The coronavirus disease 19 (COVID-19) pandemic has resulted in widespread economic, health and social disruptions. The delivery of cardiovascular care has been stifled during the pandemic in order to adhere to infection control measures as a way of protecting patients and the workforce at large. This cautious approach has been protective since individuals with COVID-19 and cardiovascular disease are anticipated to have poorer outcomes and an increased risk of death. The combination of postponing elective cardiovascular surgeries, reduced acute care and long-term cardiac damage directly resulting from COVID-19 will likely have increased the demand for cardiac care, particularly from patients presenting with more severe symptoms. The combination of increased demand and inhibited supply will likely result in huge backlog of unmet patients’ needs. The novelty, virulence and infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused substantial morbidity and mortality which have necessitated modifications to the UK government’s healthcare strategy. Without improving cost efficiency, the UK’s ageing population will likely need an increasing spend on cardiac surgery simply to maintain the same level of service. However, the government’s short-term increase in spending is unsustainable especially in the face of ongoing economic uncertainty. This means that the long-term impact of COVID-19 will only increase the need to find innovative ways of delivering equivalent or superior cardiac care at a reduced unit cost.
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.
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.
Aneurysms of a single aortic sinus are not uncommon and it may also involve dilation of the ascending aorta as well. The dilated aortic sinus usually alters the geometry of the aortic root and patients will present more often with an aortic insufficiency. Both ruptured and non-ruptured sinus of valsalva aneurysm (SOVA) can be complicated by aortic regurgitation, occurring in up to 30% to 50% of patients . Unruptured SOVA are asymptomatic, but can present as dyspnea, palpitations, angina or arrhythmia. The treatment options for unruptured SOVA include aortic root reconstruction or replacement, aortic valve repair or replacement, Bentall procedure or patch repair of the SOVA.Aortic valve resuspension is a widely practised in repair for acute Type A aortic dissection. This procedure was first described by Walter G Wolfe from the Duke University, Durham. In his original series, 24 of the 30 patients with acute aortic dissection had resuspension of the aortic valve. Further “a woven Dacron® graft was then sutured beginning at the junction of the left and right coronary cusps. The graft was fashioned and sutured above the left coronary orifice around and down to the commissure of the left and non-coronary cusps. The graft suture line was then extended along the non-coronary cusp and then around the right coronary artery completing the suture line ”. Three years later, in his updated case series he added, “the proplapsing portion of the aortic valve (usually the non-coronary cusp) was resuspended with pledgeted sutures in order to restore competency of the valve ”. It worth noting that he described a surgical procedure wherein, the aortic valve was resuspensed and supracoronray aorta was replaced.In the recently published article , the authors have successfully performed a “Wolfe Procedure” in a 78 year old female and followed up the patient for 2 years. Though authors have conscientiously extricated the option of root repair or replacement, it still raises a few concerns about the procedure which they have performed. The authors mention of a “predominant expansion of the non-coronary sinus and thinning of the wall at the level of FC 22 mm and SV 76, 7x62 mm, ST-zone 38 mm”. Though not sure of the abbreviations, Figure 1 shows an enlarged non-coronary aortic sinus. Dilated aortic sinus / annulus will distort the aortic root leading to aortic insufficiency. It is surprising that the authors have not mentioned about the status of the aortic valve and is highly inconceivable that the patient will not be having any aortic valve insufficieny for such a large aneurysm. The status of Aortic root aneurysm was detected in preoperative echocardiogram, while the status of the aortic valve was noted intraoperatively - “aortic valve leaflets did not close due to the expansion of the non-coronary sinus” . Though they have not mentioned about the aortic valve while presenting the case report, but when opening the discussion, they mention that the, “case report describes the treatment of an aortic root aneurysm by the replacement of the aortic valve together with the placement of an interposition graft with proximal scallop to recreate the non-coronary sinus (i.e., Wolfe procedure)” . It is not clear whether the authors have replaced the aortic valve in their patient or they describe in general. In either of the situations, the procedure describe by Wolfe does not mandate replacement of aortic valve; it is rather a resuspension of the valve.They have argued that the Euroscore II of 19.39% is high in regards to “patient’s age, female sex, the center’s estimated surgical volume, and the present comorbidities ”. It has to be noted that ‘Center’s surgical volume’ is not a variable in Euroscore II. It should be further emphasised, that the authors have not any mentioned any comorbidities of the patients including the left ventricular function while presenting the case. Earlier studies have reported the overestimation of surgical risk in septuagenarians and octogenarians by Euroscore II [5,6,7]. It is a well-known fact that the coronary artery of elderly patients has to be evaluated before any open heart surgery; more so when have symptoms of angina. Though the authors mention that the elderly lady had coronary heart disease with class III angina pectoris, there is no description of the native coronary arteries in the manuscript. Atrial fibrillation or arrythimas are well known presentation symptom for patients with SOVA. This may be due to compression of the coronary arteries or any chamber(s) of the heart. A preoperative CT aortagram could have added value in this regard which the authors have not provided. It is mentioned that there is “dilation of the ascending, arch, and descending aorta” preoperatively. After the procedure the size of the aortic arch is 28 mm. It is so intriguing to know the mechanism of decrease in aortic arch size postoperatively after the so called “Wolfe Procedure”. As an aortic surgeon it is curious to note the ‘plunger-top’ of a syringe buried inside the vascular graft in Figure 3. Not sure why and how it was buried, but it would be of great value, if the authors could describe the technique of using the same in detail in a separate manuscript.
Proximilisation of Frozen Elephant Trunk (FET) necessitates the ligation and reimplantation of the left subclavian artery (LSA), the origin of which is distal and posterior, make rerouting difficult and cumbersome. We describe a rather simple technique for subclavian artery exposure and effective anatomical reconstruction in the mediastinum coupled with hybrid FET utilisation for aortic aneurysm in elective and non-elective settings. The division of the sternocleidomastoid coupled with the sandbag behind the left shoulder brings the LSA superficial enabling anastomosis without any difficulty.
Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and unborn baby. Pregnancy has been recognised as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. Presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via quickest form of imaging, whether CT, MRI or transoesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the foetus concomitantly or to perform aortic repair with the foetus in utero. This review will summarise the difficulties faced when managing TAAD in pregnancy, and important questions for future research.
Background: The COVID19 pandemic gripped every nation’s healthcare system and provisions on all levels. In cardiac and aortic surgery, as it is with most specialities, elective surgeries were halted. Aims of the study: We captured reflections, contingencies, and current practices across of high-volume centres in cardiac and aortic surgery globally. We also aimed this study to assess decision on prioritization of the surgical patients, the need for personal protection equipment and choice of preoperative investigations in current dynamic and fluid climate. Methods: A validated web-based questionnaire was constructed and was circulated to the international surgeons amongst high volume cardiac and aortic surgery centres. Their intrinsic feedback on decision making, impact of the lockdown and perspectives for the future ahead us all were noted. Mixed method approach was constructed. Qualitative data analysis was introduced to signify the impact globally. Results: Overall, 23 centers from 18 countries participated in this international study. 91.7% of the respondents stopped operating on elective patients during the pandemic. Majority of the surgeons agreed that acute aortic dissection (87.1%) should be operated as emergency procedure and stable triple vessel disease (87.1%) to be considered as elective procedure. Three-fifth (60%) of the respondents relied on CT chest as a preoperative screening modality. Conclusion: In the present climate where there is paucity of evidence, this will give an interim consensus for the cardiac surgeons. With the increase in cumulative number of COVID19 patients, careful utilization of the resources regarding hospital beds and manpower is of paramount importance.