Brain and lower body protection during aortic arch surgery.

BACKGROUND: Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral perfusion [ACP]), or retrograde. In recent years nadir temperature progressively increased to 26°C-28°C (moderately hypothermic circulatory arrest [MHCA]), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10 min of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming [DR]) can provide a neuroprotection and a lower body protection similar to that provided by MHCA + ACP. METHODS: A total of 210 patients were included in the study. DHCA + DR was used in 59 patients and MHCA + ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE), or permanent (permanent neurologic deficit [PND]), and need of renal replacement therapy (RRT). RESULTS: Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%), and PNDs in 10 (4.8%). A total of 23 patients (10.9%) needed RRT. Death + PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs, and death + PND, but need of RRT (odds ratio [OR]: 7.39, confidence interval [CI]: 1.37-79.1) and composite endpoint (OR: 8.97, CI: 1.95-35.3) were significantly lower in DHCA + DR group compared with MHCA + ACP group. CONCLUSIONS: The results of our study demonstrate that DHCA + DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA + ACP. However, the data suggests that DHCA + DR when compared with MHCA + ACP provides better renal protection and reduced prevalence of composite endpoint.

Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients.

INTRODUCTION: Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting. METHODS: We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels. RESULTS: The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke. CONCLUSION: Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Human Mesenchymal Stem Cells Reendothelialize Porcine Heart Valve Scaffolds: Novel Perspectives in Heart Valve Tissue Engineering.

Heart valve diseases are usually treated by surgical intervention addressed for the replacement of the damaged valve with a biosynthetic or mechanical prosthesis. Although this approach guarantees a good quality of life for patients, it is not free from drawbacks (structural deterioration, nonstructural dysfunction, and reintervention). To overcome these limitations, the heart valve tissue engineering (HVTE) is developing new strategies to synthesize novel types of valve substitutes, by identifying efficient sources of both ideal scaffolds and cells. In particular, a natural matrix, able to interact with cellular components, appears to be a suitable solution. On the other hand, the well-known Wharton's jelly mesenchymal stem cells (WJ-MSCs) plasticity, regenerative abilities, and their immunomodulatory capacities make them highly promising for HVTE applications. In the present study, we investigated the possibility to use porcine valve matrix to regenerate in vitro the valve endothelium by WJ-MSCs differentiated along the endothelial lineage, paralleled with human umbilical vein endothelial cells (HUVECs), used as positive control. Here, we were able to successfully decellularize porcine heart valves, which were then recellularized with both differentiated-WJ-MSCs and HUVECs. Data demonstrated that both cell types were able to reconstitute a cellular monolayer. Cells were able to positively interact with the natural matrix and demonstrated the surface expression of typical endothelial markers. Altogether, these data suggest that the interaction between a biological scaffold and WJ-MSCs allows the regeneration of a morphologically well-structured endothelium, opening new perspectives in the field of HVTE.

Novel apical coring device for apicoaortic conduit insertion to treat off-pump aortic stenosis, coronary disease, and lung cancer.

The surgical treatment of concomitant cardiac disease and lung cancer represents a challenge. We report the case of a 66-year-old high-risk female patient with severe aortic stenosis as well as severely impaired left ventricular function associated with coronary artery disease involving the left anterior descending artery complicated from a severe functional mitral regurgitation in which an early-stage non-small cell carcinoma was incidentally discovered during workup. Because of the possibility of potential negative impact of cardiopulmonary bypass on the cancer prognosis and the severe impairment of systolic function of the left ventricle that impeded the treatment of lung cancer as the first step of such a complex treatment, we planned to treat all the diseases in a single-stage procedure. Using an automated delivering system composed of a ventricular connector (Correx AVB; Correx, Inc, Waltham, MA USA), we were able to perform an apicoaortic bypass as well as a left anterior descending revascularization using the left internal thoracic artery, both on a beating heart without the aid of cardiopulmonary bypass and a three-segmentectomy of the left upper lobe with the removal of paraaortic nodes. Six months postoperatively, she was asymptomatic with a noticeable increase of systolic function, a mild mitral incompetence, and no appearance of tumor recurrence. To the best of our knowledge, this is the first case described in the literature in which three major problems involving cardiac valves, coronary arteries, and the lung have been treated in one stage without cardiopulmonary bypass.

