Purpose Massive Pulmonary Thromboembolism remains an often fatal event and the treatment options are: systemic or catheter-directed thrombolysis, surgical embolectomy, and systemic anticoagulation. Paradoxical embolism is rare (less than 2% of all arterial emboli). Impending paradoxical embolism is a life-threatening syndrome usually diagnosticated serendipitously.
Methods We present the case of a 49-year-old male patient with personal history of bilateral deep vein thrombosis, referred to our center with one month history of dry cough and dyspnea that gets worst two days before de admission. CT scan showed massive bilateral pulmonary embolism in main and secondary arteries as well as thrombosis of the left subclavian artery. TEE identified a highly mobile elongated mass at the level of the left atrium that enters through the oval foramen, and pulmonary hypertension. Under general anesthesia, Bilateral pulmonary and Atrial Thromboembolectomy were performed, in addition to Patent Foramen Ovale closure with autologous pericardial patch.
Results The total CPB time was 3 hours and 16 minutes with 2 hours and 21 minutes of aortic cross-clamp time and 20 minutes for circulatory arrest time in moderate hypothermia (26º C). IOP TEE showed improvement of pulmonary hypertension, preserved biventricular function with mild tricuspid regurgitation and successful OF closure. In the ICU, moderate oxygenation dysfunction developed, most likely due to reperfusion edema. The postoperative period was uneventful, follow up a week after discharge revealed no home-oxygen required as well as an adequate left arm perfusion.
Conclusions Surgical pulmonary embolectomy for acute massive PE is safe and can be performed with acceptable in-hospital outcomes. An emergent cardiac surgery should always be considered as a treatment option for impending paradoxical embolism.
Surgical Management of a Giant Right Coronary Artery Aneurysm Associated with Coronary Arteriovenous Fistula
AM. Palacio (1) ; AF. Guerrero (2) ; JP. Umaña, (3) ; J. Camacho, (4) ; N. Sandoval (5) ; C. Obando (4) ; T. Chalela, (6) ; CA. Villa (3)
Purpose Coronary artery aneurysms are uncommon, giant aneurysms (> 2cm) are even more unusual. Coronary atherosclerosis is the principal cause. The management of patients with this entity is controversial. There are not clear recommendations on this topic because literature is confined to report cases and small case series.
Methods We describe the case of a 77-year-old female patient with a history of dyspnea, orthopnea who was diagnosed with a coronary artery fistula from the right and left coronary arteries to the coronary sinus, and was on follow-up with intention of surgical correction. Further work-up with a coronary CT angiogram also showed a giant sacular aneurysm arising from the right coronary artery ostia, measuring 9 cms. Patient was considered for surgical management bearing in mind the progressive enlargement and size of the aneurysm compared to previous imaging tests, and the high risk for sudden rupture and death.
Results Patient underwent surgery through a medium sternotomy, the heart was arrested after cardiopulmonary bypass was established with right subclavian artery, right femoral vein and superior vena cava cannulation. Surgical findings showed a giant 9x9x8 cms sacular aneurysm emerging from the right coronary ostia, impingning the aortic root, right atrium and ventricle. The aneurysm was opened and resected; the right coronary artery was ligated at the distal end of the aneurysm, and a saphenous vein graft was used to bypass the distal right coronary artery. A coronary arteriovenous fistula from the distal portion of the right coronary artery to 3 large veins draining into a severely enlarged coronary sinus was found and corrected with an autologous pericardial patch, as well as an atrial septal defect. Patient also had correction of a severe tricuspid regurgitation. Postoperative course was uneventful; the patient had a complete recovery and has been asymptomatic until current date.
Conclusions We consider surgical management is the best approach for giant coronary artery aneurysms in cases when complications such as rupture and death are very likely. There are very few reports in the literature of coronary aneurysms measuring more than 5 cms associated with coronary artery fistulas.
