Aortic Arch. The Final Frontier in Cardiac Surgery.

Aortic arch pathologies such as acute aortic dissection and aneurysmal disease represent surgical challenges. Various emerging techniques and surgical prostheses have expanded the therapeutic armamentarium over the last years with one principal objective; to simplify the operation and reduce the surgical time. Besides the classic elephant trunk which has been regarded as an evolutionary leap in the treatment of extensive thoracic disease, other novel surgical approaches such as the frozen elephant trunk, the thoracic endovascular aortic repair (TEVAR) and the hybrid open branched stent grafts have been introduced. This brief review aims to evaluate the surgical alternatives used in the management of complex aortic arch and proximal descending aorta pathologies with particular consideration given to the contemporary approaches which endorse single stage operation.

Endoscopic port access surgery for isolated atrioventricular valve endocarditis.

OBJECTIVES: Our goal was to report the clinical and echocardiographic outcomes of endoscopic port access surgery for isolated active and convalescent atrioventricular valve endocarditis (AVVE). METHODS: Our current surgical team performed endoscopic port access surgery in 66 consecutive patients with isolated AVVE (mean age, 65.5 ± 12.7 years, 37.9% women, mean EuroSCORE II 31.2 ± 24.9%, 45.5% prosthetic AVVE, Staphylococcus aureus 22.2%), between 1 May 2004 and 31 July 2015. Isolated mitral valve endocarditis was present in 53 (80.4%) patients, including 11 (16.7%) with periannular abscesses. RESULTS: Procedures performed included mitral valve repair (n = 15, 22.7%) and left ventricular septal myomectomy (n = 1, 1.5%). Reasons for sternotomy conversion (n = 6, 9.1%) included lung adhesions (n = 3, 4.5%). The mean cardiopulmonary bypass and ischaemic times were 167.2 ±48.7 and 112.6 ± 33.3 min, respectively. In-hospital morbidities included revision for bleeding (n = 6, 9.1%). The 30-day survival rate was 87.9%. Causes of in-hospital deaths (n = 12) included low cardiac output syndrome (n = 3, 4.5%). Age, critical preoperative status and EuroSCORE II score predicted deaths individually at the 5% level of significance. The Kaplan-Meier analyses (mean 63.2 ± 42.5 months) for survival and freedom from AVVE reintervention at 10 years were 69.4% and 98.4%, respectively. Of the mid-term survivors (n = 50, 93.9% complete), 94.0% (n = 47) classified as New York Heart Association (NYHA) II or less with no mitral valve regurgitation greater than Grade I. CONCLUSIONS: Complex atrioventricular valve surgery in the context of AVVE can be endoscopically performed in experienced centres and should not deter surgeons from offering patients with AVVE the potential benefits of minimally invasive cardiac surgery.

What is the optimal target for the second arterial graft in patients undergoing coronary bypass surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the anterolateral or the inferior wall served as a better location for the 2nd arterial graft in a 3-system coronary artery bypass grafting procedure. In total, more than 1800 papers were found, of which 6 represented the best evidence to answer the clinical question. All papers demonstrated equivalent early postoperative mortality and morbidity. The 3 largest studies comparing bilateral internal thoracic arteries showed no difference in perioperative mortality and morbidity regardless of whether the 2nd internal thoracic artery was used to graft the left or right system. One of these studies, however, showed significant survival benefit for the left-sided group at 8 years, whereas another study showed a reduced patency of right internal thoracic arteries when grafted to the right coronary artery and when used in situ. One study compared radial grafts to the right- and left-sided targets and showed no difference in long-term patency. Another study also reported on the angiographic patency of right internal thoracic arteries. The authors noted a non-significant increase in graft failure when non-left anterior descending arteries were grafted but no difference between circumflex or posterior descending arteries. All studies demonstrated similar or better mid- and long-term outcomes and patency rates when using the 2nd arterial graft to revascularize left-sided targets when compared with the right. However, all outcomes were similar when comparing non-left anterior descending left-sided targets with non-right coronary artery right-sided targets. Therefore, the right coronary artery itself should probably be avoided as the 2nd arterial target.

Initial experience with xenograft bioconduit for the treatment of complex prosthetic valve endocarditis.

