Congestive heart failure is highly prevalent in the elderly population and left ventricular assist device has been increasingly used in this population. LVAD therapy is more costly than medical treatment but it increases the survival and quality of life of the elderly patients with low disease acuity. Therefore careful selection of candidates and implementation of LVAD therapy earlier in the course of the disease is crucial to improve outcomes. With the technical advances and improvement in clinical management, the financial burden of LVAD therapy in the elderly will become less, making this therapy more economically feasible.
The authors in this manuscript have reported an increase in the number of vascular emergencies seen during the early phase of the COVID-19 pandemic in the Lombardy region of Italy. A significant increase in the number of acute limb ischaemia was seen during this phase along with other vascular emergencies. In this review, we have tried to examine this association between increase in vascular emergencies and COVID-19 infection. We have also described the differences in presentations, prognosis and procedural outcomes following operative interventions in these patients compared to the non-COVID patients. An attempt has been made to assess the role of adjunctive measures like intravenous heparin to improve outcomes.
To the Editor: The interesting and timely paper by Cain et al.1, in press in the Journal of Cardiac Surgery , provides important details concerning the devastating consequences of Mycobacterium chimaera (MC ) infection. In their patient extreme fragility of the mediastinal tissues was observed after repair of an acute aortic dissection; during follow-up multiple reoperations were required to treat recurrent dehiscence of the aortic grafts. Despite repeat explantation of foreign materials infection persisted with mediastinitis and eventual systemic diffusion with fatal outcome.MC infection after open cardiac surgery using cardiopulmonary bypass has been recently reported as a clinical outbreak worldwide and identified as originating by contaminated water in heater-cooler units2. Current experience shows that MC causes a slow-growing and extremely difficult to treat infection with an incubation period which has been recently demonstrated to be as long as >12 years3.We have recently treated a patient, quite similar to that reported by Cain et al.1, who presented with a pseudoaneurysm of the distal suture line twelve years after repair of type A aortic dissection4. At first operation replacement of the ascending aorta and hemiarch using of a Djumbodis®dissection system (Saint Come-Chirurgie, Marseille, France) was performed. At reoperation extremely fragile tissues were noted and, after removing the metallic stent, the aortic arch was replaced with a frozen elephant trunk technique. Cultures of the excised material grewMC . In this case we hypothesized that the stent played an important role in the onset of infection for at least 2 reasons: presence of foreign material in the blood stream and injury to the aortic wall by the edges of the stent. The case described by Cain et al.1 also supports our belief that extreme fragility of the aortic tissues caused by MB was a further important factor in the occurrence of this complication.Interestingly, a delayed diagnosis occurred in both cases; this most likely played a critical role in favouring development of extra‐cardiac manifestations of the disease, in reducing the effectiveness of antibiotic therapy due to immunologic impairment and causing a negative outcome in both patients.MB infection may have different locations ranging from single-organ to systemic manifestations5. When it involves the mediastinum and particularly the major vascular structures often results in life-threatening complications despite proper antimycobacterial treatment. An early diagnosis, even with significantly extended surveillance, appears extremely difficult due to slow-growing and long incubation period of MB .Although no specific guidelines are so far available, intra-operative prevention with improvement of setting and development of heater-cooler units is mandatory and should be based on specific recommendations5.
The well-accepted role of the Heart Team in assessing patients suffering from aortic stenosis is becoming the standard approach in most centers. A tailored approach to individual patients may lead to significant changes in outcomes even though SAVR will continue to play a major rollin the treatment of patients presenting more co-morbidities and anatomical challenges.
Early and long term Clinical outcome after Minimally Invasive Direct Coronary Bypass Grafting versus off pump Coronary Surgery via Sternotomy In this retrospective study by Cichon Romuald et al (1), 194-patients met the inclusion criteria and were divided into the MIDCAB group (n=111) and OPCAB via median sternotomy group (n=83). The conclusion was that short as well as long-term outcomes of MIDCAB in terms of mortality, myocardial infarction, stroke, and target vessel revascularization were satisfactory, and as safe and effective as OPCAB via sternotomy This retrospective study by Cichon Romuald et al (1), undoubtedly will generate interest for surgeons who want to perform minimally invasive coronary surgery. It is clear that, in order to attract patients to undergo surgery, surgeons must learn to perform minimally invasive coronary surgery. Advantages of minimally invasive coronary surgery include less post-operative discomfort, faster healing times, less risk of infection and avoidance of trauma associated with OPCAB Surgeons must also take the initiative and play an active role in the Hybrid Revascularization Procedures Current surgeons, and those in residency training programs, should learn wire skills and participate in placement of stents. There is a lot to learn from our interventional cardiologists who embrace new technology and procedures. Surgeons will have to adapt to the new reality, and move some of his/her practice outside the operating room.