Intraoperative graft verification in coronary surgery: increased diagnostic accuracy adding high-resolution epicardial ultrasonography to transit-time flow measurement.

OBJECTIVES: Transit-time flow measurement (TTFM) allows intraoperative functional assessment of grafts in coronary artery bypass grafting (CABG). The major limitation of this technique is a low positive predictive value (PPV) that could lead to unnecessary graft revisions. A combined approach with high-resolution epicardial ultrasonography (HR-ECUS) and TTFM was evaluated for the first time in terms of diagnostic accuracy. The aim of this study is to evaluate the added value of intraoperative HR-ECUS for an improved graft patency verification. METHODS: From November 2009 to September 2012, 333 patients underwent isolated CABG. A total number of 717 grafts were performed; all grafts were intraoperatively verified by means of both TTFM and HR-ECUS. RESULTS: Among 678 grafts considered functioning at TTFM, 3 (0.4%) were failing at HR-ECUS and promptly redone (2 bilateral internal mammary artery-Y-grafts and 1 left internal mammary artery to left anterior descending (LIMA-LAD)). These were confirmed as true positive at graft revision due to technical error. HR-ECUS confirmed the good functioning of the remaining 675 grafts already demonstrated by TTFM; among them, 8 showed high troponin I release (clinical false negative), whereas the remaining 667 had no high TnI release (clinical true negative). In 2 of 39 grafts malfunctioning at TTFM, HR-ECUS confirmed the graft failure; surgical inspection of the anastomosis during redo procedure (in both cases LIMA-to-LAD graft) showed a technical error leading to define those 2 grafts as 'true positive' on the basis of either direct vision and improved post-redo TTFM parameters. Finally, in 35 cases, HR-ECUS did not confirm TTFM diagnosis demonstrating a full patency of the anastomosis; these grafts had an uneventful clinical course (true negative). The main result of this study is the increase of PPV from 10% with TTFM to almost 100% of TTFM + HR-ECUS, avoiding many unnecessary graft revisions. CONCLUSIONS: HR-ECUS should be considered complimentary to TTFM. Simultaneous use of the two methods during CABG provides morphological and functional information improving considerably diagnostic accuracy of intraoperative graft verification procedure close to 100%.

Pseudoaneurysm after patch-free carotid bifurcation endarterectomy: a case report.

The purpose of this report is to present the case of a 59-year-old man affected by multivessel coronary artery disease and sterile pseudoaneurysm of the right carotid bifurcation presenting as a pulsating neck mass 1 month after patch-free carotid endarterectomy. The surgical approach included median sternotomy and incision parallel to the anterior margin of the right sternocleidomastoid muscle. The pseudoaneurysm was excised after control of the brachiocefalic trunk and insertion of a Pruit-Inahara shunt, and the carotid vessels were directly sutured without using any prosthetic or autologous material. Concomitant coronary bypass grafting was performed. The postoperative course was uneventful and there was no evidence of recurrence of pseudoaneurysm at 6-month follow-up. On the basis of this experience and of pertinent literature, the options for the management of such rare entities are discussed.

Recurrence of functional mitral regurgitation in patients with dilated cardiomyopathy undergoing mitral valve repair: how to predict it.

