Journal of Cardiac Surgery最新文献

Background. Despite the guideline recommendation, implementation of the Cox-maze (CM) IV procedure has been variable and current data are limited. Methods. We reviewed patients with concomitant CM IV procedure (05/2019−05/2020). The primary endpoints of the study were the success rate of surgical ablation and continuity of sinus rhythm (SR) 1 year after surgery. Secondary endpoints included permanent pacemaker (PPM) implantation, postoperative mortality, and identification of predictors for postoperative SR. Results. The concomitant CM IV procedure was performed in 92 patients. Indications were persistent atrial fibrillation (AF) in 40 patients (43.5%), paroxysmal AF in 36 (39.1%), and long-standing persistent AF in 16 (17.4%). At hospital discharge, SR was achieved in 49 patients (63.6%) and PPM implantation was necessary in 12 patients (13%). At 1 year after surgical ablation, SR was seen in 31 patients (59.6%) and PPM implantation was required in six further patients (6.5%). Patients with long-standing persistent AF were significantly less likely to achieve SR (odds ratio (OR): 0.18, p = 0.003), and postoperative mortality was significantly increased in this subgroup (hazard ratio (HR): 5.4, p = 0.02). In patients with enlarged left atrial (LA) diameter, the probability of achieving SR was significantly decreased (OR: 0.48, p = 0.045). Need for postoperative dialysis (HR: 12.9, p = 0.02) and prolonged stay in the intensive care unit (HR: 2.2, p = 0.01) were independently associated with increased mortality after CM IV. Conclusions. The cryothermal CM IV procedure has an overall 1-year success rate of 60% with increased rates of PPM implantation. Patients with long-standing persistent AF and increased LA diameter were significantly less likely to achieve SR.

Aim. The present study sought to evaluate the cardiovascular morphology and associated anomalies in patients with interrupted aortic arch (IAA) on CT angiography. Materials and Methods. A retrospective review of our departmental database was conducted to identify patients diagnosed with IAA on CT angiography between January 2014 and September 2022. The demographic information, anatomic characteristics, and associated cardiovascular abnormalities in patients with IAA were assessed. The morphological types of IAA were described in accordance with Celoria–Patton classification. Results. IAA was seen in 49 patients (32 males and 17 females; mean age: 15.9 months). The most common type of IAA based on the site of interruption was type A seen in 27/49 (55.1%) patients, while type B was observed in 22/49 (44.9%) patients. No patient of type C IAA was encountered in the current series. The most commonly associated cardiovascular anomaly was patent ductus arteriosus (PDA) seen in 45/49 (91.8%) patients. Atrial septal defect was seen in 15/49 (30.6%) patients, while 39/49 (79.6%) patients had a ventricular septal defect (VSD). Common arterial trunk was the most common abnormal ventriculo-arterial connection seen in 13/49 (26.5%) patients. Aorto-pulmonary window was associated with 7/49 (14.3%) patients. Conclusion. IAA is a rare congenital heart defect associated with an array of cardiovascular anomalies, most common being PDA and VSD. CT angiography is useful not only in diagnosing and characterizing the IAA but also in identifying associated anomalies which may have a bearing on the clinical presentation, prognosis, and surgical management.

Aims. We described our advancement in the field of robotic cardiac surgery, particularly in the context of coronary revascularization. We will outline how the application of the Da Vinci® X Surgical System in coronary surgery is safe, feasible, and reproducible after an adequate familiarization with the docking system, that could come from a previous mitral valve robotic program, and after a sufficient learning time period. Methods. Between February 2021 and December 2023, a cohort of 33 patients underwent coronary artery revascularization surgery, involving robotic harvesting of the left mammary artery and off-pump hand-direct bypass to the left descending coronary artery or marginal coronary artery. In cases of hybrid revascularization, percutaneous coronary intervention with drug-eluting stent placement was performed either before or after surgery. Results. There were no mortalities within 30 days and at 1 year of follow-up after surgery. Notably, 70% of patients were extubated in the operating room immediately following the surgical procedure. The median postoperative mechanical ventilation time was 0 [0–4] hours, and the median length of stay in the intensive care unit was 21 [20–48] hours. A progressive reduction of the console and instrumental Da Vinci® X Surgical System was underling after the 21^st patient. Conclusion. The promising outcomes observed in this series highlight that robotic-assisted coronary artery bypass represents a well-established technique that could be reproducible, especially when integrated into a hybrid strategy. Initiating a program in robotic-assisted coronary artery bypass surgery can be effectively attained in particularly when a well-established background in Da Vinci® X Surgical System utilization is achieved.