INTRODUCTION: The treatment of complex prosthetic valve endocarditis (PVE) with aortic root abscess remains a surgical challenge. Several studies support the use of biological tissues to minimize the risk of recurrent infection. We present our initial surgical experience with the use of an aortic xenograft conduit for aortic valve and root replacement. METHODS: Between October 2013 and August 2015, 15 xenograft bioconduits were implanted for complex PVE with abscess (13.3% female). In 6 patients, concomitant procedures were performed: coronary bypass (n=1), mitral valve replacement (n=5) and tricuspid annuloplasty (n=1). The mean age at operation was 60.3±15.5 years. The mean Logistic European system for cardiac operating risk evaluation (EuroSCORE) was 46.6±23.6. The median follow-up time was 607±328 days (range: 172-1074 days). RESULTS: There were two in-hospital deaths (14.3% mortality), two strokes (14.3%) and seven patients required permanent pacemaker insertion for conduction abnormalities (46.7%). The mean length of hospital stay was 26 days. At pre-discharge echocardiography, the conduit mean gradient was 9.3±3.3mmHg and there was either none (n=6), trace (n=6) or mild aortic insufficiency (n=1). There was no incidence of mid-term death, prosthesis-related complications or recurrent endocarditis. CONCLUSIONS: Xenograft bioconduits may be safe and effective for aortic valve and root replacement for complex PVE with aortic root abscess. Although excess early mortality reflects the complexity of the patient population, there was good valve hemodynamics, with no incidence of recurrent endocarditis or prosthesis failure in the mid-term. Our data support the continued use and evaluation of this biological prosthesis in this high-risk patient cohort.

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.

Robotic-enhanced coronary surgery in octogenarians.

Objectives: Robotic-enhanced minimally invasive direct coronary artery bypass grafting surgery (RE-MIDCAB) is based on the use of a robotic console and instrumentation for the dissection of the left internal thoracic artery (LITA). The LITA to left anterior descending (LAD) artery anastomosis is subsequently constructed through a mini thoracotomy. The purpose of this study is to present our experience of RE-MIDCAB outcomes in elderly patients. Methods: From 2002 until 2015, 44 octogenarians (the mean age of 82.9 years) underwent RE-MIDCAB. The mean logistic EuroSCORE was 9.2. The majority of the patients were male with a medical history of hypertension, dyslipidaemia and previous coronary interventions. Of these patients 25% underwent RE-MIDCAB combined with percutaneous coronary intervention (PCI) for the treatment of multi-vessel disease (hybrid revascularization). Results: All RE-MIDCABs and combined 'hybrid' PCI procedures were successfully completed. The mean intensive care unit (ICU) and hospital stay were 1.6 days and 10.9 days, respectively. There was 1 in-hospital mortality (2.3%). After an average follow-up period of 29.2 months, 5 patients required repeat revascularization procedures (9.1%). Mortality on follow-up was estimated at 25.6%. Conclusions: Our report suggests that considering the age and frailty of the octogenarian population, RE-MIDCAB is a feasible and safe procedure which is associated with acceptable mid-term results.

Combined endoscopic and transcatheter treatment of native mitral stenosis.

This report describes an approach for the treatment of high-risk native mitral valve stenosis. It incorporates the deployment of a transcatheter valve in the mitral position under full endoscopic vision, combined with endoscopic mitral repair techniques that secure valve positioning and reduce the risk of paravalvular leak. This approach could be used as a rescue procedure in centres with experience in transcatheter and endoscopic valve techniques.

Treatment of a pseudoaneurysm of the ascending aorta in association with aortopulmonary fistula following acute Type A dissection.

This report describes a rare case of aortic pseudoaneurysm with an aortopulmonary fistula in a 69-year-old woman two years following repair of a Type A aortic dissection. The patient presented with NYHA Class IV symptoms having deteriorated rapidly over a course of six weeks. We describe our successful surgical repair following a failed attempt of percutaneous closure with an atrial septal occlusion device.

Isolated tricuspid valve repair after metastatic tumor resection.

Isolated tricuspid valve repairs are performed in adults most commonly as a result of infective endocarditis, traumatic injury, rheumatic involvement, and ischemia. The use of neochordae made from polytetrafluoroethylene, being widespread in mitral valve operations, is gaining ground in tricuspid valve repair. We report a very rare case that describes isolated tricuspid valve repair using neochordae after resection of a right ventricular tumor involving the tricuspid valve. The tumor isolated was metastatic teratoma in a patient with growing teratoma syndrome. We further describe our technique of tricuspid neochord implantation and the rationale behind the repair.

The outcomes of triple-valve surgery: eleven years' experience from a single center.

BACKGROUND AND AIM OF THE STUDY: Triple-valve surgery is a challenging and complex procedure with significant risk, even at centers experienced at performing such operations. The study aim was to investigate the early and late outcomes of this surgery, performed at a single center for the past 11 years. METHODS: A total of 45 consecutive patients (19 males, 26 females; mean age 69.42 +/- 12.72 years) underwent triple-valve surgery at the authors' institution between 2000 and 2011. The mean logistic EuroSCORE was 22.46 +/- 12.8%. The most common aortic valve pathology was calcific degeneration (40%), while the mitral valves were mostly rheumatic (31%) or degenerative (26%). The tricuspid valve pathology was functional regurgitation in 64% of patients. The aortic valve procedures were all replacements, while the mitral valves were either repaired (n = 20) or replaced (n = 25). The tricuspid valves were almost exclusively repaired (n = 43). Univariate and multivariate analyses were performed to highlight predictors of mortality. A Kaplan-Meier analysis was also performed. RESULTS: The operative mortality was 8.9% (n = 4). Survival at one, three, and five years was 91%, 85.5% and 66.4%, respectively. Morbidity was not particularly high: the incidence of all postoperative neurological complications was 13%, that of transient renal impairment was 18%, and pacemaker implantation 8.9%. CONCLUSION: The results of triple-valve surgery were considerably improved compared to historical reports. Early mortality was close to that occurring after less complex procedures, while late survival was comparable to that after single-valve surgery. It is believed that the best results are achieved by centers experienced in valve procedures. Compared to older studies, rheumatic disease was not the most frequent requirement for of triple-valve surgery among the present patients.

