Early results of bare metal extension stent for thoracoabdominal aortic dissection.

Objectives: Debakey type I and IIIb aortic dissections are complicated by extension along the full length of the aorta. Over the long term, the thoracoabdominal aorta in these patients often continues to degenerate, requiring endovascular or open repair. The purpose of this investigation is to determine the early clinical outcome on aortic remodeling using a composite thoracic stent graft and thoracoabdominal bare metal extension stenting strategy. Methods: From April 2019 to April 2021, 73 patients with Debakey I/IIIb aortic dissection underwent endovascular stent graft repair of the descending thoracic aorta and repair of the thoracoabdominal aorta using bare metal extension stenting. Preoperative and follow-up surveillance computed tomography imaging scans were analyzed. Results: Fifty-three (73%) patients had a Debakey I aortic dissection, and 50 (69%) patients underwent surgery during the chronic (time to surgery >30 days) dissection phase. Mortality at 30 days was 4% (3 hyperacute patients). Stroke occurred in 3 (4%), paraparesis in 2 (2.7%), and acute renal failure requiring dialysis occurred in 2 (2.7%) patients. On postoperative and follow-up computed tomography, there was a significant increase in false lumen thrombosis (P < .001). This coincided with a significant increase in true lumen fraction suggestive of positive aortic remodeling (P < .001) at the time of latest follow-up. Conclusions: Altering the course of aortic remodeling, with placement of a dissection stent in the thoracoabdominal aorta simultaneous with descending thoracic aortic repair may promote true lumen re-expansion and false lumen thrombosis during acute and chronic dissection phases.

Remote endarterectomy to remove infected Viabahn stent-graft.

Infection of peripheral arterial vascular grafts and stent-grafts represents a complex surgical scenario, with a number of proposed management strategies. Surgical removal of infected material with adjunctive arterial reconstruction is often required. However, surgical removal is often difficult and complex. This case study demonstrates an infected Viabahn stent-graft between the external iliac artery and the superficial femoral artery, with arterial autolysis of the common femoral artery and proximal superficial femoral artery, in which a hybrid technique combining remote endarterectomy and surgical debridement was used to remove the infected stent-graft.

Whole body perfusion strategy for aortic arch repair under moderate hypothermia.

INTRODUCTION: Aortic arch reconstruction under moderate hypothermia is commonly performed with antegrade cerebral perfusion (ACP) for brain protection; however, hypothermia alone is often solely relied upon for visceral and lower body protection. We investigated whether the addition of simultaneous lower body perfusion to ACP (whole body perfusion - WBP) may ameliorate the metabolic derangements of moderate hypothermic circulatory arrest (MHCA). METHODS: Between 2008 and 2014, 106 consecutive patients underwent elective or emergent aortic arch surgery with MHCA, with either ACP only (44 patients, 66±12 years, 30% female) or WBP (62 patients, 61±15 years, 31% female). Primary outcomes included 30-day/in-hospital mortality, intensive care unit (ICU) and hospital lengths of stay (LOS) and specific parameters of metabolic recovery. RESULTS: There were no significant differences between the groups in 30-day/in-hospital mortality (ACP: 3 (6.8%), WBP: 2 (3.2%); p=0.65), stroke (ACP: 1 (2.3%), WBP: 1 (1.6%); p=1.0) or renal failure (ACP: 2 (4.5%), WBP: 1 (1.5%); p=0.57). In the WBP group, we identified a significant reduction in lactate level at ICU admission (ACP 5.5 vs. WBP 3.5 mmol/L; p=0.002), time to lactate normalization (p=0.014) and median ICU length-of-stay (ACP 3 vs. WBP 1 days; p=0.049). There was no difference in post-operative creatinine (ACP: 104, WBP: 107 µmol/L; p=0.66). After multivariable regression adjustment, perfusion strategy no longer remained an independent predictor of ICU discharge time (p=0.09), however, cardiopulmonary bypass time (p=0.02), age (p=0.012) and emergent surgery (p=0.02) were. CONCLUSIONS: A WBP strategy during aortic arch reconstruction with MHCA may be associated with more rapid normalization of metabolic parameters and reduced ICU length of stay compared to using ACP alone. Further evaluation with a randomized trial is warranted.

Cognitive Support to Promote Shared Mental Models during Safety-Critical Situations in Cardiac Surgery (Late Breaking Report).