Validation of Risk Stratification Methods for Congenital Heart Disease Surgery in Mexico City Hospital: RACHS-1 and Aristotle Scales
LM. Zúniga Alaniz (1) ; D. Roldán, (2) ; E. Hernández (2) ; NA. Pérez (2) ; S. Bocanengra, (2) ; C. Riera (2)
(1) Hospital de Cardiología , XXI Century National Medical Center, Ciudad de México, Mexico; (2) Hospital de cardiología, XXI Century National Medical Center, Ciudad de México, Mexico
Purpose Validate both methods during congenital heart surgery in the hospital unit mentioned.
Methods To reach that goal, this research describes a retrospective study done among patients from different age and genre that have had heart disease surgery —elective or urgent— but with a complete medical record. The validity of the results was analyzed with statistical methods, such as intern consistency, calibration, discrimination capacity and mortality in different risk levels.
Results We find a 0.740 Cronbach Alfa value for both scales together, significant logistic regression (p=0.001 and p=0.000, respectively), and 0.770, 0.806 ROC curve areas; even though, observed mortality (6.46%) by each scale segment exceeds expected mortality according to internationally accepted parameters for RACHS-1. Therefore it is required to develop techniques to control other variables that this methods do not consider, such as low-weight in patients or medical background like previous surgery record.
Conclusions Results allowed the researcher to conclude that both methods, RACHS-1 and basic ARISTOTLE, are feasible to be used during congenital heart surgery.
Pulmonary Valve Implant in Post-Operated Tetralogy Fallot Patients
LM. Zúniga Alaniz (1) ; D. Roldán, (2) ; E. Hernández (2) ; NA. Pérez (2) ; S. Bocanengra, (2) ; C. Castillo, (2) ; C. Riera (2)
(1) Hospital de Cardiología , XXI Century National Medical Center, Ciudad de México, Mexico; (2) Hospital de cardiología, XXI Century National Medical Center, Ciudad de México, Mexico
Purpose To determine in post-operative patients of Fallot Repair, the effects of pulmonary valve change on biventricular function and indexed volumes and in functional class, as well as mortality and post-operative complications.
Methods a retrospective, observational and cross-sectional study was conducted, which included all patients operated on pulmonary valve implants with a history of tetralogy of Fallot repair, studying the following variables: Indications of surgery; Pre and post operative functional class according to the NYHA, Pre and post operative indexed ventricular volumes, Pre and post operative LVEF, Mortality, and Postoperative complications
Results In 100% of patients a month after surgery and at the maximum follow-up of 4 years (12 patients = 46%), no mortality was identified, the main postoperative complications being: Pneumonia and acute renal injury. A significant reduction in the final systolic and diastolic volumes indexed from RV after valve change (p <0.001) was identified. A significant reduction in pulmonary insufficiency was demonstrated (p <0.001). In relation to the final diastolic volume of LV a significant increase was found (p <0.001); but in relation to the final systolic volume no significant difference was identified (p = 0.15). In relation to LVEF, a significant increase was demonstrated (p = 0.004). A significant reduction of the QRS was demonstrated (p = 0.039), as well as a significant reduction of the NYHA functional class (p <0.002).
Conclusions the pulmonary valve implant after Fallot Repair was not associated with mortality at one month and 4 years of surgery; with improvement of the functional class and with significant decreases in the volumes of the RV and increase of its systolic function.
Cardiac tamponade secondary to quilopericardium in a patient with noonan syndrome
I. Salazar-Hernández (1) ; DB. Ortega Zhindón (2) ; K. Ferreyro (3) ; O. Flores-Calderon (1) ; S. Ramirez-Castañeda (1)
(1) CardioThoracic surgery, General Hospital Doctor Eduardo Liceaga, Cuahutemoc, Mexico; (2) Cardiothoracic Surgery Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, France; (3) Cardiothoracic surgery, General Hospital of Mexico, Ciudad de México, Mexico
Purpose The Quilopericardio is a rare pathology, of primary origin or secondary to surgical procedures, thrombosis of the vena cava or subclavian, lymphangiomas, mediastinal neoplasms, cystic hygromas and radiation. The initial management is through the drainage and administration of total parenteral nutrition
Methods A 35-year-old woman admitted to the emergency department with short-term dyspnea, with orthopnea, decreased heart sounds and arterial hypotension, with no response to treatment. An echocardiogram was performed reporting a global pericardial effusion of approximately 1200cc with diastolic collapse of the right atrium
Results Pericardiocentesis is performed by draining 1000cc of milky fluid with improvement of hemodynamic parameters. The study of the liquid reports: cholesterol of 217mg / dl establishing a diagnosis of Quilopericardio. The tomographic study reports superior vena cava thrombosis Pericardial drainage is maintained until obtaining 0cc in 24hrs and support NPT. Theechocardiogram at 6 months of follow-up without complications or recurrencesct thrombus vena cava superiorCT thrombus vena cava superior
Conclusions The Quilopericardio is a rare entity per se, which may have an idiopathic origin or be secondary to different pathologies that obstruct the adequate lymphatic drainage. The main causes of this entity are associated with obstructions or vascular dysplasias.
