Concomitant Tricuspid Valve Ring Annuloplasty During Mitral Valve Surgery Versus Mitral Valve Surgery Alone: A Systematic Review and Meta-Analysis.

AIM: Although current guidelines recommend concomitant tricuspid annuloplasty for moderate or greater tricuspid regurgitation (TR) and/or dilated annulus, there remains significant variation in undertaking concomitant tricuspid valve surgery (TVA) across different centres. This meta-analysis aimed to compare the clinical outcomes of concomitant tricuspid valve surgery for patients with moderate or greater TR and/or dilated annulus at the time of mitral valve (MV) surgery. METHOD: A systematic review of the literature using six databases. Eligible studies include comparative studies on TVA concomitant with MV surgery versus MV surgery alone. A meta-analysis was performed on studies reporting outcomes of interest to quantify the effects of concomitant tricuspid ring annuloplasty. RESULTS: Two randomised controlled trials and six cohort studies were included in the analysis. 1,941 patients were included in the analysis, of whom, 1,090 underwent concomitant TVA and 851 underwent MV surgery alone. Pooled analysis demonstrated that there was less progression of moderate/severe TR in the concomitant group (3.0% vs 9.6%; odds ratio [OR] 0.29; 95% confidence interval [CI] 0.13-0.55; p=0.0001). There was no significant difference in in-hospital mortality (3.0% vs 3.8%; OR 0.79; 95% CI 0.47-1.34; p=0.38). The rate of permanent pacemaker implantation was higher in the concomitant group although this did not reach statistical significance (7.6% vs 5.3%; OR 1.30; 95% CI 0.85-1.98; p=0.23). Cardiopulmonary bypass was longer in the concomitant TVA group by 20 minutes (mean difference 13.9-26.0; p<0.00001). CONCLUSIONS: Our study demonstrated that concomitant tricuspid ring annuloplasty at the time of MV surgery is associated with a significantly lower rate of TR progression without increasing the operative mortality. There is a trend towards a higher permanent pacemaker implantation rate although this did not reach statistical significance.

Recurrent infection and embolism following tricuspid valve repair for infective endocarditis in an intravenous drug user: A clinical dilemma.

Management of infective endocarditis (IE) in intravenous drug users (IVDUs) can be challenging due to risk of reinfection following surgery. Although complex repair techniques that can be utilized to reconstruct the tricuspid valve after extensive debridement, treatment of active IVDU is incomplete without effective post-operative harm reduction intervention program.

Salvage debulking surgery and hyperthermic intrathoracic chemotherapy for massive recurrent mesothelioma in the mediastinum.

Mediastinal malignant pleural mesothelioma with signs of tamponade is rare. Indication for reoperation for recurrent malignant pleural mesothelioma is a controversial but viable option in selected patients. We report a case of a 68-year-old man presenting with epithelioid malignant pleural mesothelioma who underwent a total of three debulking surgeries (pleurectomy/decortication) combined with hyperthermic intrathoracic chemotherapy. Five years after the first procedure, a third urgent operation was performed for recurrence of a large mediastinal mesothelioma causing acute symptoms of pericardial constriction and tamponade. The patient was alive for eight years since the first treatment and 36 months after the second reoperation.

In patients with thoracic aortic graft infection, is graft explantation and replacement superior to in situ graft preservation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether graft explantation and replacement are superior to graft preservation in patients with thoracic aortic graft infections. Altogether, more than 487 papers were found using the reported search; of these, 7 comparative studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Although thoracic aortic graft infection is uncommon following cardiac surgery, it still carries a significant risk of in-hospital mortality and poor long-term survival. Current findings in the literature are limited to retrospective cohort studies with relatively small sample sizes; also, there is a lack of randomized controlled trials on this topic. There was significant heterogeneity in patient groups and variation in surgical techniques across centres. In this context, a graft-sparing approach may be a safe therapy with comparable early mortality and late survival outcomes in carefully selected patients. The selection may include the absence of graft pseudoaneurysm, anastomotic leak and fistula; the presence of indolent infection in patients with poor clinical conditions; and significant frailty and comorbidities where the risks of surgical explantation exceed the benefits. The rate of reinfection is low following both graft replacement and the graft-sparing approach. Moreover, the use of a tissue flap improves the surgical outcomes.

Myocardial infarction and ventricular fibrillation due to iatrogenic right coronary artery occlusion following tricuspid valve annuloplasty: a case report.

