Helga B Brynjarsdottir, Arni Johnsen, Alexandra A Heimisdottir, Sunna Rún Heidarsdottir, Anders Jeppsson, Martin I Sigurdsson, Tomas Gudbjartsson
Objectives: Surgical revascularization is an established indication for patients with advanced coronary artery disease and reduced left ventricular ejection fraction (LVEF). Long-term outcomes for these patients are not well-defined. We studied the long-term outcomes of patients with ischaemic cardiomyopathy who underwent surgical revascularization in a well-defined nationwide cohort.
Materials and methods: A retrospective study on 2005 patients that underwent isolated coronary artery bypass grafting in Iceland between 2000 and 2016. Patients were categorized into two groups based on their preoperative LVEF; LVEF ≤35% (n = 146, median LVEF 30%) and LVEF >35% (n = 1859, median LVEF 60%). Demographics and major adverse cardiac and cerebrovascular events were compared between groups along with cardiac-specific and overall survival. The median follow-up was 7.6 years.
Results: Demographics were similar in both groups regarding age, gender and most cardiovascular risk factors. However, patients with LVEF ≤35% more often had diabetes, renal insufficiency, chronic obstructive pulmonary disease and a previous history of myocardial infarction. Thirty-day mortality was 4 times higher (8% vs 2%, P < 0.001) in the LVEF ≤35%-group compared to controls. Overall survival was significantly lower in the LVEF ≤35%-group compared to controls, at 1 year (87% vs. 98%, P < 0.001) and 5 years (69% vs. 91%, P < 0.001). In multivariable analysis LVEF ≤35% was linked to inferior survival with an adjusted hazard ratio of 2.0 (95%-CI 1.5 - 2.6, p<0.001).
Conclusions: A good long-term outcome after coronary artery bypass grafting can be expected for patients with reduced LVEF, however, their survival is still significantly inferior to patients with normal ventricular function.
{"title":"Long-term outcome of surgical revascularization in patients with reduced left ventricular ejection fraction-a population-based cohort study.","authors":"Helga B Brynjarsdottir, Arni Johnsen, Alexandra A Heimisdottir, Sunna Rún Heidarsdottir, Anders Jeppsson, Martin I Sigurdsson, Tomas Gudbjartsson","doi":"10.1093/icvts/ivac095","DOIUrl":"10.1093/icvts/ivac095","url":null,"abstract":"<p><strong>Objectives: </strong>Surgical revascularization is an established indication for patients with advanced coronary artery disease and reduced left ventricular ejection fraction (LVEF). Long-term outcomes for these patients are not well-defined. We studied the long-term outcomes of patients with ischaemic cardiomyopathy who underwent surgical revascularization in a well-defined nationwide cohort.</p><p><strong>Materials and methods: </strong>A retrospective study on 2005 patients that underwent isolated coronary artery bypass grafting in Iceland between 2000 and 2016. Patients were categorized into two groups based on their preoperative LVEF; LVEF ≤35% (n = 146, median LVEF 30%) and LVEF >35% (n = 1859, median LVEF 60%). Demographics and major adverse cardiac and cerebrovascular events were compared between groups along with cardiac-specific and overall survival. The median follow-up was 7.6 years.</p><p><strong>Results: </strong>Demographics were similar in both groups regarding age, gender and most cardiovascular risk factors. However, patients with LVEF ≤35% more often had diabetes, renal insufficiency, chronic obstructive pulmonary disease and a previous history of myocardial infarction. Thirty-day mortality was 4 times higher (8% vs 2%, P < 0.001) in the LVEF ≤35%-group compared to controls. Overall survival was significantly lower in the LVEF ≤35%-group compared to controls, at 1 year (87% vs. 98%, P < 0.001) and 5 years (69% vs. 91%, P < 0.001). In multivariable analysis LVEF ≤35% was linked to inferior survival with an adjusted hazard ratio of 2.0 (95%-CI 1.5 - 2.6, p<0.001).</p><p><strong>Conclusions: </strong>A good long-term outcome after coronary artery bypass grafting can be expected for patients with reduced LVEF, however, their survival is still significantly inferior to patients with normal ventricular function.</p>","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9419690/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74280095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Francesco Epis, Liliane Chatenoud, Alberto Somaschini, Ilaria Bitetti, Fulvio Cantarero, Alessandro Cristian Salvati, Daniela Rocchi, Salvatore Lentini, Elena Giovanella, Gina Portella, Martin Langer
Objectives: Sickle-cell disease (SCD) patients are considered to be at high risk from open-heart surgery. This study assessed the role of a simple sickling-prevention protocol.