Dear Editor, First we would like to thank Dr Lopez de la Cruz for her comments and interest about our recently published article “the odyssey of suturing cardiac wounds: lessons from the past”. We highly appreciated and agree with the complements she made especially about Larrey and Milton role in this field. One should also note Theodore Tuffier’s attempt at cardiac resuscitation in 1898 in a young man dying on the wards at La Pitié Hospital (Paris)¹. Although this act was performed on an unwounded heart it adds information about the history of surgical approach in such dramatic condition. We do recognize left anterolateral thoracotomy as the gold standard in an emergency room to treat a penetrating cardiac injury. However a median longitudinal sternotomy may be discussed in our opinion if the patient arrived directly in a cardiac surgery operating theater. The patent presented in our paper was directly brought in our operative theater of cardiac surgery and managed immediately by cardiac surgeons and cardiac anesthesiologists, with a cardiopulmonary bypass ready, dedicated scrub nurses and perfusionist. In such specific conditions a sternotomy may be discussed, depending on the context and the anatomical suspected lesions (it was the option retained in the presented case and the surgical procedure was safely performed with good outcome). Clearly, in a peripheral hospital or at the emergency room sternotomy is not an option to be considered and we agree with Dr Lopez de la Cruz.
Left ventricular assist devices (LVADs) have become integral to the treatment of advanced heart failure. Surgical bleeding is a known complication of LVAD placement but is most associated with intraperitoneal pump locations. Here we describe a case of massive postoperative hemorrhage secondary to erosion of an intrapericardial LVAD into an intercostal artery with an associated rib fracture.
Title: The Time May Soon Be At HandRunning Head: Time May Soon Be At HandAuthors: Saqib Masroor, MD1 and Donald B. Glower MD21. University of Toledo College of Medicine and Life Sciences, Department of Surgery, Division of Cardiothoracic Surgery2. Duke University Medical Center, Department of Surgery, Division of Cardiothoracic SurgeryMeeting Presentation: NoneDisclosure: NoneWord Count: 1213
Background and Aim: Clinical education has been disrupted by the COVID-19 pandemic. We present a standardized remote alternative online cardiothoracic surgery primer to accommodate a shortened clinical calendar. Methods: A week-long cardiothoracic surgery course consisting of virtual case-based lectures and small groups as well as surgical operation walkthroughs was conducted iteratively through April and May 2020 at Emory University School of Medicine, Atlanta, GA for new clinical third-year medical students. Results: Remote learning platforms helped maintain medical student clinical education. Cardiothoracic procedure video walkthroughs were highly demanded for remote learning. Virtual small group discussions were felt to be invaluable in facilitating active problem solving and clinical decision making of cardiothoracic surgery. Conclusion: Our online cardiothoracic surgery curriculum can be a framework for alternative medical student clinical education. Student feedback is necessary as we adapt to teaching during the COVID-19 pandemic and future global disruptions.
Currently available evidence supports the safety and efficacy of rapid deployment and sutureless prostheses for aortic valve replacement (AVR) in aortic stenosis as suggested by the International Expert Consensus in 2016. Following the increasing experience and the good results obtained in AVR, the use of sutureless and rapid deployment prostheses in peculiar situations, at times as an ‘off-label’ indication, has been reported demonstrating to represent an effective solution to challenging surgical problems, such as described by Piperata et al. in a recent issue of the Journal of Cardiac Surgery for the treatment of active infective endocarditis complicated by an extensive aortic annulus abscess. The considerable experience acquired so far with rapid deployment and sutureless valves has stimulated many surgeons to use such devices in patients in whom limiting the overall ischemic time is felt to be of paramount importance, but also in different surgical scenarios. Therefore, we believe the time has come to strongly support the unusual or even ‘off label’ employment of these devices by including them in future recommendations.
Background: Acute type A aortic dissection (ATAAD), is a surgical emergency often requiring intervention on the aortic root. There is much controversy regarding root management; aggressively pursuing a root replacement, versus more conservative approaches to preserve native structures. Methods: Electronic database search we performed through PubMed, Embase, SCOPUS, google scholar and Cochrane identifying studies that reported on outcomes of surgical repair of ATAAD through either root preservation or replacement. The identified articles focused on short- and long-term mortalities, and rates of re-operation on the aortic root. Results: There remains controversy on replacing or preserving aortic root in ATAAD. Current evidence supports practice of both trends following an extensive decision-making framework, with conflicting series suggesting favourable results with both procedures as the approach that best defines higher survival rates and lower perioperative complications. Yet, the decision to perform either approach remains surgeon decision and bound to the extent of the dissection and tear entries in strong correlation with status of the aortic valve and involvement of coronaries in the dissection. Conclusions: There exists much controversy regarding fate of the aortic root in ATAAD. There are conflicting studies for impact of root replacement on mortality, whilst some study’s report no significant results at all. There is strong evidence regarding risk of re-operation being greater when root is not replaced. Majority of these studies are limited by the single centred, retrospective nature of these small sample sized cohorts, further hindered by potential of treatment bias.
