How to make an aortic root replacement simulator at home.

There is a paucity of low-fidelity and cost-efficient simulators for training cardiac surgeons in the aspects of aortic root/valve replacement. In this study we addressed this training challenge by creating a low-fidelity, low-cost but, at the same time, anatomically realistic aortic root replacement simulator for training purposes. We used readily available, low cost materials such as lint roller tubes, foam sheet, press-and-seal bags, glue, plywood sheet, heat-shrink sleeving tubes and condoms as the basic material to create a low-fidelity, aortic root, training simulator. We constructed a multi-purpose, anatomically realistic aortic root simulator using the above materials, both time- and cost-efficiently, using the minimum of surgical equipment. This simulator is easy to construct and enables self-training in major techniques of aortic root replacement as well as in stentless valve implantation for trainees in cardiac surgery.

Transcatheter aortic valve implantation: from fantasy to reality.

Increased life expectancy has led to the presentation of more complicated patients in old age for the replacement of the aortic valve. The emergence of Transcatheter Aortic Valve Implantation (TAVI) was considered as a significant breakthrough in the management of symptomatic, moribund patients suffering from aortic valve stenosis who had been rejected for surgical intervention. A novel technology often has a long journey from the point at which it is created to its every-day-use. It is now obvious that TAVI practice in multiple institutes around the world has gone beyond the evidence. Serious concerns have been raised questioning the current TAVI practice. Analysis of future TAVI use may assist clinicians and healthcare managers to understand and deploy this technology in accordance with the evidence.

The mitral chordometer: a novel device for mitral valve repair.

We introduce a novel device to accurately gauge the length of the artificial chordae and, at the same time, allow a secure platform against which artificial chordae can be tied securely. The distal end of the device contains a concave apparatus that seats on the papillary muscle. A movable lateral member is adjusted to sit below the free edge of the adjacent normal leaflet to provide a template for tying the artificial chordae to the prolapsing posterior leaflet to the correct height.

Staged hybrid treatment of ascending aorta aneurysm post cardiac surgery.

We describe the management of ascending aorta aneurysm following a recurrent sternotomy wound infection in 2 male patients. The patients had undergone cardiac surgery using cardiopulmonary bypass with late complications of chronic sternal wound infection and saccular aneurysm at the aortic cannulation site. In both patients, following a multidisciplinary approach, a customized stent graft was implanted endovascularly into the ascending aorta to seal the aneurysm orifice followed by resternotomy, repair of the aneurysm and omentopexy. Both patients' postoperative course was uneventful.

Aortic valve replacement in a Jehovah's Witness: a case of multi-disciplinary clinical management for bloodless surgery.

An 81-year-old female Jehovah's Witness (JW) patient with severe aortic stenosis required aortic valve replacement (AVR). However, the patient's religious beliefs precluded the use of primary blood components. Since the definitive treatment of AVR required bloodless open heart surgery, careful peri-operative plans were set forth by a multi-disciplinary team involving the cardiothoracic surgeon, haematologist and anaesthetist. The patient went on to successfully recover postoperatively. This case highlights: 1) The importance of carefully navigating through the most recent clinical and ethical protocol involved in the surgical management of JW's. 2) The importance of preparing individually tailored pre, intra and postoperative plans that are delivered through a multi-disciplinary clinical team to ensure the best and safest possible outcomes.

Does the number of wires used to close a sternotomy have an impact on deep sternal wound infection?

