How We Perform a David Procedure With an Upper Hemisternotomy Approach

Objective Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183–208] vs 212 [183–223] min, P = 0.309) and aortic cross-clamp (169 [155–179] vs 188 [155–199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.

A study on correlation of coronary sinus lactate and troponin T levels with perioperative outcome in patients undergoing cardiac surgery on cardio pulmonary bypass

Myocardial ischemia is a metabolic phenomenon that occurs in patients undergoing open heart surgery like coronary artery bypass grafting (CABG), valvular heart surgery, vascular surgeries etc., due to stress imposed during cardiopulmonary bypass (CPB), obligatory interruption of coronary blood flow during aortic cross clamp and reperfusion after aortic cross clamp release. The present study is designed to have a detailed study on estimation of coronary sinus lactate and troponin t levels in patients undergoing cardiac surgery with cardiopulmonary bypass and its correlation with various parameters related to the perioperative outcomes.

Ventricular Fibrillation After Release of an Aortic Cross-Clamp in Valvular Surgery: Independent Risk Factors, Outcomes, and Incidence from Access Routes

Background Predictors and clinical outcomes of VF-ACC and the relative VF-ACC incidence with various access routes have not been well documented. This study aimed to identify predictors, clinical outcomes, and relative incidences of ventricular fibrillation after the release of an aortic cross-clamp (VF-ACC) with various access routes in valvular surgery.Patients and methods In this single-center and retrospective cohort study, we screened 228 consecutive patients undergoing valve surgery, and a total of 119 patients were included in the study. The primary outcomes were the relative incidence and predictors of VF-ACC with access routes, and secondary endpoints included effects of VF-ACC on 30-day mortality, perioperative ventricular arrhythmias (VAs), and heart failure with ejection fraction < 50% (HFEF < 50%).Results VF-ACC incidence varied on the basis of access routes. VF-ACC occurred in 58.3% of patients with aortic valve replacement via transverse aortotomy (TAo-AVR), in 48.6% of patients with aortic and mitral replacements via transseptal and transverse aortotomy access (TSAo-MAVR), and in 20% of patients with mitral valve replacement via transseptal access (TS-MVR). Seven independent risk factors were identified: HTK solution (AOR: 4.90, p = 0.002), smoking status (AOR: 6.30, p = 0.001), cerebrovascular disease (CBD) [(AOR: 7.08, p = 0.022)], regional wall motion abnormality (RWMA) [(AOR: 8.33, p < 0.001)], perioperative VAs (AOR: 4.85, p = 0.001), HFEF < 50% (AOR: 5.66, p = 0.002), and left ventricular mass index (LVMI) [(AOR: 0.962, CI: 0.941–0.984)].Conclusions VF-ACC was the most common in TAo-AVR and the least common in TS-MVR. HTK solution, smoking status, CBD, perioperative VAs, HFEF < 50%, and RWMA were associated with an increased risk of VF-ACC, and low LVMI acted as a protective factor. Patients with VF-ACC commonly experienced perioperative VAs or HFEFs < 50%.Clinical trial registration: ChiCTR2100050961.

Early Postoperative Results of On-Pump Coronary Endarterectomy: Is Gender a Risk Factor?

Background: Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) is an effective but still controversial surgical strategy for the treatment of diffuse coronary artery disease. In this study, we aimed to investigate the impact of gender differences on operative and early postoperative results of patients who underwent CABG with CE. Methods: This retrospective study included 141 patients who had undergone CE combined with CABG from January 2015 to December 2020, as well as 141 patients without CE as the control group. First, patients with and without CE were compared. Next, patients undergoing CE were divided into 2 groups according to gender (group 1, male patients; group 2, female patients). Results: Of the 141 patients who underwent CE combined with on-pump CABG, 95 (67.3%) were male, and median age was 66 years (range 58 to 71.2). Of the 141 patients who underwent isolated on-pump CABG, 99 (70.2%) were males, and median age was 63 years (range 41 to 80.4). The data for these 2 groups (with and without CE) were compared. Previous percutaneous coronary intervention (PCI), presence of diabetes mellitus, and perfusion time were significantly more common in the CE group. There were 95 patients in group 1, with a median age of 65 years (range 58 to 69), and 46 patients in group 2, with a median age of 66 (64 to 71.2). There were no difference between the groups in terms of age, body mass index, hyperlipidemia, chronic obstructive pulmonary disease, peripheral artery disease, or previous coronary intervention. The need for positive inotropic support and postoperative atrial fibrillation were found to be significantly more common in group 2 (P = .022 and .039, respectively). Defibrillation after releasing the aortic cross clamp was also significantly more common in group 2 (P = .025). Conclusion: In our study, the need for defibrillation after aortic cross-clamp releasing in the perioperative period, the need for inotropic support and the incidence of atrial fibrillation in the post-operative period, increased significantly in the female gender. CE can be performed safely in both genders with acceptable mortality and morbidity rates.