The emergence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in December 2019, presumed from the city of Wuhan, Hubei province in China and the subsequent declaration of the disease as a pandemic by the World Health Organization (WHO) as COVID-19 in March 2020, had significant impact on health care systems globally. Each country responded to this disease in different ways but broadly by fortifying and prioritising health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on 23rd of March 2020 and all health care services were focussed to challenge the impact of COVID-19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so-called “Nightingale Hospitals” were created de novo to bolster bed provision and industries were asked to direct efforts to the production of ventilators. A government led public health campaign was publicised under the slogan of: “Stay home, Protect the NHS (National Health Service), Save lives”. The approach had a significant impact on delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on Aorto-vascular disease. We describe our Aorto-vascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID-19 pandemic.
Background: Despite recent advancements in prevention, treatment, and management options, cardiovascular diseases contribute to one of the leading causes of morbidity and mortality. Several studies highlight the compelling evidence for the existence of healthcare inequities and disparities in the treatment and management control of cardiovascular diseases. Aims: To explore the role of racial disparities in the treatment of various cardiovascular diseases, highlighting the role of socioeconomic and cultural factors, and ultimately postulate solutions to eliminate the disparities. Methods: A comprehensive review of literature was conducted using appropriate keywords on search engines of SCOPUS, Wiley, PubMed, and SAGE Journals. Conclusion: By continued research to eliminate healthcare inequalities, there exists a potential to improve health-related outcomes in minority populations.
A 77-year-old man with diabetes, dyslipidemia, and a smoking history presented with asymptomatic gross hematuria and left hydronephrosis. Computed tomography (CT) angiography revealed a left ureteral tumor and abdominal aortic aneurysm. Cardiac catheterization revealed right coronary artery (RCA) stenosis. First, a left nephroureterectomy was performed via a midline abdominal incision. To achieve minimal invasiveness, a median sternotomy was avoided, and off-pump coronary artery bypass grafting of the RCA was performed with the great saphenous vein graft, using the left renal artery as the graft inflow. Y-grafting was subsequently performed. Without any postoperative complications, CT angiography confirmed graft patency. This procedure has potential use for removing ureteral tumors by surgeons and clinicians in clinical settings.
Abstract The first clinical implantation of the “Essen I prosthesis” took place in 2005, which was then followed by E-Vita open plus. With further advancements E-Vita Neo and E-Novia was introduced. These devices enable the surgeons to perform FET in zone 0/1 which eventually reduce the incidence of paraplegia, recurrent laryngeal nerve palsy and proximalization of supraaortic arch vessels. E-vita open plus and successors alleviate frozen elephant trunk operations rendering more stable results in promoting positive remodelling of the distal aorta.
LETTER TO THE EDITOR RESPONSEWe thank Dr. Del Giglio et al. for their comments. As it was stated in our paper1, our primary goal was to describe our approach and procedural details to MIAVR by way of RALT. For further reading we would also like to draw attention to our video tutorial regarding RALT-MIAVR2. Nevertheless, we would like to congratulate Dr. Del Giglio and his colleagues for their significant contribution to the field of minimally invasive aortic valve treatment3 4 56.We completely agree with Dr. Del Giglio et al. that our statement regarding preoperative CT-scanning being mandatory is somehow misleading. However, other colleagues also consider a preoperative CT scan obligatory for RALT-MIAVR7 providing important additional information over TEE8. Three-dimensional reconstructed multidetector CT images allow virtual planning of the exposure leading to a reduced ischemia time and a reduced conversion rate9. It has also been shown that systematic preoperative CT screening in MIMVS is associated with lower risk of postoperative stroke and a trend towards lower operative mortality10. Although we agree with Dr. Del Giglio et al. that CT assessment is helpful at the beginning, it remains accommodating throughout the complete learning curve and thereafter. Andre Plass et al.11 wrote that preoperative planning with multi-slice CT leads to an improved mental preparation and to an efficient and accurate surgical strategy including the choice of the optimal ICS. In their Letter to the Editor , Dr. Del Giglio et al. wrote that surgical access site selection does not require a CT scan, that the third ICS is the right one in most cases and that the surgeon could easily change to the second ICS from the same skin incision. We agree that changing ICS is easily possible, yet it also means added surgical damage and this should be avoided whenever possible. An automated method determining the closest ICS to the STJ as the optimal incision location for MIAVR has already been introduced12. A novel MIAVR tool that combines 3D imaging with quantitative planning measures has also been described13. The access angle is strongly associated with procedure complexity13 and with CPB time, x-clamping time and access difficulty13. Moodley et al.14 