Aorta & Aortic Arch
Endovascular treatment for Aortic Type A Dissection, a feasible and durable procedure
MA. MEDINA PEÑALOZA (1) ; J. Camacho, (2) ; JR. Cabrales (3) ; JP. Umaña, (3) ; T. Chalela, (2) ; C. Obando (4) ; AF. Guerrero (5) ; N. Sandoval (6)
Purpose Acute Aortic Type A dissection is a complex and potentially fatal disease; open surgical repair remains the gold standard with surgical mortality rates between 14 and 25%. However up to 20% of patients are not being treated due to comorbidities. Endovascular stent graft deployment is an alternative but its safety and durability remain controversial.
Methods We present a case of an 81-year-old female with acute chest pains 10 days before admission and that was treated as an ACS at another institution. Given her advanced age, fragility and comorbidities (HTA, COPD, AFIB) she had a Euroscore II of 20.9%, making her a high-risk candidate for open surgical repair. CT scan showed a proximal intimal tear 4 cm above the STJ, with a huge intramural hematoma extending to the origin of the innominate and with a maximum aortic diameter of 5.8 cm. Under general anesthesia a modified (home made) Zenith 38mm diameter stent graft was implanted through the left axillary artery and deployment was carefully performed under pace maker assist and TEE monitoring.
Results The total surgical time was 62 minutes, the stent graft deployment was successful, both angiogram and TEE showed no endoleaks, and blood flow through supra aortic trunks and coronary Ostia was normal. The postoperative period was uneventful, long term follow up was accomplished up to 14 months, where the patient remained asymptomatic. CT showed that the stent-graft was stable and the dissection almost disappeared.
Conclusions Endovascular treatment for Acute Type A Aortic dissection is a reasonable alternative in a well-selected group of patients, as long as the device appears to stay stable over time. Well-conducted studies are needed to establish safety and durability of this intervention.
Aorta & Aortic Arch
Komerell's Diverticulum with right aortic arch: an open surgical approach
D. Klein Ferreira (1) ; M. Suksteris (2) ; JB. Petracco (1) ; MA. Goldani (1)
(1) Cardiovascular Surgery, Hospital São Lucas da PUCRS, Porto Alegre, Brazil; (2) Cardiovascular surgery residen, Hospital São Lucas da PUCRS, Porto Alegre, Brazil
Purpose Komerell's Diverticulum is a rare disease, specially in elderely ages, the majority of cases are diagnosed in childhood. Prevalence of right aortic arch with aberrant left subclavian artery is also low, and the purpouse was describe this case.
Methods Case report of a 58-year-old woman presented with dysphagia to solids. The angioCT scan showed right aortic arch, with aberrant subclavian artery, with a retroesophageal origin, and a Komerell's Divericulum. The echocardiogram showed Ejection Fraction of 44%, Coronary angiogram was normal.
Results Patient underwent postero-lateral thoracotomy.We perfomed ligation of Komerell's Diverticulum and ligation of arterious. There were no complications. Patient was disacharged after 7 days of hsopitalization, drain tube tooked of at second post-operative day. Two months after surgery, patient was assyntomatic.
Conclusions Komerell's divesticulum is an uncommon pathology. In Brazil, it is separeted vascular, cardiac and thoracic surgery, we believe that cardiac and vascular sugery must work together to better treat this type of patient.
