Mechanical Thrombectomy for Stroke After Cardiac Surgery.

Stroke after cardiac surgery remains a devastating complication and its treatment options are limited. Systemic fibrinolysis is a relative contraindication, because it raises the risk of systemic hemorrhage. Endovascular therapy, mechanical thrombectomy, and intra-arterial fibrinolysis have emerged as safer options. We present three patients who developed strokes following cardiac surgery who underwent successful mechanical thrombectomy and review the literature on this subject. doi: 10.1111/jocs.12776 (J Card Surg 2016;31:517-520).

Elective and urgent coronary surgery in octogenarians.

OBJECTIVES: To analyze the influence of surgical myocardial revascularization on early and late mortality in octogenarians and compare the survival rates with age adjusted general population. METHODS: Between 2007 and 2014, 182 octogenarian patients underwent elective or urgent coronary artery bypass grafting surgery. Logistic regression was performed to evaluate the in-hospital mortality predictors. The comparison of long term survival between our population and age adjusted general population was made using one-sample log-rank test. RESULTS: The in-hospital mortality was 4,4% and its predictors on univariable analysis were non sinus rhythm (p=0,001), acute coronary syndrome less than 7 days prior to surgery (p=0,021), ejection fraction less than 50% (p=0,04) and the need for conversion to on pump surgery (p=0,04). On multivariate logistic regression non sinus rhythm and acute myocardial infarction less than 7 days before surgery were independent predictors of in-hospital mortality. Follow-up at one-year showed survival rate of 86,2% and at five years 58,4%. There was no significant difference in survival rates between the study group and the age adjusted standard population (p=0,96). The group was divided in two groups: (1) complete revascularization and (2) incomplete revascularization. There was no significant difference in survival (p=0,32 and p=0,19, respectively) compared to the age adjusted standard population. CONCLUSIONS: Coronary artery bypass grafting in octogenarians is safe and has an important impact on long term survival, with five-year survival being similar to the age adjusted standard population.

Objetivos: Analisar o impacto da revascularização miocárdica cirúrgica na mortalidade precoce e tardia em octogená- rios e comparar a sobrevida com a população geral ajustada para a idade. Métodos: Entre 2007 e 2014, 182 octogenários foram submetidos a cirurgia de revascularização miocárdica eletiva ou urgente. Utilizou-se regressão logística para avaliar os preditores de mortalidade intra-hospitalar. A comparação da sobre- vivência a longo prazo entre a população em estudo e a população ajustada para a idade efetuou-se com o teste one sample log-rank. Resultados: A mortalidade intra-hospitalar foi 4,4% e os seus preditores, na análise univariável, foram ritmo não sinusal (p=0,001), síndrome coronário agudo menos de 7 dias antes da cirurgia (p=0,021), fração de ejeção menos de 50% (p=0,04) e conversão em cirurgia on pump (p=0,04). Na análise multivariada, o ritmo não sinusal e síndrome coronário agudo menos de 7 dias antes da cirurgia foram preditores independentes de mortalidade intra-hospitalar. No seguimento a um ano a sobrevivência foi de 86,2% e a cinco anos de 58,4%. Não se verificou diferença significativa na sobrevivência entre o grupo de estudo e a população geral ajustada para a idade (p=0,96). A população em estudo foi dividida em dois grupos: (1) revascula- rização completa e (2) revascularização incompleta. Não se verificou diferença significativa (p=0,32 e p=0,19, respetivamente) quando comparados com a população geral ajustada para a idade. Conclusão: A cirurgia de revascularização miocárdica em octogenários é segura e tem um importante impacto na sobrevida a longo prazo, com sobrevivência a cinco anos semelhante à população geral ajustada para a idade.

Aortic coarctation repair in the adult.

Aortic coarctation can be repaired surgically or percutaneously. The decision should be made according to the anatomy and location of the coarctation, age of the patient, presence of other cardiac lesions, and other anatomic determinants (extensive collaterals or aortic calcification). This article reviews the different therapeutic options available, explaining the differences between children and adults, describing different approaches to the same disease, exemplified by three cases of nonclassic surgical approach and one percutaneous treatment.

Surgical treatment of ascending aorta and innominate artery trunk aneurysm with displaced brachiocephalic vessels.