OBJECTIVES: We studied the influence of the number of sternotomy mechanical fixation points on deep sternal wound infection (DSWI). METHODS: Between September 2007 and February 2011, 2672 patients underwent a standard peri-sternal wire closure following a median sternotomy for a first-time cardiac surgery. Data were collected during the study period. RESULTS: The mean age of the patients was 66 ± 11 and 1978 (74.0%) were male. The mean body mass index (BMI) was 28.9 ± 9.3 and the median of the logistic EuroSCORE was 3.14, with a range of 0.88-54.1. Postoperatively, 40 (1.5%) patients developed DSWI after 14 ± 6 days, of whom 39 (92.5%) had positive deep sternal wound specimen cultures, predominantly Staphylococci (62.5%). The risk of DSWI was significantly increased in patients in whom eight or fewer paired points of sternal wire fixation were used when compared with patients in whom nine or more paired points of fixation were used (P = 0.002). Preoperative myocardial infarction (P = 0.001), elevated BMI (P = 0.046), bilateral internal mammary artery harvest (P < 0.0001), postoperative hypoxia (P < 0.0001), sepsis (P = 0.019) and postoperative inotrope use (P = 0.007) significantly increased the risk of DSWI. CONCLUSIONS: DSWI is associated with hypoxia, ischaemia, sepsis and mechanical sternal instability. DSWI may be prevented by using nine or more paired fixation points when closing with standard peri-sternal wires.

Is fine-needle aspiration diagnosis of malignancy adequate prior to major lung resections including pneumonectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether a fine-needle aspiration (FNA) diagnosis is of sufficient reliability for the diagnosis of lung cancer prior to a major lung resection. Altogether, 112 papers were found using the reported search, of which 13 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The tabulated studies include two meta-analyses, one systematic review, one randomized controlled trial (RCT) and nine cohort studies. The specificity reported for FNA in the diagnosis and staging of lung cancer ranged from 96.2 to 100%. One meta-analysis reported a specificity of 97%. Another meta-analysis reported a specificity of 98.8%. A systematic review reported a specificity of 97%. An RCT reported a specificity of 96.2-100%. We conclude that the FNA for lung cancer is reported to be highly specific prior to major lung resection with a very low false positive rate. However, although a false positive may occasionally be acceptable in lobectomies, where the lobes are often removed without histology, all steps should be taken to avoid a false positive result in pneumonectomy considering the serious consequences of embarking upon such an operation in the small number of patients with a false positive result, and we recommend that a positive FNA result should be confirmed by means of alternative sampling methods. We also acknowledge that obtaining an additional biopsy specimen would add to the risk of morbidity and costs; therefore, any benefits should be weighed against risks and additional costs.

Redo-redo aortic root replacement with a mechanical valved conduit in a patient with von Willebrand's disease: Case report.

A 40 year-old female, with a history of cardiac surgery for congenital aortic valve stenosis and von Willebrand's disease (VWD) presented with increasing shortness of breath due to mixed aortic valve dysfunction. With a paucity of such cases in the literature, we describe the successful outcome of a patient with VWD who underwent elective redo-redo aortic root replacement with a mechanical valved conduit. She was given a three-month trial of warfarin pre-operatively to evaluate the extent of bleeding risk. Her post-operative course was uneventful and she was discharged home after six days.

Transient global amnesia as the presenting feature of heparin-induced thrombocytopenia.

A 57-year-old man developed transient global amnesia within an hour of bolus unfractionated heparin administration on day 4 post-mitral valve replacement. Both immunoglobulin G-specific enzyme-linked immunosorbent assay and serotonin release assay were strongly positive for the antibodies that cause heparin-induced thrombocytopenia. The patient's cognitive functions returned to normal following discontinuation of unfractionated heparin and warfarin and commencement of lepirudin infusion.

One-stage repair of an aortic dissection and aortic coarctation.

Ascending aortic dissection with aortic coarctation has a high mortality. There are few reports of successful surgical management of the combined condition. We report a case of a successful one-stage repair of type A aortic dissection with aortic coarctation, using an extra-anatomic bypass to connect the ascending to the abdominal aorta.

Aortic pseudoaneurysm complicating sternal wound infection following CABG.

Pseudoaneurysm of the ascending aorta following coronary artery bypass grafting is a rare complication. In this report we present two such cases. We were successful in repairing the false aneurysm and sternal dehiscence in one case. The clinical features, diagnosis and surgical management are discussed.