To address the, currently unmet, need for intra-operative safety-critical cognitive support in cardiac surgery, we have developed, validated, and implemented a series of customized checklists to address intra-operative emergencies, using a simulated operative setting. These crisis checklists are designed to provide cognitive and communication support to the operative team to reduce the likelihood of adverse events and improve adherence to best-practice guidelines. We recruited a number of content specialists including members of the hospital safety network and intraoperative cardiac surgery team members, and utilized a Delphi consensus method to develop procedure-specific guidelines for select intraoperative crises. Cardiac surgery team members were subsequently trained on utilizing the developed checklists, performed operative simulations, and were surveyed to determine checklist facility and effectiveness. We developed and validated five checklists for the following cardiac surgery crisis scenarios: (a) Cardiopulmonary Bypass Failure; (b) Systemic Air Embolism; (c) Venous Air Lock; (d) Protamine Reaction; Heparin Resistance. Upon initiation of the crisis management, a crew resource management approach was triggered. A member of the operative team was designated as the "reader" for each scenario to guide the team through the process. After training, 89% of operative team members surveyed indicated that they would like the crisis checklist to be used if they had one of these events occurring to them. Crisis management challenges members of the cardiac surgery team in reasoning accurately and according to best practice during periods of high cognitive workload and psychological stress. These crisis checklists were developed, validated, and simulated with the goal of supporting human performance and shared mental models in the clinical setting.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization.

OBJECTIVE: Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. METHODS: In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. RESULTS: Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. CONCLUSIONS: In patients undergoing robotic-assisted CABG, ultrafast-track cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

An Early Canadian Experience With the Correx Automated Coring and Apical Connector Device for Aortic Valve Bypass.

OBJECTIVE: Aortic valve replacement is the standard of care for severe, symptomatic aortic valve stenosis (AS); however, anatomy or pre-existing comorbidities may preclude conventional or alternative transcatheter approaches. Aortic valve bypass (AVB) may be performed as a salvage procedure for the relief of symptomatic aortic stenosis in patients who are not suitable candidates for aortic valve replacement. METHODS: At our institution, seven patients underwent AVB using the Correx automated coring and apical connector system. All patients had severe AS with New York Heart Association functional class 3 symptoms and were not candidates for conventional or transcatheter approaches. Via a left anterolateral thoracotomy to access the descending aorta and left ventricular apex, we used the Correx system (Correx, Waltham, MA USA) to anastomose a valve conduit to the left ventricular apex proximally and the descending aorta distally. Three patients required cardiopulmonary bypass. RESULTS: In all seven patients, the automated coring and apical connector was successfully deployed. There were two in-hospital deaths in this series. Immediately postoperatively and at 3 months, there was a significant reduction in mean and peak valve gradients, and all surviving patients performed at New York Heart Association functional class 1. CONCLUSIONS: Aortic valve bypass seems to be an acceptable alternative for the treatment of severe AS in high-risk patients who are not candidates for aortic valve replacement. The Correx automated system may improve the clinical applicability and surgical reproducibility of AVB in appropriately selected patients in which conventional or transcatheter aortic valve replacement is not a feasible options.

Internal Jugular Vein Avulsion Complicating Dual-Lumen VV-ECMO Cannulation: An Unreported Complication of Avalon Cannulas.

The Avalon Elite dual lumen cannula (Avalon Laboratories, Rancho Dominguez, CA) was developed as a means of single-site cannulation for veno-venous extracorporeal membrane oxygenation in patients with severe refractory respiratory failure. This cannulation strategy has several advantages over conventional strategies, however, is not without complication. We describe a case of right internal jugular vein "on a stick" (avulsion) after cannulation with the Avalon Elite cannula, and corroborate the critical importance of imaging guidance when using this system.

Complex tricuspid valve repair for infective endocarditis: leaflet augmentation, chordae and annular reconstruction.

Surgical treatment of tricuspid valve (TV) endocarditis remains a challenge because of extensive valve destruction, high risk of reinfection, poor outcomes with valve replacement and complex patient compliance issues. Reconstruction of the TV is certainly favoured over replacement; however, diffuse, multifocal vegetations and complete debridement often leave insufficient building materials necessary for repair. We describe our surgical reconstructive technique that relies upon extensive autologous pericardial patch augmentation of the destroyed TV leaflets to establish leaflet coaptation, supplemented with expanded polytetrafluoroethylene neo-chordae and annular reconstruction. We report our outcomes in a series of patients with grossly infected TVs with more than 50% of valvular destruction.