Background. Advancing age is a nonmodifiable risk factor for the development of coronary artery disease. Furthermore, patients >65 years old are considered at high risk for coronary artery bypass grafting (CABG). The aim of this study was to investigate whether there were any differences in clinical outcomes for patients with a mean age ≥65 undergoing CABG on or off pump. Methods. Systematic searches were conducted in EMBASE, PubMed, Web of Science, and Cochrane Central Registry of Controlled Trials (CENTRAL). The key search terms used were “cardiopulmonary bypass” OR “On pump” AND “off pump” OR “beating heart” AND “coronary artery bypass grafting” OR “CABG” AND “age.” This was followed by a meta-analysis assessing the primary outcomes mortality, myocardial infarction, renal failure, and stroke in the short—(30 days) and midterm (12–44 months) and repeat revascularisation at midterm follow up. Secondary outcomes investigated included postoperative atrial fibrillation, number of units of blood transfused, ventilation time, length of intensive care unit stay, and length of hospital stay. Results. 14 studies involving 10,260 participants, 5,141 of whom had on-pump CABG and 5,119 of whom had off-pump CABG were identified. There was a significantly greater need for repeat revascularisation in the off-pump group (risk ratio 1.47, 95% confidence interval 1.07 to 2.01, I² = 0%, p = 0.02) at midterm follow up. The off-pump group also had a shorter hospital stay. All other comparisons were insignificant. Conclusion. A number of different factors contribute to whether the increased need for repeat revascularisation for off-pump patients is truly clinically significant. This requires further investigation in meta-analysis based on longer-term trials in patients with a mean age ≥65. Otherwise, the similarity in clinical outcomes for patients in this age group suggests the choice to carry out CABG on or off pump should continue to be at the surgeon’s discretion.

Background. Efforts to expand the heart donor pool have included the use of extended criteria donors (e.g., advanced age or comorbid conditions). Another potential avenue is donor hearts with pre-existing coronary artery disease (CAD). Methods. A retrospective cohort study was performed using the Organ Procurement and Transplantation Network database between 10/1/1987 and 12/3/2020. Postoperative complications, graft failure, and survival were examined between recipients of donor hearts with abnormal (CAD donor) versus normal (non-CAD donor) coronary angiogram. Analysis was performed in unmatched cohorts as well as after propensity score matching. Results. A total of 12,230 heart transplant recipients were identified, of which 940 (7.6%) had an abnormal donor coronary angiogram. There were no differences between CAD and non-CAD donor groups in acute rejection, stroke, or dialysis prior to discharge or treatment for rejection <1 year. However, the CAD donor group had a greater pacemaker incidence (5.2% vs. 3.6%, P = 0.02). After matching, 785 patients were in each group and there were no differences in perioperative outcomes or treatment for rejection <1 year. There was no difference in 10-year freedom from graft failure (53.1% vs. 54.6%, log rank = 1.03, and P = 0.31) or cumulative survival (54.7% vs. 55.8%, log rank = 0.63, and P = 0.43) between the matched CAD and non-CAD donor groups. Conclusion. The presence of CAD may not be a contraindication to transplantation. Carefully selected donor hearts with CAD may have equivalent postoperative and long-term outcomes to donor hearts without CAD. Further study in this area may expand the pool of donors.

Objectives. Aortic arch replacement is a major surgical intervention. This meta-analysis aims to combine the international literature on the branch-first technique to describe its outcomes and offer a comparison to the standard techniques. Methods. PubMed and Cochrane were searched for studies on the branch-first technique in aortic arch surgery including those comparing this technique with the conventional ones. Mortality, neurological complications, bleeding, and renal replacement therapy were the major endpoints of interest. Subgroup analysis was performed for both single- and double-armed studies. Odds ratios with 95% confidence interval were used as summary estimates. The random-effects model was used for all outcomes. Results. Ten studies from three countries with a total of 498 patients were included. Proportional analysis of the branch-first technique estimated mortality of (3%, 95% CI [0.02–0.05]), neurological complications of (8%, 95% CI [0.03–0.13]), re-exploration for bleeding of (9%, 95% CI [0.05–0.13]), and renal replacement therapy of (9%, 95% CI [0.05–0.12]). This meta-analysis revealed no significant differences between the branch-first technique and the conventional technique in mortality (5% vs. 15%, OR = 0.32, 95% CI [0.08–1.18], p = 0.09, I2 = 40%), neurological complications (10% vs. 16%, OR = 0.53, 95% CI [0.24–1.21], p = 0.13, I2 = 0%), or renal replacement therapy (12% vs. 14%, OR = 0.72, 95% CI [0.33–1.59], p = 0.41, I2 = 0%). Conclusions. Branch-first technique provides a promising alternative approach in aortic arch surgery with no different surgical risks and potentially reduced operative complexity. Randomised controlled trials are needed to further investigate the safety and advantages of this technique.