Aorta & Aortic Arch
Short-term and long-term outcome of endovascular aortic repair in patients with aortic diseases: A Single Centre Experience
R. Figueroa (1) ; J. Ramirez (1) ; N. Ramirez (1) ; M. Leyva-Martinez (1) ; A. Gomez-Ortiz (1) ; L. Zuñiga (1)
Purpose Open surgical repair for aortic diseases is associated with a high perioperative mortality. Alternative approaches via minimally invasive have become more common in the surgical treatment. This study describes our experience with aortic disease in a Cardiovascular Surgery Department.
Methods From September 2016 to June 2019, a total of 55 consecutive patients underwent thoracic and abdominal endovascular aortic repair. A short-term and long-term analysis was conducted – up to 30 days and 1 year post surgically, respectively.
Results A total of 55 patients underwent endovascular aortic repair, 73% (n=40) were male aged 76 (+/- 13) years, while 62% (n=34) were from rural areas with 16% (n=9) of these underwent TEVAR and 87% (n=48) underwent endovascular treatment of AAA. The median EUROSCORE was 3,6 (+/- 4), and 100% (n=55) of the patients underwent a successful endovascular procedure without any conversion to open surgery or any any peri-operative mortalities reported. The median ICU length of stay was 3 (+/- 1) days, and the reoperation rate was 1,8% (n=1) at 30 days. In the 1-year follow-up, the mortality was 7.2% (n=4).
Conclusions Undergoing endovascular aneurysm repair is an appropriate and safe surgical approach in our population and showed low short-term and long-term mortality.
Aorta & Aortic Arch
Two-Stage Hybrid Procedure for Stanford A Aortic Dissection
B. Ferreira (1) ; AG. Everding (2) ; HR. Diaz (2) ; A. Gutierrez (2)
(1) Instituto Cardiovascular de Mínima Invasión, Zapopan, Mexico; (2) Cardiocirugia, Instituto Cardiovascular de Mínima Invasión, Zapopan, Mexico
Purpose Stanford A aortic dissection has a mortality of up to 50% within the first 48 hours. The mortality of the conventional technique (5-20%), excludes approximately half of the patients due to their age or comorbidities. Hybrid procedures offer maximum benefit with lower surgical risk, especially for high-risk patients.
Methods 50-year-old male with uncontrolled HTN and severe chest pain. Thorax AngioTAC shows aortic dissection Sandford A, above coronary ostiums to inguinal arteries, aortic valve without lesions. First surgical-stage: deep hypothermic circulatory arrest (DHCA) and anterograde selective brain protection. Right axillary cannulation and 7fr introducer in the left common carotid. In turn, cannulation of the left femoral arteria for retrograde perfusion to abdominal structures. Aortic arch debranching and graft placement #28 term-terminal anastomosis. Left femoral knot stays for second surgical-stage. Second-stage (24 hours later): descending aortic stent placed through previous left-femoral knot. Hemostasis is confirmed.
Results First Stage: Surgical performing-time: 360 min. XCT: 102 min. CPBT: 77 min.
Mediastinal catheter bleeding at 12 hours: 865 ml. Stay at ICU: 4 days. Starts wandering at the 5th day. Hospital discharged at the 7th day. No complications.
Conclusions Although the gold standard for extensive aortic dissection remains the Elephant Trunk technique, technological advances and their increasing experience open up poorly documented novel alternatives, which in selected patients decreases surgical risk and gives good reproducible results.
Aorta & Aortic Arch
Clinical correlation between Ecuador and Asia people bearing C3 genes
CA. LATORRE DAVILA (1) ; DSR. Oscar (1) ; IMG. Andres (1) ; LCS. Jorge (1) ; SRM. Edgar (1) ; BB. Antonio (1)
(1) CONGENITAL HEART SURGERY, INSTITUTO NACIONAL DE CARDIOLOGIA IGNACIO CHAVEZ, Mexico City, Mexico
Purpose Demonstrate the presence of some clinical pathologies of Asian origin in South American patients
Methods We present the case of a southamerican male, older 55 y/o patient, with pulses absence in upper extremities, dispnea, claudication of arms during exercise, blurred vision and night sweats. all these signs suggesting takayasu arteritis.