Methods: Perioperative non-specific and SCD-specific morbidity and 30-day mortality are investigated in a retrospective cohort study on patients undergoing isolated mitral valve surgery. Patients with and without SCD were compared. In the SCD cohort, a bundle of interventions was applied to limit the risk of sickling: 'on-demand' transfusions to keep haemoglobin levels of around 7-8 g/dl, cardiopulmonary bypass (CPB) with higher blood flow and perfusion temperature, close monitoring of acid-base balance and oxygenation.
Results: Twenty patients with and 40 patients without SCD were included. At baseline, only preoperative haemoglobin levels differed between cohorts (8.1 vs 11.8 g/dl, P < 0.001). Solely SCD patients received preoperative transfusions (45.0%). Intraoperative transfusions were significantly larger in SCD patients during CPB (priming: 300 vs 200 ml; entire length: 600 vs 300 ml and 20 vs 10 ml/kg). SCD patients had higher perfusion temperatures during CPB (34.7 vs 33.0°C, P = 0.01) with consequently higher pharyngeal temperature, both during cooling (34.1 vs 32.3°C, P = 0.02) and rewarming (36.5 vs 36.2°C, P = 0.02). No mortality occurred, and non-SCD-specific complications were comparable between groups, but one SCD patient suffered from perioperative cerebrovascular accident with seizures, and another had evident haemolysis.
Conclusions: SCD patients may undergo open-heart surgery for mitral valve procedures with an acceptable risk profile. Simple but thoughtful perioperative management, embracing 'on-demand' transfusions and less-aggressive CPB cooling is feasible and probably efficacious.
目的:镰状细胞病(SCD)患者被认为是开胸手术的高危人群。本研究评估了简单的镰状病预防方案的作用。方法:回顾性队列研究分离二尖瓣手术患者围手术期非特异性和scd特异性发病率和30天死亡率。比较有无SCD患者。在SCD队列中,应用了一系列干预措施来限制镰状病变的风险:“按需”输血以保持血红蛋白水平在7-8 g/dl左右,体外循环(CPB)具有更高的血流量和灌注温度,密切监测酸碱平衡和氧合。结果:纳入有SCD患者20例,无SCD患者40例。在基线时,只有术前血红蛋白水平在队列之间存在差异(8.1 g/dl vs 11.8 g/dl, P)。结论:SCD患者可以在可接受的风险情况下接受二尖瓣手术。简单但周到的围手术期管理,包括“按需”输血和低侵略性CPB冷却是可行的,可能是有效的。
{"title":"Simple open-heart surgery protocol for sickle-cell disease patients: a retrospective cohort study comparing patients undergoing mitral valve surgery.","authors":"Francesco Epis, Liliane Chatenoud, Alberto Somaschini, Ilaria Bitetti, Fulvio Cantarero, Alessandro Cristian Salvati, Daniela Rocchi, Salvatore Lentini, Elena Giovanella, Gina Portella, Martin Langer","doi":"10.1093/icvts/ivac205","DOIUrl":"https://doi.org/10.1093/icvts/ivac205","url":null,"abstract":"<p><strong>Objectives: </strong>Sickle-cell disease (SCD) patients are considered to be at high risk from open-heart surgery. This study assessed the role of a simple sickling-prevention protocol.</p><p><strong>Methods: </strong>Perioperative non-specific and SCD-specific morbidity and 30-day mortality are investigated in a retrospective cohort study on patients undergoing isolated mitral valve surgery. Patients with and without SCD were compared. In the SCD cohort, a bundle of interventions was applied to limit the risk of sickling: 'on-demand' transfusions to keep haemoglobin levels of around 7-8 g/dl, cardiopulmonary bypass (CPB) with higher blood flow and perfusion temperature, close monitoring of acid-base balance and oxygenation.</p><p><strong>Results: </strong>Twenty patients with and 40 patients without SCD were included. At baseline, only preoperative haemoglobin levels differed between cohorts (8.1 vs 11.8 g/dl, P < 0.001). Solely SCD patients received preoperative transfusions (45.0%). Intraoperative transfusions were significantly larger in SCD patients during CPB (priming: 300 vs 200 ml; entire length: 600 vs 300 ml and 20 vs 10 ml/kg). SCD patients had higher perfusion temperatures during CPB (34.7 vs 33.0°C, P = 0.01) with consequently higher pharyngeal temperature, both during cooling (34.1 vs 32.3°C, P = 0.02) and rewarming (36.5 vs 36.2°C, P = 0.02). No mortality occurred, and non-SCD-specific complications were comparable between groups, but one SCD patient suffered from perioperative cerebrovascular accident with seizures, and another had evident haemolysis.