The retrospective observational study of clinical outcomes of single dose infusion of warm blood cardioplegia in patients undergoing cardiac surgery

Objective: The aim of the study was to assess the safety and efficacy of a normothermic cardioplegia solution N trademark use and obtain additional information about dosing regimens during normothermic or mild hypothermic cardiac surgery. Methods: A retrospective observational study included 150 cardio surgery patients. The primary endpoint was the intraoperative acute heart failure development. The secondary endpoints were the postoperative Troponin T concentrations, the need for catecholamine support, and the repeated infusion of a cardioplegia solution. Results: The duration of aortic cross-clamping varied from 17 to 154 minutes, median 59 [interquartile range, 46 - 73] minutes. Spontaneous sinus rhythm recovery was observed in 136 (90.7%) patients. Intraoperative acute heart failure was observed in 1 case. The Troponin T concentrations were 0.331 plus-or-minus sign 0.143 ng/mL after surgery. Mortality was 2% (3 patients). Eight patients received an additional volume of N trademark solution to maintain asystole. Among 16 patients with a cross-clamp duration greater than 90 minutes epinephrine was used in 3 (18.8%) patients in doses of more than 0.05 mcg/kg/min. Among 134 patients cross-clamp duration less than 90 minutes the catecholamine support was used in 4 (3%) patients, p=0.027. Conclusions: A primary single-dose infusion of cardioplegia solution N trademark provides myocardial protection for 59 (interquartile range, 46-73) minutes and up to 154 minutes. The catecholamine support in the group of aortic cross-clamp duration less than 90 minutes was used lesser than in the group of aortic cross-clamp duration greater than 90 minutes (3% and 18.8%, respectively). The cardioprotection during cardiopulmonary bypass surgery especially in elderly patients with concomitant disease needs to be confirmed in future investigations.

Initial results of aortic valve reconstruction using autologous pericardium (Ozaki's procedure)

Introduction: This study report the clinical characteristics, surgical indications, surgical technique and initial outcomes of autologous pericardial aortic valve reconstruction using Ozaki’s procedure. Methods: The study included consecutive patients with isolated aortic valve disease who underwent Ozaki’s procedure between June 2017 and December 2019. Aortic valve cups were reconstructed by autologous pericardium using Ozaki’s procedure. Results: Seventy-two patients were enrolled (mean age 52.9 ± 13 years; 53 males) and consisted of 30 aortic stenosis cases, 20 aortic regurgitation cases, and 22 patients with a combination of both 72 patients, a bicuspid aortic valve was present in 20, and 7 patients had infective endocarditis. Surgery was performed via a full or partial sternotomy. The procedure was successful in 70 case, and two patients were converted to prosthetic valve replacement. The aortic cross-clamp time was 106.3 ± 13.8 minutes, cardiopulmonary bypass time was 136.7 ± 18.5 minutes. One patient died of cardiac tamponade in hospital, and two patients underwent reoperation due to bleeding and sternal infection, respectively, were observed during the follow-up period of 30 days. 1-month postoperative echocardiography revealed that one patient had moderate aortic valve regurgitation, max trans-valvular pressure gradient was 16.1 ± 2.3 mmHg, and aortic valve area was 2.5 ± 0.2 cm ². Conclusions: Aortic valve reconstruction using autologous pericardium by Ozaki’s procedure was feasible, good hemodynamics, and can be applied to all lesions of the aortic valve.

Totally endoscopic resection of atrial myxoma: early results of 26 patients in E hospital

Objective: Myxoma is the most common form of non-malignant tumor that arises from connective tissue. Totally endoscopic surgery without robotic assistance can resect the entire atrial myxoma. This study aim to evaluate the early results of this surgical method. Methods: From January 2019 to April 2021, 26 patients (20 females, 6 males, mean age 49.5 ± 14.3) were diagnosed with atrial myxoma. All tumors of those patients were resected by totally endoscopic surgery. We evaluated the early outcome of this method based on the following criteria: mortality rates, conversion to open surgery, cardiopulmonary bypass time, aortic cross-clamp time, postoperative time. Results: Totally endoscopic surgery to resect atrial myxoma was successfully performed in all patients with surgical ports on the thoracic wall. The largest incision was not more than 1.5 cm in diameter. Mean cardiopulmonary bypass time was 134 ± 39 minutes, aortic cross-clamp time was 81.4 ± 26.4 minutes, mechanical ventilation time was 10.5 ± 4.6 hours, ICU length of stay was 2.1 ± 0.9 days, postoperative time was 6.9 ± 5.4 days. We had one case in which the excision of myxoma was performed contemporaneously with mitral valve annuloplasty. Conclusions: Initial outcomes of totally endoscopic surgery to resect atrial myxomas were satisfactory. However, to fully evaluate the effectiveness of this method, we need to conduct a long-term follow-up of these patients.

Computed tomography imaging of resuscitative endovascular balloon occlusion of the aorta (REBOA): pearls and pitfalls

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is performed in patients with hemorrhagic shock who develop massive subdiaphragmatic bleeding. This procedure enables rapid and less invasive aortic blockade compared to resuscitative thoracotomy and aortic cross-clamp procedures. However, the REBOA procedure is often blindly performed in the emergency department without fluoroscopy, and the appropriateness of the procedure may be evaluated on computed tomography (CT) after REBOA. Therefore, radiologists should be familiar with the imaging features of REBOA. We present a pictorial review of the radiological findings of REBOA along with a description of the procedure, its complications, and pitfalls.

Use of Sutureless and Rapid Deployment Prostheses in Challenging Reoperations

Sutureless and rapid-deployment bioprostheses have been introduced as alternatives to traditional prosthetic valves to reduce cardiopulmonary and aortic cross-clamp times during aortic valve replacement. These devices have also been employed in extremely demanding surgical settings, as underlined in the present review. Searches on the PubMed and Medline databases aimed to identify, from the English-language literature, the reported cases where both sutureless and rapid-deployment prostheses were employed in challenging surgical situations, usually complex reoperations sometimes even performed as bailout procedures. We have identified 25 patients for whom a sutureless or rapid-deployment prosthesis was used in complex redo procedures: 17 patients with a failing stentless bioprosthesis, 6 patients with a failing homograft, and 2 patients with the failure of a valve-sparing procedure. All patients survived reoperation and were reported to be alive 3 months to 4 years postoperatively. Sutureless and rapid-deployment bioprostheses have proved effective in replacing degenerated stentless bioprostheses and homografts in challenging redo procedures. In these settings, they should be considered as a valid alternative not only to traditional prostheses but also in selected cases to transcatheter valve-in-valve solutions.