Results The patient underwent several imaging studies. A Computed Angiotomograpghy evidenced a total oclusion of supra-aortic vessels. Medical treatment was started with corticosteroids to decrease the sistemic inflamatory response, with good results.
Conclusions This vasculitis has an annual incidence of 1-2 / million in the western population, so it is crucial to have a high index of suspicion to reach a diagnosis
Aorta & Aortic Arch
E-vita and Thoraflex Prostheses - Comparison of Postoperative Outcomes in a 10-year Local Experience in Frozen Elephant Trunk Grafting of the Complex Thoracic Aortic Pathology
FL. Popescu (1) ; J. Mascaro (2)
(1) Cardiothoracic surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK, United Kingdom; (2) Cardiothoracic surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
Purpose The aim of the study is to compare the postoperative outcomes in FET procedures (renal dysfunction, neurological injuries, respiratory complications, duration of ITU admission, destination on discharge) using Evita and Thoraflex grafts
Methods This is a retrospective study, analysing 149 FET procedures that were performed between April 2009 and April 2019. The aetiology of the thoracic aortic disease included only aneurysm and chronic dissection for which Evita and Thoraflex grafts were used for grafting.
Results Out of a total of 115 patients, 90 patients had Thoraflex, and 25 patients had E-vita. Only one case of paraplegia in the E-vita cohort, and 8 cases of permanent neurological injury, in the Thoraflex cohort.Permanent haemodialysis was required thrice in Evita cohort, and 16 patients in the Thoraflex group.2 patients required tracheostomies, 2 were reintubated, other two developed pulmonary embolism and 5 chest infection cases amongst the E-vita cohort. 16 tracheostomy postoperatively, 5 chest infections, 1 pulmonary embolism and 2 drainage of large pleural effusion in the Thoraflex cohort. The median ITU stay was similar in both groups (11.39 nights in the Thoraflex group and 11.25nights in the E-vita group). There were 3 deceased patients during the admission in the E-vita cohort, and 12 deaths for Thoraflex patients. There were similar cross clamp times (~ 180mins) and CPB time (~ 297mins) in both cohorts.
Conclusions Although the Evita cohort was smaller in sample, there were more postoperative complications associated with this prosthesis. A more in-depth analysis of the type of surgery, premorbid status and intraoperative times are indicated to illicit a significant difference in the postoperative outcomes between the two prostheses.
Initial Experience In Valve-Sparing Aortic Root Replacement As Treatment For Aortic Root Aneurism In Mexico: A Retrospective Study
J. Leyva (1) ; C. Riera (1) ; A. Ramirez (1) ; F. Villanueva (1) ; J. Salgado (1) ; E. Hernández (1) ; C. Murillo (1)
(1) Cardiothoracic Surgery, UMAE Hospital de Cardiologia CMN S. XXI, Ciudad de México, Mexico
Purpose Valve-sparing aortic root replacement Yacoub’s remodeling technique was first described in 1983 for aortic root aneurism. There are many reports worldwide about the use of this technique; however, there are no reports in the Mexican population. Here we report our initial experience using this procedure in our medical center.
Methods A retrospective review of the clinical records from October 2017 to July 2019 in our hospital was carried out. Records showed that four patients with aortic root aneurism underwent aortic surgery with Yacoub’s technic. Patients age ranged from 13 to 65 years old and none of them had Marfan’s syndrome. The after-surgery outcomes studied were: length of stay, surgical reintervention, residual aortic valve regurgitation, surgical site infection or mediastinitis, stroke, NYHA functional classification, and early and mid-term mortality.
Results All patients are still under follow-up at one and two years from intervention (mean follow-up time 18 months). They had a mean length of stay in intensive care unit of 8 days (5-13 days), and total mean length of stay 27 days (14-61 days). Reintervention was needed in 2 patients during intrahospital stay, for active bleeding and reoperation for hemostasis (n=1), and for gauze depacking (n=1). Aortic valve trivial (n=1), mild (n=1), moderate (n=1) and severe (n=1) regurgitation were found at the 3 months control echocardiogram.During the surgical procedure, a transesophageal echocardiogram was performed and none or mild aortic valve insufficiency were observed. None of the patients had surgical site infection neither mediastinitis. No strokes occurred in early or mid-term after surgery. In out of-hospital follow-up, patients were in NYHA functional class I (n=2) and NYHA functional class II with dyspnea (n=2). First month and medium-term mortality were 0%.