</p><p><strong>Conclusions: </strong>SCD patients may undergo open-heart surgery for mitral valve procedures with an acceptable risk profile. Simple but thoughtful perioperative management, embracing 'on-demand' transfusions and less-aggressive CPB cooling is feasible and probably efficacious.</p>","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/4c/51/ivac205.PMC9426665.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10793283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We report the case of a 74-year-old man treated for refractory non-malignant pericardial effusion using a pericardioperitoneal shunt. After the failure of conventional pericardiocentesis, a pericardioperitoneal shunt using a Denver shunt was inserted to drain the pericardial effusion into the peritoneal cavity. At 3-year follow-up, the effusion was well controlled and the shunt remained patent.
{"title":"Pericardioperitoneal shunt for the treatment of refractory non-malignant pericardial effusion.","authors":"Ishida Masaru, Kajiyama Tetsuya, Satoh Hisashi","doi":"10.1093/icvts/ivac215","DOIUrl":"https://doi.org/10.1093/icvts/ivac215","url":null,"abstract":"<p><p>We report the case of a 74-year-old man treated for refractory non-malignant pericardial effusion using a pericardioperitoneal shunt. After the failure of conventional pericardiocentesis, a pericardioperitoneal shunt using a Denver shunt was inserted to drain the pericardial effusion into the peritoneal cavity. At 3-year follow-up, the effusion was well controlled and the shunt remained patent.</p>","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9415194/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40631202","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We encountered a rare case of pulmonary sequestration supplied from the right renal artery, which was resected by video-assisted thoracic surgery with carbon dioxide insufflation and indocyanine green-guided technique. A 41-year-old woman with intralobar pulmonary sequestration supplied from the right renal artery was referred to our department. At the time of surgery, we used carbon dioxide insufflation to improve the manoeuvrable workspace for shutting off aberrant arteries and indocyanine green fluorescence guidance to differentiate the boundary of the sequestered lung from the normal lung. These procedures helped in the efficient resection of the lesion.
{"title":"Thoracoscopic resection of pulmonary sequestration with carbon dioxide insufflation and indocyanine green.","authors":"Sachie Koike, Masahisa Miyazawa, Nobutaka Kobayashi","doi":"10.1093/icvts/ivac209","DOIUrl":"https://doi.org/10.1093/icvts/ivac209","url":null,"abstract":"<p><p>We encountered a rare case of pulmonary sequestration supplied from the right renal artery, which was resected by video-assisted thoracic surgery with carbon dioxide insufflation and indocyanine green-guided technique. A 41-year-old woman with intralobar pulmonary sequestration supplied from the right renal artery was referred to our department. At the time of surgery, we used carbon dioxide insufflation to improve the manoeuvrable workspace for shutting off aberrant arteries and indocyanine green fluorescence guidance to differentiate the boundary of the sequestered lung from the normal lung. These procedures helped in the efficient resection of the lesion.</p>","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9380781/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40683645","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Video description: A 34-year-old male patient presented at the emergency department with fever, dysphagia and thoracic pain. His previous medical history consisted of caustic ingestion 18 years before, resulting in oesophageal-aorta fistula treated by aortic endograft placement and oesophageal exclusion with retrosternal colonic interposition. Diagnosis of thoracic stent graft infection was made based on clinical, microbiological and radiological criteria. After multidisciplinary consultation which involved thoracic surgery unit, the patient was considered eligible for aortic endoprosthesis explantation. The video shows the surgical intervention of removal of the aortic endograft and aortic reconstruction with homograft conduit by extrapleural approach in thoraco-phreno-laparotomy.