The surgical treatment of ascending aortic and arch aneurysms, even though technically complex and requiring care to avoid neurological sequelae, is well established. Nevertheless, the presence of a significant innominate artery trunk aneurysm implies an adaptation of the surgical options available. We report a case of an aortic aneurysm that involved the ascending aorta, the proximal transverse arch and the brachiocephalic trunk with cranial displacement of the right subclavian and common carotid arteries. This pattern, meant that it was mandatory to change the usual surgical approach. We resected the ascending aorta and the proximal aortic arch replacing them with a dacron prosthesis in a usual fashion. Nevertheless, we were compelled to perform the anastomoses of the innominate trunk branches in an extrathoracic fashion. Furthermore, to ensure an uninterrupted cerebral perfusion, the usual surgical steps were personalized. The anatomical findings, computed tomographic images, surgical technique, cerebral protection and postoperative evaluation are described.

Inhaled nitric oxide reduces ischemia-reperfusion injury in rat lungs from non-heart-beating donors.

OBJECTIVE: If lungs could be retrieved from non-heart-beating donors, the critical shortage of lungs for transplantation could be alleviated. However, lungs subjected to warm ischemia develop edema when reperfused. We hypothesized that ventilation of rat lungs from non-heart-beating donors with nitric oxide during the period of warm ischemia alone, with reperfusion, or both might reduce ischemia-reperfusion injury. METHODS: An isolated perfused rat lung model measured the filtration coefficient and accumulation of lung water by the wet/dry weight ratio. Donor rats were euthanized, and then lungs were retrieved immediately after death or 2 or 3 hours postmortem. Lungs retrieved postmortem were either not ventilated or ventilated with 100% oxygen alone or 40 ppm nitric oxide in oxygen. In the circuit, lungs were ventilated with alveolar gas with or without 40 ppm nitric oxide. RESULTS: Nitric oxide administration to the non-heart-beating donor or in the perfusion circuit reduced filtration coefficient and wet/dry weight ratio. Lungs retrieved 2 hours postmortem ventilated with nitric oxide or treated with nitric oxide on reperfusion had filtration coefficients and wet/dry weight ratios similar to those of lungs retrieved immediately after death. Nitric oxide was most beneficial when administered both during warm ischemia and at reperfusion in lungs retrieved 3 hours postmortem. Nitric oxide administration in the circuit was associated with increased lung levels of lung cyclic guanosine monophosphate, determined by enzyme-linked immunosorbent assay. CONCLUSIONS: Administration of nitric oxide to non-heart-beating donors during warm ischemia and with reperfusion might facilitate transplantation of lungs from non-heart-beating donors by reducing ischemia-reperfusion injury and capillary leak.

Triangular resection and folding of posterior leaflet for mitral valve repair.

The conventional treatment of mitral insufficiency, due to posterior leaflet prolapse, is quadrangular resection. This technique sacrifices a great amount of valve tissue resulting in leaflet stiffness and altered annular geometry. To avoid such problems we performed a small triangular leaflet resection sparing the second-order chordae, a folding plasty, implantation of artificial chordae, and annuloplasty. Fourteen patients underwent this procedure. No hospital death and no repair failure were observed. Echocardiography at 12 months on 12 patients showed trivial incompetence in three and mild in one and an overall improvement of end-diastolic and end-systolic diameters. Our technique has the main objectives of sparing second-order chordae and subvalvular apparatus in order to preserve mobility of the posterior mitral leaflet, left ventricular geometry, and function. Preliminary results are encouraging.

Ex vivo evaluation of human lungs for transplant suitability.

BACKGROUND: If lungs could be retrieved from non-heart-beating donors, the critical shortage of lungs for transplant could be alleviated. An obstacle to this approach is the inability to predict these lungs' suitability for transplant. We used human lungs deemed unsuitable for transplant to develop a method to perfuse and ventilate human lungs ex vivo to assess gas exchange and vascular resistance, and to perform bronchoscopic inspection and radiographic evaluation. METHODS: Lungs were retrieved from six brain-dead organ donors after cold Perfadex (Vitrolife, Kungsbacka, Sweden) flush, stored cold for 6 to 13 hours (mean, 8.7 hours) then perfused and rewarmed in a modified cardiopulmonary bypass circuit. Circuit perfusate was buffered colloid-crystalloid containing type-specific leukocyte-filtered blood (hematocrit of 10%-12%), circulated through a membrane oxygenator ventilated with CO2 and nitrogen to deoxygenate it. Lungs were ventilated with fraction of inspired oxygen (Fio2) 0.5 when 32 degrees C was reached. Gas exchange and vascular resistance was assessed at 5 L/minute flow at 37 degrees C, Fio2 0.5 and 1.0. Bronchoscopy, plain radiographs, and spiral computed tomographic (CT) scans were performed. Lung biopsies were obtained pre- and post-reperfusion. RESULTS: Ex vivo perfusion did not cause increased wet to dry ratio, or major abnormalities by microscopy but was associated with elevated tissue levels of conjugated dienes. The alveolar-arterial difference in partial pressure of oxygen (Pao2)/Fio2 ratio in the ex vivo circuit was generally higher than in the six donors. Ex vivo radiographs and CT scans were abnormal in all lungs, confirming unsuitability of these lungs for transplant. CONCLUSIONS: Ex vivo evaluation of human lungs is feasible and may be useful to evaluate transplant suitability of lungs retrieved after circulatory arrest from non-heart-beating donors.