Conclusions Even though the Yacoub’s technic was develop close to 30 years ago, there are no previous reports in Mexico. We found it is feasible in our population regardless of age and resources. More experience is needed to improve outcomes; however, these four patients that went to the procedure are encouraging.
Initial Experience Of Two Colombian Centers In Aortica Valve Preservation Surgery By Reimplantation “David´S Technique”
G. Prieto (1) ; L. Montes (1) ; JC. Villalba (1) ; JE. Lopez (2) ; R. Riascos (2) ; F. Palencia (1) ; A. Gonzales (3)
Purpose We aim to describe the initial results of our first patients undergoing aortic valve preservation surgery (David´s technique) in two different centers in south Colombia.
Methods Retrospective series review of patients undergoing root / ascending aorta replacement with aortic valve reimplantation, since we began using this technique in March 2018 until today. 17 patients, mostly men(88.2%), underwent David procedure.
Results Mean age was 53.9years-old, LVEF was 45.9%+/-10.88 and Euroscore II was 7.42+/-5.14. Indication for surgery was severe aortic regurgitation(AR) in 88.2%, 3 patients had bicuspid valve and 3 had Marfan phenotype. Mean diameter of the aortic root(valsalva sinuses) was 54.9mm. Time of CEC and ischemia were 191 +/-23.9 and 163 +/-19.2 minutes respectively.Most frequent implanted tube in the root was 32mm and in the ascending aorta was 28mm.13(76%) patients needed an additional procedure on the cusps: all of them had plication of the free edge of one or several leaflets, 2(15.4%) required reinforcement of the free edge and in 2(15.4%) bicuspid valves the intercomisural raphe was resected. 1 patient had biological aortic valve replacement for moderate AR in the intraoperative TEE. 1 patient(5.8%)died in the early postoperative period with suspected massive pulmonary embolism. 1 patient(5.8%)with sickle cell trait and thrombocytopenia required reintervention for major bleeding. Lengths of stay in ICU and hospitalization were 4.3 days and 9.6 days respectively. At early follow-up, all patients had NYHA<II and AR<I
Conclusions Our first patients undergoing aortic valve reimplantation (David´s technique) for the management of aortic root aneurysm with or without valvular regurgitation showed good early results. It is necessary to continue with strict follow-up to verify its effectiveness in the medium and long term.
Contemporary Outcome of Aortic valve replacement in the elderly
(1) Cirugía Cardiotoracica Pediátrica, Instituto Nacional de Cardiología Ignacio Chavez, Ciudad de México, Mexico; (2) Cirugia cardiotoracica adultos, National Institute of Cardiology Ignacio Chavez, Ciudad de México, Mexico; (3) Cardiac surgery, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, Mexico
Purpose Transcatheter aortic valve implantation (TAVI) is a safe therapeutic option, however in developing countries, sometimes can´t perform. The surgical aortic valve replacement (AVR) has unpredictable long-term prognosis in elderly. This study evaluated outcomes of elderly patients after AVR, focus on the impact of this procedure on overall survival.
Methods The data collected were retrospectively evaluated, of elderly patients who underwent AVR, between October 2017 and June 2018; We review medical records to summarize demographic characteristics, comorbid conditions and details of operations. Late follow-up was obtained from medical records or telephone conversations with patients. The surgical technique was perform by cardiopulmonary bypass, cardioplegia was administered by aortic root cannula, directly in coronary ostium or both methods. AVR was done using the standard technique, the implantation of the valve prosthesis was performed with separate “U” points.
Conclusions AVR has a low acceptable hospital mortality, even in the elderly. The procedure can be performed safely an effectively as demonstrated in our study. Conventional surgery remains the standard gold treatment, however, an analysis of a greater number of cases is required.