This study was aimed at identifying predictive variables for recurrence of mitral regurgitation (MR) in patients with dilated cardiomyopathy (DCM) undergoing mitral valve (MV) repair. From January 1997 to December 2005, 142 patients with DCM, 105 (73.9%) ischemic and 37 (26.1%) non-ischemic, underwent MV repair. Mean age was 66+/-10 years and mean MR grade was 3.2+/-0.7 (scale 1+ to 4+). Ninety-seven (71% ischemic, 29% non-ischemic), out of 98 still alive at follow-up, were included in this retrospective analysis. In all cases MV posterior annuloplasty was performed; all patients were followed-up by echocardiography (mean time interval of 44+/-28 months) to evaluate MR recurrence (>or=2+/4+). Thirty-day mortality was 9.2% (13 patients). Mean MR grade at follow-up was 0.9+/-0.9. Four-year freedom from MR recurrence was 65.5%+/-8.3. Cox analysis showed left ventricular end-diastolic volume index (LVEDVi, OR=1.03, P=0.016, AUC=0.72), left ventricular end-systolic volume index (LVESVi, OR=1.03, P=0.033, AUC=0.71), left ventricular ejection fraction (LVEF, OR=0.82, P=0.001, AUC=0.72), mitral valve coaptation depth (MVCD, OR=1.6, P=0.017, AUC=0.72) to be predictive variables for MR recurrence. Preoperative left ventricular dilatation and function along with degree of papillary muscle displacement can be helpful in identifying patients with higher probability to undergo a durable MV repair.

Evaluation of less invasive method for saphenous vein harvest in patients with type II diabetes.

BACKGROUND: Diabetes mellitus is an established risk factor for leg wound healing complications after great saphenous vein harvest. Leg healing complications occur in 1-25% of coronary artery bypass graft patients, and are often underestimated. PATIENTS AND METHODS: The records of 230 patients enrolled in a prospective trial to evaluate a minimally invasive approach compared with conventional longitudinal harvest were reviewed. Of 100 patients with diabetes, 49 had undergone minimally invasive harvest (group A). Forty-nine patients from the pool without diabetes who underwent minimally invasive harvest were selected using propensity scoring analysis (group B), and 46 diabetic patients operated using a conventional technique (group C) were matched to group A patients. Ninety-five patients with and 49 without diabetes finally entered the study. The quality of leg wound healing was quantified by ASEPSIS score by two independent surgeons in a blinded manner. The occurrence of complications was compared between groups. RESULTS: Fewer leg wound healing complications occurred in diabetic patients in the minimally invasive compared with the conventional group (P < 0.0001). Rates of complications were comparable among diabetic and non-diabetic patients operated using the minimally invasive technique. The intraoperative flow of vein grafts obtained by the minimally invasive technique was comparable to that of veins harvested using the conventional technique. CONCLUSION: These data suggest that postoperative leg wound morbidity can be significantly attenuated by the adoption of a less invasive approach, even in high-risk patients with diabetes. The advantages are not offset by the co-existence of other cardiovascular risk factors or by a long history of diabetes.

Open clip-free radial artery harvesting with the harmonic shears.

BACKGROUND: The Ultracision Harmonic Scalpel is associated with several advantages in radial artery (RA) harvesting. It allows fewer hemostatic clips to close the collateral branches, less thermal injury of the conduit, and reduced time of harvesting in comparison with the conventional RA harvesting technique with electrocautery and hemostatic clips. We recently started open RA harvesting with the harmonic shears (HSH). In this study, we aimed at evaluating the feasibility of this simplified ultrasonically activated harvesting technique, and report the results of RA harvesting with HSH. METHODS: The RA harvesting with HSH was performed in 20 patients operated on for myocardial revascularization from July 2004 to December 2005. RESULTS: The harvest of the RA was completed in little time, without any complication. Neither bleeding from the collateral branches nor spasm alongside the entire length of the RA was observed. No bleeding occurred from the muscles of the forearm. CONCLUSION: This technique of RA harvesting with HSH is impressive in terms of short time of harvest, complete absence of clips for the collateral branches, and no thermal injury of the conduit.

The "button inside" technique for the aortic root replacement: a modified button technique.

Modified button technique for reattachment of coronary arteries in the aortic root replacement is reported. Anastomosis of the coronary buttons is performed from the inside of the composite valve graft previously including the coronary buttons in the composite valve graft. Reduced tension is present between coronary arteries and the composite valve graft once the heart is beating and the systemic pressure is increasing. In this way coronary buttons are reinforced directly by the composite aortic wall graft prosthesis. The coronary ostia are perfused with lower tension at the site of the coronary anastomoses. No bleeding from the suture line of the coronary buttons occurs using this new surgical approach.