{"title":"Extrapleural approach for thoracoabdominal infected aortic endograft: surgical and circulatory strategies.","authors":"Matteo Cazzaniga, Massimo Torre, Alfredo Lista, Valerio Stefano Tolva","doi":"10.1093/icvts/ivac208","DOIUrl":"https://doi.org/10.1093/icvts/ivac208","url":null,"abstract":"Video description: A 34-year-old male patient presented at the emergency department with fever, dysphagia and thoracic pain. His previous medical history consisted of caustic ingestion 18 years before, resulting in oesophageal-aorta fistula treated by aortic endograft placement and oesophageal exclusion with retrosternal colonic interposition. Diagnosis of thoracic stent graft infection was made based on clinical, microbiological and radiological criteria. After multidisciplinary consultation which involved thoracic surgery unit, the patient was considered eligible for aortic endoprosthesis explantation. The video shows the surgical intervention of removal of the aortic endograft and aortic reconstruction with homograft conduit by extrapleural approach in thoraco-phreno-laparotomy.","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/69/0f/ivac208.PMC9443981.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10679112","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nabil Hussein, Jef Van den Eynde, Connor Callahan, Alvise Guariento, Can Gollmann-Tepeköylü, Malak Elbatarny, Mahmoud Loubani
Objectives: With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula.
Methods: Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI).
Results: Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity.
Conclusions: Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.
目的:随着训练时间和术中暴露时间的减少,有必要对受训人员的进步进行客观评估。本系统综述的重点是评价学员的技术技能表现使用客观的评估,在心胸外科及其纳入培训课程。方法:纳入EBSCOHOST、Scopus和Web of Science数据库及相关文献文献列表,对心胸外科实习医师/住院医师的技术技能进行客观评价。数据提取包括已执行的任务;评估设置和使用的工具;评审员人数/水平;研究结果及评估是否纳入培训课程。使用医学教育研究质量工具(MERSQI)对研究的方法学严谨性进行评分。结果:纳入54项研究进行定量综合。其中6项为随机对照试验。心脏外科是使用客观评估方法最常见的专科,冠状动脉吻合是最常用的测试任务。最常用的是基于likert的评估工具(61%)。85%的研究是基于模拟的,其余的是术中研究。专家外科医生主要用于客观评估(78%),46%使用盲法。30项(56%)研究探讨了技术性能的客观变化,其中97%的研究表明技术性能有所改善。其他研究主要是验证评估工具。39%的研究将这些评估工具纳入培训课程。所有研究MERSQI评分的平均值±标准差为13.6±1.5,显示出高效度。结论:尽管有有效的技术技能评估工具可用,并证明了受训人员的进步,但缺乏将其定期纳入培训课程。有必要将这些评估结合起来,以提高心胸外科医生培训计划的效率和透明度。
{"title":"The use of objective assessments in the evaluation of technical skills in cardiothoracic surgery: a systematic review.","authors":"Nabil Hussein, Jef Van den Eynde, Connor Callahan, Alvise Guariento, Can Gollmann-Tepeköylü, Malak Elbatarny, Mahmoud Loubani","doi":"10.1093/icvts/ivac194","DOIUrl":"https://doi.org/10.1093/icvts/ivac194","url":null,"abstract":"<p><strong>Objectives: </strong>With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula.</p><p><strong>Methods: </strong>Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI).</p><p><strong>Results: </strong>Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity.</p><p><strong>Conclusions: </strong>Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.</p>","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/12/a4/ivac194.PMC9403301.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40641092","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Atrioventricular groove disruption is a rare and potentially fatal complication of mitral valve replacement. It does not occur with mitral valve repair. Friable tissues, advanced age and posterior annular calcification are important predisposing factors. Most ruptures usually occur in the operating room, which gives the operating surgeon a better chance at salvaging the situation. Nevertheless, mortality remains high particularly if the rupture happened in the intensive care unit or later and it can be as high as 50–90%. In dealing with this complication surgically, there are 2 major approaches that have been described in the literature, the ‘external’ and the ‘intracardiac’ the external repair technique is usually conducted on cardiopulmonary bypass using direct suturing or felt-reinforced suturing or both of the ruptured atrioventricular groove. This can be supplemented with the application of bioglue (cryolife). Further atrial patching and coronary bypass grafting of the circumflex coronary artery may be required [1]. The intracardiac approach entails going back on pump and under cardioplegic arrest, explant the MV prosthesis and patch the posterior atrioventricular groove with fresh autologous pericardium or bovine pericardium then place the prosthetics valve again [2]. There are case reports of utilizing other additional technical tips. Raevsky et al. present a case report of a 23-year-old female with shone complex, who developed atrioventricular groove disruption after mitral valve replacement. To accomplish the repair and because of difficult exposure, they had to utilize ‘the commando procedure principles’, sacrificing the native ‘bicuspid’ aortic valve [3]. That was a commendable salvage for a deadly complication. The way the problem was handled is innovative and though very complicated, the outcome was