Novel Technique for Aortic Valve Reconstruction with Three Same-Sized Autologous Pericardial Leaflets - Useful Application of 3D Hologram Evaluation in order to enhance reproducibility-
T. Tedoriya (1) ; R. Okano (2) ; T. Miyauchi (1) ; M. Fukuzumi (2) ; Y. Gatate (1)
(1) Cardiovascular Center, Ageo Central General Hospital, Ageo, Japan; (2) Cardiovascular surgery, Ageo Central General Hospital, Ageo, Japan
Purpose Aortic valve leaflet reconstruction using three same-sized autologous pericardium leaflets (ATLAS) has been performed for patients of the aortic valve disease with narrow aortic annuls or contra-indication of valve prosthesis. We evaluated ATLAS procedure with 3D-Hologram from CT data in order to enhance reproducibility of this procedure.
Methods Basic technique; 1) three same-sized leaflets were tailored to original templates referred by STJ diameter, 2) the new commissures and nadirs were confirmed based on VR image, 3) leaflets were sutured on the cusp-suture line, 4) commissure coaptation stitches were placed to prevent from minor leakage and coronary orifices obstruction.
Enrolled patients underwent ECG-triggered cardiac CT. Axial images with slice thickness of 0.625mm were obtained during mid-to-end diastole. Subtracted volume rendering CT data were converted to the workstation to obtain 3D-VR image for assessment of pre- and post-operative valve structure.
Results From 2015, we have performed ATLAS for 24 patients (10 females). Nine cases had AS, whereas 14 cases were AR, and one was ASR. Two of them were bicuspid. Although we had two intraoperative conversion to AVR, after introduction of 3D-VR analysis, there was no conversion with additional nadir plication in 4 cases. Intraoperative TEE revealed less than trivial leakage in all cases . There was no operative and in-hospital death nor no major complication. All patients were followed up for 5 to 50 months (median 27months) of follow-up period. One patients died due to LOS at 26 months after the surgery. One patients required redo-AVR due to perforation of pericardial cusp. UCG finding showed mild AR in one , and less than trivial in the other 21 cases. Mean AVPG were 8.7±4.5mmHg(at 1Y: 7.0 ± 3.0 and 2Y: 8.8 ± 3.0).
Conclusions ATLAS is a simple and reproducible procedure facilitating anatomically physiologic correction of aortic valve diseases. Preoperative evaluation by 3D-VR imaging had notably provides valuable information for adjustment of the aortic root. Early and Midterm outcomes were satisfying with excellent hemodynamic data for maximum 50 months follow up period.
INSPIRIS Aortic Valve Replacement in a Young Patient with Endocarditis: The First Case Report with Early Follow-up
B. Smood (1) ; A. Goldstone, (1) ; C. Burke, (2) ; J. Bavaria (1)
(1) Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, United States of America; (2) Cardiothoracic surgery, University of Washington, Seattle, United States of America
Purpose Almost no data exists for use of the INSPIRIS valve in aortic valve replacement, particularly in young patients with endocarditis. We present the first case report with early follow-up of aortic valve replacement using the INSPIRIS valve for endocarditis.
Methods A 38-year-old male presented with subacute symptoms of malaise, fevers, and shortness of breath. Infectious workup and echocardiography revealed endocarditis with a Sievers type 1 bicuspid aortic valve, septic emboli, and cerebral infarction with hemorrhagic transformation. The decision was made to surgically replace the valve. Through the aortotomy, a 1.5cm vegetation extending to the ventricular surface of the noncoronary leaflet was visualized. Both aortic leaflets were excised. The anterior leaflet of the mitral valve had small vegetations on the ventricular surface, and was debrided. A 27mm INSPIRIS valve was used to replace the aortic valve.
Results Upon weaning from cardiopulmonary bypass, there was no residual aortic insufficiency or paravalvular leak. Transvalvular mean gradient was measured at 7mmHg with normal biventricular function. Nine months after aortic valve replacement with the INSPIRIS valve, the patient has fully recovered, remains neurologically intact, and is free from endocarditis. Repeat echocardiography demonstrates no vegetations on the bioprosthetic valve, and near perfect valve hemodynamics. He has since completed a half-Iron Man competition.
Conclusions This first case report indicates the INSPIRIS valve is an acceptable consideration for aortic valve replacement in young patients with endocarditis and warrants further study.
