Pass On What You Have Learned: A Structured Mentor-Mentee Concept for the Implementation of a Minimally Invasive Mitral Valve Surgery Program

<b><i>Introduction:</i></b> Starting a minimally invasive cardiac surgery (MICS) for mitral valve repair (MVR) program is challenging as it requires a new learning curve, but compromising surgical results at the same time is not acceptable. Here, we describe our surgical educational experience of starting a new MICS program at a university heart center in Germany. <b><i>Methods:</i></b> A dedicated team for the new MICS program including 2 cardiac surgeons, 1 cardiac anesthetist, 1 perfusionist, and 1 scrub nurse was chosen. The use of long shafted instruments was trained in a low-cost self-assembled MICS simulator, and the EACTS endoscopic dry lab course was visited. Thereafter, 1 MICS center was visited for direct observation and peer-to-peer education for 6 weeks. The mentor observed the first 10 cases performed by the mentee. The surgical mitral valve expertise of 1 single cardiac surgeon was retrospectively analyzed between April 2016 and April 2021. <b><i>Results:</i></b> Before the implementation of the MICS-MVR program, 18 mitral valve operations have been performed through sternotomy between April 2016 and October 2018 including 12 replacements and 6 ring annuloplasties. After starting the MICS-MVR program, 73 mitral operations have been performed by the same surgeon of which 53 video-assisted through minithoracotomy (72.6%). 83.1% of the MICS procedures included complex repair (<i>n</i> = 38) and ring annuloplasty (<i>n</i> = 6). Open heart MV surgery was necessary in 20 patients due to concomitant procedures (<i>n</i> = 8), redo procedures (<i>n</i> = 2), severe endocarditis (<i>n</i> = 4), or contraindication for MICS such as PAD (<i>n</i> = 6). There have been no deaths, 1 stroke, and 1 cardiac vascular (RCX) complication. Two patients required conversion to sternotomy and one pericardiocentesis in the long term. <b><i>Conclusion:</i></b> Typically, excellent exposure and high repair rates of the MV has led us offer MICS approach to a majority of patients with isolated MV disease. Careful planning and a strict mentor-mentee concept facilitated a safe startup of an MICS program in a busy university heart center.

655 The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction

Aims Recent studies have shown that evolution RL bidirectional rotational mechanical sheath (Cook Medical, USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. Methods and results The study population comprised 84 patients (77% male; mean age 65 ± 18 years) undergoing TLE. After multidisciplinary evaluation, a combined procedure was considered. The main indication for TLE was infection in 54 cases (64%).Overall, 152 leads were extracted with a mean implant duration of 94 ± 63 months (range: 6–421). Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6% (77/84), 97.6% (82/84), and 98.6% (150/152), respectively. Eighteen combined procedures were performed in 12 patients (14%), such as ‘hybrid approach’ (n = 2) or TLE concomitant to: (i) transcatheter aspiration procedure for large vegetation (n = 8); (ii) left ventricular assistance device implantation as bridge to cardiac transplantation (n = 1); (iii) permanent pacing with epicardial leads (n = 6); and (iv) tricuspid valve replacement (n = 1).One major complication (1.2%) and 11 (13%) minor complications were encountered. No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21 ± 18 months, 17 patients (20%) died. They were more often diabetics (P = 0.02), and they underwent TLE more often for infection (P = 0.004). Conclusions Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators.

John W Kirklin: The Greatest Scientific Cardiac Surgeon of the Century

John Webster Kirklin was an American cardiothoracic surgeon, prolific author and medical educator who is best remembered for refining John Gibbon’s heart-lung bypass machine via a pump-oxygenator to make feasible under direct vision routine open-heart surgery. His other advances, on which success of heart surgeries depends, including teamwork, developments in establishing the correct diagnosis before surgery and progress in computerized intensive care unit monitoring after open heart surgery. Wayne Miller refers to Dr Kirklin in the 1970s as “arguably the best practicing open heart surgeon anywhere. He was one of cardiac surgery’s most accomplished researchers, a scientist whose mind was sometimes compared, flatteringly, to a computer.” John W Kirklin and Brian G Barratt-Boyes drafted the book ‘Cardiac Surgery’, which is considered as the Bible of the subject. Cardiovasc j 2021; 14(1): 93-96

First female cardiac surgeon

For a long time, medicine was the prerogative of men, and women were not allowed to this area. And despite the prohibitions and moral values of those times, women left a mark in the history of medicine. Key words: women, medicine, history, cardiac surgery

Giant Left Atrial Myxoma Presenting with Cough-Syncope Syndrome

We report the case of a 41-year-old female patient with symptoms of cerebrovascular accident manifesting with loss of consciousness during episodes of cough. Computed multislice chest tomography showed a 7.3- by 4.15-cm mass in the left atrium. A transesophageal echocardiogram showed a giant mass in the left atrium that passed through the mitral valve to the left ventricle, and severe obstructive stenosis was suggested by the mean transmitral gradient. After a comprehensive assessment of the mass, we decided to perform surgery. The pedunculated and fragile mass was attached to the interatrial septum with its handle, and the majority of it prolapsed through the mitral valve to the left ventricle and became stacked among the mitral valve leaflets. The removed mass was analyzed histopathologically and was found to be a myxoma. It is important for the cardiac surgeon to surgically remove an atrial myxoma because of the risks associated with embolization, including sudden death, as myxoma can block the blood supply from the atrium to the ventricle.

Management of Post Tracheotomy Hemorrhage and Evaluation of Causing Factors

Objective: To understand the frequency, causes, and treatment of post-tracheostomy hemorrhage. Study Design: A prospective study of tracheostomy cases. Place and duration: ENT, Head & Neck Surgery department of Lady Reading Hospital MTI, Peshawar and Azra Nahid Medical College, Lahore for duration of one year from July 2019 to June 2020. Methodology: All hospitalized patients who underwent tracheostomy and had bleeding during this period were included. The parameters specified were demographics, time since surgery, degree of bleeding, causes of bleeding, and treatment. A total of 208 patients who have done with tracheostomy were selected. Results: Tracheostomy was performed in a total of 208 patients, 142 men and 66 women. Their ages ranged from 20 to 70 years old. 22 patients (10.6%) had postoperative bleeding, most of them have oozingfrom or around the stoma, but 5 patients were taken to the operating room for hemostasis. Three of them had Tracheo- innominate artery fistula and two died before undergoing surgery. One of the three trachea-innominatefistulae were successfully treated by a cardiac surgeon. The remaining cases required diathermy, transfixing thyroid isthmus or vein descent or relegation of veins. Conclusions: Hemorrhage after tracheostomy is not uncommon in intensive practice, bleeding occurred in 10.5% of our cases. Hemorrhage occurs because of inadequate hemostasis, aspiration trauma, infection, coagulopathy and granulation. Rarely, there may be massive and life-threatening bleeding from tracheo-innominate fistula that requires aggressive and urgent exploration. In such a situation, an experienced cardiac surgeon and anesthesiologist is very important and can lead to a better result. Key words: Tracheostomy, post-tracheostomy hemorrhage, Tracheo-innominate artery fistula (TIF)

Balloon atrial septostomy through azygos vein in two cases of D-TGA with left atrial isomerism

Balloon atrial septostomy is a palliative procedure that is performed in D-transposition of great arteries when surgery is not immediately available. Although D-TGA and left isomerism association are rare, it is an important condition as the BAS procedure approach is unique. In this case report, we present two cases of D-TGA with left isomerism where BAS was performed due to restrictive atrial septal defect and lack of immediate availability of the paediatric cardiac surgeon.