Objectives. To investigate the predictive value of serum cold-inducible RNA-binding protein (CIRP) and postoperative acute kidney injury (AKI) after total aortic arch replacement. Methods. Eighty-six patients with acute Stanford type A aortic dissection (ATAAD) admitted to hospital from October 2019 to February 2021 were retrospectively selected as the study subjects. All patients underwent total aortic arch replacement under moderate hypothermic circulatory arrest (MHCA) with selective antegrade cerebral perfusion (SACP). Detection of the level of serum CIRP after admission and perioperative clinical data of patients were collected and analyzed. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to stage renal function. Patients were divided into a non-AKI-3 group (n = 70) and an AKI-3 group (n = 16) according to the stage of postoperative renal function. The risk factors for postoperative AKI KDIGO stage 3 were analyzed by a multivariate logistic regression model. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy. Results. In 86 patients, postoperative AKI-3 stage accounted for 18.6% (16/86). Compared with the non-AKI-3 group, the AKI-3 group had a higher preoperative BMI index, C-reactive protein, and CIRP level; a longer intraoperative cooling time, cardiopulmonary bypass time, and aortic cross-clamping time; and a higher intraoperative coronary artery bypass ratio (all P < 0.05). Multivariate logistic regression results showed that CIRP (OR = 1.001, 95% CI: 1.000–1.002, P = 0.012) was an independent risk factor for postoperative AKI KDIGO stage 3. Conclusion. The serum CIRP is associated with postoperative acute kidney injury after total aortic arch replacement in ATAAD patients and may serve as a predictive indicator for early detection and intervention to improve the prognosis.

As surveillance and the diagnosis of pathology grow, increasing numbers of patients are undergoing major aortic interventions globally. As a result, surgeons and physicians will encounter thoracic aortic graft infections with increasing frequency. These infections are extremely challenging, high-risk problems to deal with. This article provides a comprehensive overview of the pathogenesis, diagnosis, and management both medical and surgical of this high-risk complication. We provide proposed diagnostic criteria and suggested algorithm for the management of this important group of patients.

Heart transplantation from donors after circulatory death (DCD) has demonstrated increased primary graft dysfunction. Durable mechanical circulatory (MCS) recipients have slightly higher perioperative risk but excellent long-term survival. We sought to determine if the use of DCD donors impacted outcomes for patients with MCS. The United Network for Organ Sharing database was queried from 2019 to 2023 for all adult recipients who underwent heart transplant with a durable left ventricular assist device (LVAD). Outcomes were compared for recipients of DBD and DCD donors. Kaplan–Meier analysis was used to compare survival. A total of 3449 recipients underwent heart transplant who met the study criteria. The number of DCD and DBD donors was 288 (8.4%) and 3161 (92.6%). There was no difference in the length of stay, postoperative dialysis, pacemaker, stroke rate, or in-hospital mortality. Recipients with durable LVADs of DCD donors had a higher rate of treatment for rejection within the first year. Overall survival was not different between DBD and DCD donors (p = 0.153). Postoperative and survival outcomes for DCD donation remain similar between patients with and without MCS. These findings may help decrease waitlist time for patients with durable MCS.

Objective. The learning curve of coronary artery bypass grafting with multiple arterial grafting and without the use of cardiopulmonary bypass (off-pump) is perceived as an advanced subspeciality associated with increased surgical risk. We compared the trends and early clinical outcomes between trainees and consultants as the first operator in the United Kingdom. Methods. All patients who underwent elective or urgent isolated coronary artery bypass grafting from 1996 to 2019 were extracted from the National Adult Cardiac Surgery Audit database. Trends and early clinical outcomes between trainees and consultants as the first operator were compared in the whole cohort and after propensity score matching. Results. Of the total coronary artery bypass graft procedures, trainees performed 24.39% (n = 79759/327025). Trainees performed 27.10% (63934/235920) on-pump without multiple arterial graft procedures compared to consultants. The consultants had a shorter cardiopulmonary bypass time (82.81 (SD: 35.36) vs 86.21 (SD: 30.07) minutes, p < 0.001) and aortic cross-clamp time (48.05 (SD: 22.46) vs 50.66 (SD: 19.49) minutes, p < 0.001). However, consultants had a higher mortality (1.6% vs 1.0%, p < 0.001) and incidence of postoperative dialysis (2.1% vs 1.5%, p < 0.001). Trainees performed 16.78% (8089/48220) multiple arterial graft procedures, with no differences compared with consultants for in-hospital mortality (1.0% vs 0.9%, p = 0.42), cerebral vascular accident (transient ischaemic attack (0.5% vs 0.5%) and permanent stroke (0.6% vs 0.4%), p = 0.33), return to theatre (4.2% vs 4.47%, p = 0.089), postoperative renal dialysis (1.4% vs 1.1%, p = 0.076), and deep sternal wound infection (0.6% vs 0.6%, p = 0.87). Trainees performed 17.17% (8661/41778) off-pump cases. Consultants had a higher in-hospital mortality (1.2% vs 0.9%, p = 0.045) with no differences in cerebral vascular accident (transient ischaemic attack (0.2% vs 0.3%) and permanent stroke (0.4% vs 0.4%), p = 0.27), return to theatre (3.8% vs 3.9%, p = 0.69), postoperative renal dialysis (2.0% vs 1.6%, p = 0.059), and deep sternal wound infection (1.0% vs 0.8%, p = 0.66). Conclusion. Trainees in the United Kingdom have adequate exposure to advanced coronary surgery without compromising patients’ safety.