10% in the control group (p < 0.0001). Activated leukocyte counts decreased by 86% in the filtered group and increased by 116% in the control group (p < 0.0001). In the filtered group, the expression of CD11b, CD18, and CD612L decreased by 60%, 21%, and 79%, respectively, and in the control group it increased by 24%, 6%, and 28% (p < 0.0001). Leukocyte-depleting filters preferentially remove activated leukocytes and reduce the expression of CD11b, CD18, and CD62L during the in vitro extracorporeal circulation of human blood.