good. However, in our opinion, this is not for the average cardiac surgeon and the principle remains to emphasize that such complication should not happen. We should teach young surgeons how to avoid such a complication. Simple preservation of the posterior leaflet or at least part of it prevents this complication. In Deniz et al.’s series of 513 mitral valve replacement patients, there were no cases of ventricular rupture with preservation of the posterior leaflet [4]. Being careful in detaching the mitral valve from the papillary muscles and paying attention to details is of utmost importance. This case report involves a young patient with probably ‘good’ tissue quality and preserved left ventricular function. No doubt this contributed to patient’s recovery. Imagine this patient was a 70–75 years old (most patients reported in the literature are in the older age range) who has some mitral valve annular calcification, left ventricular dysfunction and friable tissues and underwen this procedure that took 475 min (almost 8 h) of pump time and 310 min (5 h) of aortic cross-clamping was performed. What would be the chances of survival? Hones
{"title":"An ounce of prevention is worth a pound of cure.","authors":"Zohair Al Halees","doi":"10.1093/icvts/ivac216","DOIUrl":"https://doi.org/10.1093/icvts/ivac216","url":null,"abstract":"Atrioventricular groove disruption is a rare and potentially fatal complication of mitral valve replacement. It does not occur with mitral valve repair. Friable tissues, advanced age and posterior annular calcification are important predisposing factors. Most ruptures usually occur in the operating room, which gives the operating surgeon a better chance at salvaging the situation. Nevertheless, mortality remains high particularly if the rupture happened in the intensive care unit or later and it can be as high as 50–90%. In dealing with this complication surgically, there are 2 major approaches that have been described in the literature, the ‘external’ and the ‘intracardiac’ the external repair technique is usually conducted on cardiopulmonary bypass using direct suturing or felt-reinforced suturing or both of the ruptured atrioventricular groove. This can be supplemented with the application of bioglue (cryolife). Further atrial patching and coronary bypass grafting of the circumflex coronary artery may be required [1]. The intracardiac approach entails going back on pump and under cardioplegic arrest, explant the MV prosthesis and patch the posterior atrioventricular groove with fresh autologous pericardium or bovine pericardium then place the prosthetics valve again [2]. There are case reports of utilizing other additional technical tips. Raevsky et al. present a case report of a 23-year-old female with shone complex, who developed atrioventricular groove disruption after mitral valve replacement. To accomplish the repair and because of difficult exposure, they had to utilize ‘the commando procedure principles’, sacrificing the native ‘bicuspid’ aortic valve [3]. That was a commendable salvage for a deadly complication. The way the problem was handled is innovative and though very complicated, the outcome was good. However, in our opinion, this is not for the average cardiac surgeon and the principle remains to emphasize that such complication should not happen. We should teach young surgeons how to avoid such a complication. Simple preservation of the posterior leaflet or at least part of it prevents this complication. In Deniz et al.’s series of 513 mitral valve replacement patients, there were no cases of ventricular rupture with preservation of the posterior leaflet [4]. Being careful in detaching the mitral valve from the papillary muscles and paying attention to details is of utmost importance. This case report involves a young patient with probably ‘good’ tissue quality and preserved left ventricular function. No doubt this contributed to patient’s recovery. Imagine this patient was a 70–75 years old (most patients reported in the literature are in the older age range) who has some mitral valve annular calcification, left ventricular dysfunction and friable tissues and underwen this procedure that took 475 min (almost 8 h) of pump time and 310 min (5 h) of aortic cross-clamping was performed. What would be the chances of survival? Hones","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9415191/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40703588","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Matheus Duarte Pimentel, José Glauco Lobo Filho, Heraldo Guedis Lobo Filho, Emílio de Castro Miguel, Sergimar Kennedy Pinheiro Paiva, João Igor Silva Matos, Matheus Augusto Mesquita Fernandes, Francisco Vagnaldo Fechine Jamacaru
Objectives: Approaches to improve saphenous vein (SV) patency in coronary artery bypass graft (CABG) surgery remain relevant. This study aimed to evaluate the effects of different preservation solutions and different pressures of intraluminal distention on the endothelium of SV segments in CABG.