Giant thoracoabdominal ganglioneuroblastoma in a 17-year-old patient.

The most common malignant neurogenic tumors in children are neuroblastic tumors, classified as ganglioneuroblastoma or neuroblastoma. Ganglioneuroblastomas usually occur at the sympathetic ganglia in the mediastinum, whereas neuroblastomas occur in the abdominal cavity. We describe a case of large posterior mediastinal ganglioneuroblastoma extending from the aortic arch to the left renal hilum in a 17-year-old boy. Despite chemotherapy, post-treatment computed tomography showed disease progression. The patient underwent a thoracolaparotomy incision and excision of the tumor. These malignant mediastinal tumors can potentially grow to a very large size. If alternative treatment has failed, resection can be accomplished with relative safety.

Uniportal video-assisted thoracic surgery: the lesser invasive thoracic surgery.

OBJECTIVES: We evaluated whether single-port video-assisted thoracic surgery is feasible without compromising outcomes, and whether the technique could be reproduced by a trainee. METHODS: In a 6-month period, 37 operations were performed by single-port video-assisted thoracic surgery. Of the 37 patients, 27 (73%) were male and the mean age was 45.1 ± 21 years. Twenty-three (62%) were operated on by consultants and 14 (38%) by trainees. The procedures included 19 (51.3%) operations for treatment of pneumothoraces, 8 (21.6%) metastasectomies, 7 (18.9%) lung biopsies, 2 (5.4%) empyema débridements, and 1 (2.7%) pleuropericardial window. RESULTS: Mean operative time was 51.8 ± 14.7 min. Patient-controlled analgesia infusion was used for 1.3 ± 1 days. Three (8.1%) patients needed an operative reintervention, but there was no intensive treatment unit admission or hospital mortality. Mean postoperative hospital stay was 3.3 ± 2.7 days. On follow-up, all patients had a tissue diagnosis and all lung nodules were R0 resections. Patients operated on by consultants and trainees had similar preoperative profiles and postoperative outcomes, except that those operated on by trainees used patient-controlled analgesia significantly longer (1.8 ± 1.48 vs. 1 ± 0.48 days; p = 0.03). CONCLUSION: Single-port video-assisted thoracic surgery can be performed and reproduced well without compromising outcomes. It is considered aesthetically better and may reduce analgesic requirements, but it might not reduce hospital stay.

Platelet-rich plasma (PRP) promotes fetal mesenchymal stem/stromal cell migration and wound healing process.

Numerous studies have shown the presence of high levels of growth factors during the process of healing. Growth factors act by binding to the cell surface receptors and contribute to the subsequent activation of signal transduction mechanisms. Wound healing requires a complex of biological and molecular events that includes attraction and proliferation of different type of cells to the wound site, differentiation and angiogenesis. More specifically, migration of various cell types, such as endothelial cells and their precursors, mesenchymal stem/stromal cells (MSCs) or skin fibroblasts (DFs) plays an important role in the healing process. In recent years, the application of platelet rich plasma (PRP) to surgical wounds and skin ulcerations is becoming more frequent, as it is believed to accelerate the healing process. The local enrichment of growth factors at the wound after PRP application causes a stimulation of tissue regeneration. Herein, we studied: (i) the effect of autologous PRP in skin ulcers of patients of different aetiology, (ii) the proteomic profile of PRP, (iii) the migration potential of amniotic fluid MSCs and DFs in the presence of PRP extract in vitro, (iv) the use of the PRP extract as a substitute for serum in cultivating AF-MSCs. Considering its easy access, PRP may provide a valuable tool in multiple therapeutic approaches.

The prominent role of cardiac magnetic resonance imaging in coronary artery disease.

The role of cardiac magnetic resonance (CMR) in coronary artery disease is prominent. CMR provides functional and structural heart disease assessment with high accuracy. It allows accurate cardiac volume and flow quantification and wall motion analysis both at rest and at stress. CMR myocardial perfusion studies detect myocardial ischemia and provide insights into the morphology of the myocardial tissue. CMR imaging noninvasively differentiates causes of myocardial injury such as ischemia or inflammation; stages of myocardial injury, such as acute or chronic; grade of myocardial damage, such as reversible or irreversible; myocardial fibrosis or scar. There is an emerging role of CMR in patients with acute chest presentation since it can demonstrate causes of chest pain other than coronary artery disease such as myocarditis, pericarditis, aortic dissection and pulmonary embolism. CMR is noninvasive and radiation-free. It's combined approach of functional and structural cardiac assessment makes it unique compared with other imaging modalities.