BACKGROUND: Iatrogenic right coronary artery (RCA) injury is a rare complication of tricuspid valve annuloplasty. Given that surgical intervention is increasingly favoured for tricuspid regurgitation, it is of great importance to recognize potential complications following tricuspid valve surgery. CASE SUMMARY: A 72-year-old man underwent surgical mitral and tricuspid valve repair. The early post-operative course was complicated by recurrent ventricular fibrillation episodes. Due to haemodynamic instability, a re-sternotomy and another cardiopulmonary bypass run were required. The patient subsequently underwent coronary angiography study which confirmed RCA occlusion. The occluded posterior left ventricular (PLV) branch was reopened by balloon angioplasty. However, despite multiple attempts it was not possible to pass a coronary guide wire into the posterior descending artery (PDA). An intravascular ultrasound examination revealed that the ostium of the PDA was compressed by external factors leaving a narrow slit-like appearance with no accessible lumen. Subsequently, a drug-eluting stent was placed into the PLV branch. The PDA was not accessible on repeated re-canalization attempts. The patient later successfully recovered from the right ventricular myocardial infarction. DISCUSSION: Right coronary artery occlusion should be considered as a differential diagnosis for significant rhythm disturbances and haemodynamic instability in the peri- and post-operative period following tricuspid valve annuloplasty. A low threshold for diagnostic angiography is needed to avoid potential delay in life-saving revascularization.

Frozen elephant trunk does not increase incidence of paraplegia in patients with acute type A aortic dissection.

OBJECTIVE: We seek to assess the safety of total arch replacement with frozen elephant trunk for acute type A aortic dissection in respect to the risks of operative mortality, stroke, and paraplegia using an international multicenter registry (ARCH). METHODS: The ARCH Registry database from 37 participating centers was analyzed between 2000 and 2015. Patients who underwent emergency surgery for acute type A aortic dissection treated by total arch replacement with or without frozen elephant trunk were included. Operative mortality, permanent neurologic deficits, and spinal cord injury were primary end points. These end points were analyzed using univariate and hierarchical multivariate regression analyses, as well as conditional logistic regression analysis and post hoc propensity-score stratification. RESULTS: A total of 11,928 patients were enrolled in the ARCH database, of which 6180 were managed with total arch replacement. A comprehensive analysis was performed for 978 patients who underwent total aortic arch replacement for acute type A aortic dissection with or without frozen elephant trunk placement. In propensity-score matching, there were no significant differences between total arch replacement and frozen elephant trunk in terms of permanent neurologic deficits (11.9% vs 10.1%, P = .59) and spinal cord injury (4.0% vs 6.3%, P = .52) For patients included in the post hoc propensity-score stratification, frozen elephant trunk was associated with a statistically significantly lower mortality risk (odds ratio, 0.47; P = .03). CONCLUSIONS: The use of frozen elephant trunk for acute type A aortic dissection does not appear to increase the risk of paraplegia in appropriately selected patients at experienced centers. The exact risk factors for paraplegia remain to be determined.

Giant Aortic Thrombus in the Ascending Aorta and Perforation of Bowel Associated With Cocaine Use.

A floating giant aortic thrombus is a rare finding in the absence of any coagulation disorder. Patients usually remain asymptomatic until the development of embolic complications. Our report highlights cocaine abuse as a potential cause of aortic thrombus and bowel perforation. Clinicians should have a high index of suspicion when treating patients with a history of illicit cocaine use with signs and symptoms of arterial ischemia. The risks of cardiovascular and abdominal complications related to cocaine use should not be underestimated. Prompt diagnosis is required to circumvent potentially life-threatening complications.

Surgical septal myectomy or alcohol septal ablation: which approach offers better outcomes for patients with hypertrophic obstructive cardiomyopathy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether surgical septal myectomy (SM) is more beneficial than alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy. Altogether 218 articles were found using the reported search, of which 15 studies represented the best evidence to answer the clinical question. There were 14 observational studies and 1 meta-analysis study. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these articles are tabulated. Surgical SM was generally performed in younger patients whereas percutaneous ASA was favoured in patients with advanced age and significant co-morbidities. In a large study comprising 716 patients, the reduction of median residual left ventricular outflow tract (LVOT) gradient at 3 months was comparable after ASA (102 ± 52-10 mmHg) and SM (92 ± 39-9 mmHg). The New York Heart Association (NYHA) functional class and symptomatic improvement for either approach was comparable. Findings from the meta-analysis study showed that patients who underwent ASA had a higher incidence of post-procedure device implantation (odds ratio 3.09; P < 0.00001), as reported in 6 other studies. The risk of permanent pacemaker insertion during follow-up (FU) varied between 2.4-12.5% in SM and 1.7-22.0% in ASA. Isolated surgical myectomy and ASA are safe and effective in abolishing outflow obstruction, although the resolution of LVOT pressure gradient is more complete with surgery. The post-procedural and late mortality rates between the 2 groups are consistently low and comparable in carefully selected patients. Nonetheless, ASA is associated with the increased likelihood of complications such as permanent pacemaker implantation, early sustained-VT and VF, and re-intervention. Overall, when performed by experienced cardiologists and surgeons, both techniques are safe and effective in most cases and therefore treatment should be offered based on patient choice.