Methods: Forty-two SV segments obtained from 12 patients undergoing CABG were divided into 7 groups. Group 1 (control) was prepared without preservation or intraluminal distension, while the other 6 groups were preserved in autologous heparinized autologous arterial blood or normal saline (NS), with distention pressures 30, 100 and 300 mmHg. To assess the effects of using these solutions and pressures on the endothelium, the grafts were analysed by scanning electron microscopy, with the measurement of endothelial damage degree.
Results: Segments in group 1 showed minimal endothelial damage. SV grafts preserved with NS had significantly greater endothelial damage both compared to the control group and compared to groups preserved with autologous arterial blood (P < 0.001). Segments distended with pressures up to 100 mmHg showed less damage when compared to those distended at 300 mmHg, with the ones subjected to higher pressures presenting a maximum degree of damage, with considerable loss and separation of endothelial cells, extensive foci of exposure of the basement membrane and numerous fractures of the intimate layer, without differences regarding the solution used.
Conclusions: Preparation of SV using NS and with intraluminal distension pressures above 100 mmHg is factors related to increased damage to the venous endothelium.
{"title":"Effect of preservation solution and distension pressure on saphenous vein's endothelium.","authors":"Matheus Duarte Pimentel, José Glauco Lobo Filho, Heraldo Guedis Lobo Filho, Emílio de Castro Miguel, Sergimar Kennedy Pinheiro Paiva, João Igor Silva Matos, Matheus Augusto Mesquita Fernandes, Francisco Vagnaldo Fechine Jamacaru","doi":"10.1093/icvts/ivac124","DOIUrl":"10.1093/icvts/ivac124","url":null,"abstract":"<p><strong>Objectives: </strong>Approaches to improve saphenous vein (SV) patency in coronary artery bypass graft (CABG) surgery remain relevant. This study aimed to evaluate the effects of different preservation solutions and different pressures of intraluminal distention on the endothelium of SV segments in CABG.</p><p><strong>Methods: </strong>Forty-two SV segments obtained from 12 patients undergoing CABG were divided into 7 groups. Group 1 (control) was prepared without preservation or intraluminal distension, while the other 6 groups were preserved in autologous heparinized autologous arterial blood or normal saline (NS), with distention pressures 30, 100 and 300 mmHg. To assess the effects of using these solutions and pressures on the endothelium, the grafts were analysed by scanning electron microscopy, with the measurement of endothelial damage degree.</p><p><strong>Results: </strong>Segments in group 1 showed minimal endothelial damage. SV grafts preserved with NS had significantly greater endothelial damage both compared to the control group and compared to groups preserved with autologous arterial blood (P < 0.001). Segments distended with pressures up to 100 mmHg showed less damage when compared to those distended at 300 mmHg, with the ones subjected to higher pressures presenting a maximum degree of damage, with considerable loss and separation of endothelial cells, extensive foci of exposure of the basement membrane and numerous fractures of the intimate layer, without differences regarding the solution used.</p><p><strong>Conclusions: </strong>Preparation of SV using NS and with intraluminal distension pressures above 100 mmHg is factors related to increased damage to the venous endothelium.</p>","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9419693/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84893417","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Charlotte Sandström, Håkan Roos, Olof Henrikson, Erika Fagman, Åse A Johnsson, Anders Jeppsson, Mårten Falkenberg
Objectives: Patients with expanding chronic aortic dissection and patent proximal entries are sometimes poor candidates for open surgery or TEVAR. Occlusion of proximal entries with endovascular plugs has previously been suggested in selected patients, but clinical results over time are unknown. This study analyses aortic remodelling and clinical outcome after proximal entry occlusion.