reported that mandatory CT-screening of the chest, abdomen and pelvis revealed significant subclinical aorto-iliac atherosclerosis resulting in a change in surgical approach in 21% of asymptomatic or mildly symptomatic patients scheduled for MIMVS (Figures 1 through 3). Regarding the interpreting and reconstructing of CT scans we agree with Dr. Del Giglio et al. that this means technological skills, time and financial resources. But with transcatheter cardiac procedures becoming more popular, it is important for the society of surgeons to master all aspects of case planning, which not only includes analysis and measurement but also the reconstruction of CT scans. As pointed out by Dr. Del Giglio et al. MIAVR has to reproduce the gold-standard conventional procedure in terms of safety, effectiveness and especially operative times through a respectful approach; yet in our opinion, preoperative non-invasive CTA screening in every patient scheduled for a RALT-MIAVR procedure remains crucial.In view of truly MIAVR, we believe that arterial and venous central cannulation both at the same time through the same incision does not reduce surgical trauma and could lead to central working port obstruction or significant narrowing. We believe that peripheral cannulation of the femoral vasculature is as safe and reproducible as central cannulation if the individualized anatomical characteristics allow for it. When carrying out percutaneous femoral arterial cannulation, we never perform a blind puncture of the femoral vessels. We prefer to have zoomed-in snapshots from our reconstructed CT scans on display in the OR to accurately puncture the CFA as displayed in figures 1 and 2 for example. Data set published by Eugene A. Grossi et al.15, suggest that if in older patients a femoral perfusion technique is chosen, preoperative evaluation of the aorta and distal vasculature would demonstrate that a given patient would not be at increased neurological risk15. This would include CTA of the aorta with runoff and TEE evaluation of the descending aorta15. They also published that RAP is associated with an increased risk of stroke in patients with severe PVD and should be reserved for selected patients without significant atherosclerosis. Such a thoughtful screening approach has been used also by Murphy and associates16 in robotic mitral valve surgery for example15. M. Murzi et al.17 were able to show that the use of RAP in MIMVS was associated with a higher incidence of neurological complications in older patients (>70 years old) with atherosclerotic burden compared with AAP. Still, their study had several limitations as it was based on a retrospective analysis of patients undergoing consecutive MIMVS over a 12-year period and potential bias might have been present17. The observational retrospective analysis of K. Bedeir et al.18 proved that femoral artery cannulation may be associated with increased stroke rates in isolated mitral valve surgery and that antegrade arterial cannulation (direct aortic or axillary cannulation (figure 2)) may be preferable in MIAVR. However, their consensus was that these preliminary data should trigger a larger-scale randomized prospective trial to confirm or refute these findings18.In pursuance of reducing hemolysis during CPB19, body temperature is maintained at around 34°C and DO2-guidance (goal-directed-perfusion). This is also helpful in regard to optimal venous drainage as it allows the surgeon1,2, to safely reduce the calculated pump flow. Furthermore, we augment venous drainage with the use of vacuum assistance (−20 to −35 mmHg) to decompress the right heart1. On one hand, R.K. Mathews et al.20 were not able to show a significant increase in hemolysis or sub-lethal red blood cell membrane damage, associated with the use of augmented venous drainage. On the other hand, D. Goksedef et al.21 showed that based on their results, negative suction at 80 mmHg may cause greater hemolysis than non-vacuum-assisted drainage or vacuum-assisted drainage at 40 mmHg. For this reason, we try to keep the vacuum assistance between 0 and -35 mmHg. Besides, it has been proved that application of a controlled, negative low pressure to the venous return does not cause hemolysis worse than gravitational CPB22.At last, Dr. Del Giglio et al. reported concerns about our SLL-PEEP (maximum 20 cmH2O) technique to inflate the left lung which pushes the aorta towards the surgical access. It is true that increased airway pressure or the application of high tidal volumes may cause damage or disruption of alveolar epithelial cells, by generating transpulmonary pressures that exceed the elastic properties of the lung parenchyma above its resting volume23. It has been demonstrated that the duration of mechanical stress defined as the stress versus time product affects the development of pulmonary inflammatory response23. However, in a recent meta-analysis of postoperative pulmonary complications after intraoperative ventilation, only a high driving pressure was associated with an increased incidence24. Therefore, it is highly unlikely that in an apneic patient on CPB, the elevation of the PEEP-level of 5 to 20 cmH2O without a resulting change of driving pressure has any significant negative effect on pulmonary outcome.In summary, we agree with the important points addressed by Del Giglio et al. Central cannulation and its AAP is possible without the need for preoperative CT scanning. However, for the sake of MIAVR (no rib resection, no IMA sacrifice) we prefer peripheral percutaneous cannulation. For such a RAP cannulation strategy, there is sufficient convincing literature that preoperative CTA scanning should be considered.