Trends in lung pH and PO2 after circulatory arrest: implications for non-heart-beating donors and cell culture models of lung ischemia-reperfusion injury.

BACKGROUND: A better understanding of lung tissue environment after circulatory arrest would allow more accurate cell culture models to study ischemia-reperfusion lung injury and facilitate retrieval of lungs from non-heart-beating donors. METHODS: To establish the time course of changes in pH and PO2 in lung tissue after circulatory arrest, 12 Sprague-Dawley rats were sacrificed. After sternotomy, pH and PO2 microelectrodes were inserted into the lungs and sealed by application of Focal Seal. Rats were maintained at normothermia (37 degrees C). Two groups of rats (n = 6 atelectatic, n = 6 room air-inflated) were followed for 4 hours after arrest, when lung tissue adenine nucleotide levels were measured by chromatography and cell death was quantified by trypan blue exclusion. Human umbilical vein endothelial cells underwent simulated ischemia and 6 hours of cold storage by replacement of culture medium with cold Perfadex. Interleukin (IL)-6 and IL-8 were measured in medium 21 hours later by enzyme-linked immunosorbent assay (ELISA). RESULTS: In both groups of rats, lung [H+] increased linearly with time. In atelectatic lungs, PO2 fell precipitously, but in inflated lungs, PO2 decreased linearly for 60 to 75 minutes post-mortem and then became stable. After 4 hours at 37 degrees C, most parenchymal lung cells were dead in both groups. IL-6 and IL-8 levels increased significantly in medium of cultured endothelial cells subjected to cold storage without hypoxia. CONCLUSIONS: In room-air-inflated lungs maintained at 37 degrees C, oxygen consumption continues for at least 1 hour after circulatory arrest. Warm atelectasis is poorly tolerated. Hypothermic storage can induce elaboration of cytokines by endothelial cells in the absence of hypoxia.

Isoproterenol reduces ischemia-reperfusion lung injury despite beta-blockade.

BACKGROUND: If lungs could be retrieved from non-heart-beating donors (NHBDs), the shortage of lungs for transplantation could be alleviated. The use of lungs from NHBDs is associated with a mandatory warm ischemic interval, which results in ischemia-reperfusion injury upon reperfusion. In an earlier study, rat lungs retrieved 2-h postmortem from NHBDs had reduced capillary leak measured by filtration coefficient (Kfc) when reperfused with isoproterenol (iso), associated with an increase in lung tissue levels of cyclic AMP (cAMP). The objective was to determine if this decrease in Kfc was because of beta-stimulation, or would persist despite beta-blockade. MATERIALS AND METHODS: Donor rats were treated intraperitoneally with beta-blockade (propranolol or pindolol) or carrier, sacrificed, and lungs were retrieved immediately or 2 h postmortem. The lungs were reperfused with or without iso and the beta-blockers in the reperfusate. Outcome measures were Kfc, wet:dry weight ratio (W/D), lung levels of adenine nucleotides and cAMP. RESULTS: Lungs retrieved immediately after death had normal Kfc and W/D. After 2 h of ischemia, Kfc and W/D were markedly elevated in controls (no drug) and lungs reperfused with beta-blockers alone. Isoproterenol-reperfusion decreased Kfc and W/D significantly (P < 0.01) even in the presence of beta-blockade. Lung cAMP levels were increased only with iso in the absence of beta-blockade. CONCLUSIONS: The attenuation of ischemia-reperfusion injury because of iso occurs even in the presence of beta-blockade, and may not be a result of beta-stimulated increased cAMP.