Methods: Between 2007 and 2016, 14 patients, with expanding chronic aortic dissection, considered poor candidates for standard treatment, were treated with endovascular plugs in proximal entries located in the arch (n = 6) or descending aorta (n = 8). The Amplatzer™ Vascular Plug II was used for entries ≤4 mm and the Amplatzer™ Septal Occluder or Amplatzer™ Muscular VSD Occluder for entries 5-16 mm. Patients were followed for 0.5-13 years (median 7.3) with clinical visits and computed tomography. Diameters and cross-sectional areas along the aorta were measured.
Results: Occlusion of proximal entries was achieved in 10/14 patients (71%), including 4 patients with an adjunctive reintervention needed for complete seal in the segment. Unchanged or reduced maximum thoracic aortic diameter was observed in all 10 patients with successful occlusion. In 4 patients, proximal occlusion was not achieved and early conversion to FET (n = 1), FET/TEVAR (n = 2) or TEVAR (n = 1) was performed. Two aorta-related deaths occurred during follow-up, both after early conversion.
Conclusions: Endovascular occlusion of proximal dissection entries of expanding chronic aortic dissections can induce favourable aortic remodelling and may be considered in selected patients with expanding chronic aortic dissection who are poor candidates for open surgery or stent graft repair.
{"title":"Endovascular plugs to occlude proximal entries in chronic aortic dissection.","authors":"Charlotte Sandström, Håkan Roos, Olof Henrikson, Erika Fagman, Åse A Johnsson, Anders Jeppsson, Mårten Falkenberg","doi":"10.1093/icvts/ivac201","DOIUrl":"https://doi.org/10.1093/icvts/ivac201","url":null,"abstract":"<p><strong>Objectives: </strong>Patients with expanding chronic aortic dissection and patent proximal entries are sometimes poor candidates for open surgery or TEVAR. Occlusion of proximal entries with endovascular plugs has previously been suggested in selected patients, but clinical results over time are unknown. This study analyses aortic remodelling and clinical outcome after proximal entry occlusion.</p><p><strong>Methods: </strong>Between 2007 and 2016, 14 patients, with expanding chronic aortic dissection, considered poor candidates for standard treatment, were treated with endovascular plugs in proximal entries located in the arch (n = 6) or descending aorta (n = 8). The Amplatzer™ Vascular Plug II was used for entries ≤4 mm and the Amplatzer™ Septal Occluder or Amplatzer™ Muscular VSD Occluder for entries 5-16 mm. Patients were followed for 0.5-13 years (median 7.3) with clinical visits and computed tomography. Diameters and cross-sectional areas along the aorta were measured.</p><p><strong>Results: </strong>Occlusion of proximal entries was achieved in 10/14 patients (71%), including 4 patients with an adjunctive reintervention needed for complete seal in the segment. Unchanged or reduced maximum thoracic aortic diameter was observed in all 10 patients with successful occlusion. In 4 patients, proximal occlusion was not achieved and early conversion to FET (n = 1), FET/TEVAR (n = 2) or TEVAR (n = 1) was performed. Two aorta-related deaths occurred during follow-up, both after early conversion.</p><p><strong>Conclusions: </strong>Endovascular occlusion of proximal dissection entries of expanding chronic aortic dissections can induce favourable aortic remodelling and may be considered in selected patients with expanding chronic aortic dissection who are poor candidates for open surgery or stent graft repair.</p>","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/a8/8c/ivac201.PMC9346262.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40537628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This year, the Perceval sutureless valve is reaching its 15th anniversary. The first-in-man trial of this tissue valve was performed in 2007 and later completed with larger prospective trials for CE approval and initiation of commercial use [1, 2]. Since then, many centres across the world are using this tissue valve on a regular basis in a wide variety of patients with aortic valve disease. At this moment, Perceval is the only truly sutureless valve on the market, allowing aortic valve replacement without the use of a single suture that has to be knotted. Roughly estimated, around 75 000 valves have been implanted worldwide at this moment. Around 2016–2017, 9 years after the first-in-man experience, the manufacturer decided to change their advice towards sizing of the prosthesis. After the observation of high pacemaker rates in the largest valve size (XL size) and some isolated cases of stent invagination due to oversizing, a new advice was given to use the commercial valve sizers differently. The actual valve is still slightly bigger in diameter compared to the white side of the corresponding sizer, so if this side fits into annulus with slight resistance, this is the correct size to choose. In the meantime, additional evidence exists that demonstrates the clear negative effects of oversizing this nitinol-based, sutureless valve [3]. Fabre et al. [4] are