Acute complete uterine inversion after controlled cord traction of placenta following vaginal delivery: a case report.

Early recognition and active management of the third stage of labor will reduce the risks associated with uterine inversion. All staff members in the maternal unit should be updated with Green-Top guidelines No. 52 and be appropriately trained in the PROMPT course to provide a standardized approach in obstetric emergencies.

Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis.

BACKGROUND: Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection. METHODS: A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement. RESULT: Fourteen retrospective studies met the inclusion criteria and 2,221 patients were included in the final analysis. Pooled analysis showed that hemiarch replacement was associated with a lower risk of post-operative renal dialysis [risk ratio (RR) =0.72; 95% confidence interval (CI): 0.56-0.94; P=0.02; I(2)=0%]. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65-1.09; P=0.20; I(2)=0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation. CONCLUSIONS: Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation.

Is moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion superior to deep hypothermic circulatory arrest in elective aortic arch surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether moderate hypothermia circulatory arrest with selective antegrade cerebral perfusion (SACP) is more beneficial than deep hypothermic circulatory arrest in elective aortic arch surgery. Altogether, 1028 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There were four retrospective observational studies, one prospective randomized controlled trial and one meta-analysis study. There were no local or neuromuscular complications related to axillary arterial cannulation reported. In the elective setting, four studies showed that the in-hospital mortality for moderate hypothermia is consistently low, ranging from 1.0 to 4.3%. In a large series of hemiarch replacement comparing 682 cases of deep hypothermia with 94 cases of moderate hypothermia with SACP, 20 cases (2.8%) of permanent neurological deficit were reported, compared to 3 cases (3.2%) in moderate hypothermia. Three observational studies and a meta-analysis study did not identify an increased risk of postoperative renal failure and dialysis following either deep or moderate hypothermia although a higher incidence of stroke was reported in the meta-analysis study with deep hypothermia (12.7 vs 7.3%). Longer cardiopulmonary bypass time and circulatory arrest time were reported in four studies for deep hypothermia, suggesting an increased time required for systemic cooling and rewarming in that group. Overall, these findings suggested that in elective aortic arch surgery, moderate hypothermia with selective antegrade cerebral perfusion adapted to the duration of circulatory arrest can be performed safely with acceptable mortality and morbidity outcomes. The risk of spinal cord and visceral organ complications is low with the use of this cerebral adjunct. Current studies did not identify an advantage in terms of postoperative bleeding when compared with deep hypothermia. The moderate hypothermia strategy reduced operative time without increasing the mortality and morbidity of surgery.

Body Mass Index and Smoking Affect Thioguanine Nucleotide Levels in Inflammatory Bowel Disease.

INTRODUCTION: Optimal levels of the thiopurine metabolite, 6-thioguanine nucleotides [6-TGN] correlate with remission of inflammatory bowel disease [IBD]. Apart from variations in the thiopurine methyl transferase [TPMT] gene, little is known about other predictors of 6-TGN levels. Obesity adversely affects response to infliximab and adalimumab and clinical course in IBD, but little is known about the interaction of thiopurines and obesity. We investigated the relationship between body mass index [BMI] and 6-TGN levels and sought to examine other predictors of 6-TGN levels. METHODS: This retrospective cohort study included patients with concurrent measurements of 6-TGN and BMI. The association between 6-TGN and clinical variables including BMI was estimated using a multivariable linear regression model. RESULTS: Of 132 observations, 77 [58%] had Crohn's disease and 55 [42%] ulcerative colitis. BMI, smoking, and TPMT levels were associated with 6-TGN levels in multivariable analysis. Every 5kg/m(2) increase in BMI was associated with an 8% decrease in 6-TGN (0.92; 95% confidence interval [CI] 0.87-0.98; p = 0.009). Smokers had higher 6-TGN levels in comparison with non-/ex-smokers [1.43; 95% CI 1.02-2.02; p = 0.041]. Patients with intermediate TPMT had higher 6-TGN compared to those with normal levels [2.13; 95% CI 1.62-2.80; p < 0.001]. Obese patients were more likely to have sub-therapeutic 6-TGN levels and a higher methyl mercaptopurine nucleotide [MMPN/TGN] ratio despite a similar dose of thiopurines. CONCLUSIONS: Active smoking and intermediate TPMT values were associated with higher 6-TGN levels but increasing BMI resulted in lower 6-TGN and higher MMPN levels. This may explain the worse outcome that has been reported previously in obese IBD subjects.