to be congratulated on their correct reporting of their overall experience and outcome with this technology. In the article, the authors focus specifically on the need for permanent pacemaker implantation, early after valve surgery using this sutureless valve. Two chronological study cohorts were defined: the experience before and after 2016. The new sizing strategy and which elements were changed are well described in the article. The need for pacemaker implantation decreased significantly from 16% to 5.9%. We recently published our experience with Perceval, also looking at 2 cohorts in time, namely before and after 2017 [5]. A similar observation of a significantly decreased need for postoperative pacemakers from 11% to 6% was made, strengthening the observation made by Fabre. Regarding the analysis of the reasons why this pacemaker rate drops, we certainly agree with the new sizing method as an important factor in avoiding conduction disturbance after placement of the valve. We showed that just by downsizing by 1 size, the higher pacemaker rates disappear. The effect of the balloon dilation and the effect of the height of the Perceval positioning are more debatable in our opinion. Correct and complete decalcification on the other hand—as also mentioned by Fabre et al.—is important to obtain a good result with sutureless technology. In conclusion, the observation made in this article is correct and corresponds to experiences in other centres. The main driver behind the decrease in pacemaker rate, however, in our opinion, is the new sizing method. The effect of ballooning and the higher implan
{"title":"The importance of sizing in sutureless valves.","authors":"Bart Meuris, Marie Lamberigts, Delphine Szecel","doi":"10.1093/icvts/ivac206","DOIUrl":"https://doi.org/10.1093/icvts/ivac206","url":null,"abstract":"This year, the Perceval sutureless valve is reaching its 15th anniversary. The first-in-man trial of this tissue valve was performed in 2007 and later completed with larger prospective trials for CE approval and initiation of commercial use [1, 2]. Since then, many centres across the world are using this tissue valve on a regular basis in a wide variety of patients with aortic valve disease. At this moment, Perceval is the only truly sutureless valve on the market, allowing aortic valve replacement without the use of a single suture that has to be knotted. Roughly estimated, around 75 000 valves have been implanted worldwide at this moment. Around 2016–2017, 9 years after the first-in-man experience, the manufacturer decided to change their advice towards sizing of the prosthesis. After the observation of high pacemaker rates in the largest valve size (XL size) and some isolated cases of stent invagination due to oversizing, a new advice was given to use the commercial valve sizers differently. The actual valve is still slightly bigger in diameter compared to the white side of the corresponding sizer, so if this side fits into annulus with slight resistance, this is the correct size to choose. In the meantime, additional evidence exists that demonstrates the clear negative effects of oversizing this nitinol-based, sutureless valve [3]. Fabre et al. [4] are to be congratulated on their correct reporting of their overall experience and outcome with this technology. In the article, the authors focus specifically on the need for permanent pacemaker implantation, early after valve surgery using this sutureless valve. Two chronological study cohorts were defined: the experience before and after 2016. The new sizing strategy and which elements were changed are well described in the article. The need for pacemaker implantation decreased significantly from 16% to 5.9%. We recently published our experience with Perceval, also looking at 2 cohorts in time, namely before and after 2017 [5]. A similar observation of a significantly decreased need for postoperative pacemakers from 11% to 6% was made, strengthening the observation made by Fabre. Regarding the analysis of the reasons why this pacemaker rate drops, we certainly agree with the new sizing method as an important factor in avoiding conduction disturbance after placement of the valve. We showed that just by downsizing by 1 size, the higher pacemaker rates disappear. The effect of the balloon dilation and the effect of the height of the Perceval positioning are more debatable in our opinion. Correct and complete decalcification on the other hand—as also mentioned by Fabre et al.—is important to obtain a good result with sutureless technology. In conclusion, the observation made in this article is correct and corresponds to experiences in other centres. The main driver behind the decrease in pacemaker rate, however, in our opinion, is the new sizing method. The effect of ballooning and the higher implan","PeriodicalId":13621,"journal":{"name":"Interactive cardiovascular and thoracic surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9372564/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40669772","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}