Early and long-term outcomes of Minimally Invasive Cardiac Surgery: A Single Centre Experience
R. Figueroa (1) ; J. Ramirez (1) ; N. Ramirez (1) ; V. Ordoñez (1) ; MC. Perez (1) ; MF. Laverde (1)
Purpose The minimally invasive approach is an alternative to the median sternotomy with superior results as well as a better aesthetically outcome. This study describes our experience with minimally invasive cardiac surgeries in a cardiac surgical center in Tolima, Colombia.
Methods Between November 2015 and June 2019, a total of 64 patients underwent MICS, compared to 33 patients whom underwent minimally invasive aortic valve replacement (MIAVR), 18 minimally invasive atrial septal defect closure, and 13 minimally invasive mitral valve replacement (MIMVR). A short-term and long-term analysis was conducted.
Results The mean age was 54 ± 17 years, 40% were female, and 41% of these came from rural areas. The median EUROSCORE was 1,14 (+/- 1,2). The predominant condition was functional valve regurgitation in 44% (n=20) of the cases, followed by degenerative disease in 40% (n=17), rheumatic disease in 15.5% (n=7), endocarditis in 4.5%. The mean extracorporeal circulation time was 100 ± 26 minutes, while the mean aortic cross-clamp time was 77 ± 22 minutes. There were no in-hospital mortalities reportes, nor was there any sternotomy convertion or strokes reported. The median ICU length of stay was +/- 2 days, with only 1.8% (n=1) reoperation rate at 30 days. The overall mortality at 1 year was 1.5% (n=1).
Conclusions Minimally invasive cardiac surgery is a safe and reproducible approach associated with low mortality and morbidity, while additionally being a good alternative to conventional surgical access.
Release in Valve Replacement Surgery. Retrospective Study
DB. Ortega Zhindón (1) ; O. Flores-Calderon (2) ; K. Ferreyro (3) ; K. Aguilar, (3) ; I. Salazar-Hernández (2) ; S. Ramirez-Castañeda (4)
(1) Cardiothoracic Surgery Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico; (2) Cardiothoracic surgery, General Hospital of Mexico, Ciudad de México, Mexico; (3) Cardiothoracic surgery, General Hospital of Mexico, Ciudad de México, Mexico; (4) Cardiothoracic surgery, General Hospital Doctor Eduardo Liceaga, Mexico City, CDMX, Mexico, Mexico
Purpose Identify the clinical and surgical results of patients undergoing cardiac surgery for valve replacement in the Cardiac Surgery Unit of the General Hospital of Mexico "Dr. Eduardo Liceaga ”
Methods We carry out a descriptive, observational, retrospective, transversal and retrolective study. We included 163 patients undergoing cardiac surgery for valvular replacement due to cardiac valvular pathology, during the period from January 1, 2014 to December 31, 2018; We review the files and collect: diagnoses, demographic characteristics, functional class, death, causes of death, cardiovascular risk factors, surgical prognosis scales, postoperative complications, characteristics of valve prostheses, need for reintervention and survival. We analyze with the tests: Pearson's r, Spearman's Rho, Student's t, ANOVA, logistic regression and Kaplan-Meier and Cox tests.
Results We include 163 patients, an average age of 54 years ± 14, 54.6% men. The main cardiovascular risk factors were: obesity (63.2%) and systemic arterial hypertension (49.1%). The main valve affected was the aortic, degenerative etiology (46%), mainly aortic valve surgery. After the valve replacement, the functional class improved in one stage, with 90% of the patients in the NYHA stages I and II. The main complications were respiratory infections, post-surgical bleeding and sepsis, a global survival of 70% at 60 months of follow-up. The main determinants in post-surgical evolution and survival were the improvement of the functional class (p = 0.0001), the presentation of post-surgical complications mainly bleeding (p = 0.0001) and the post-surgical follow-up (p = 0.0001).
Conclusions It was possible to identify that the survival of the patients improves significantly after the resolution of the different valvulopathies, with a favorable impact on the functional class and their post-surgical follow-up. Surgical complications reducing them to the maximum determines a positive result in those patients undergoing valve replacement surgery.
Traumatic Aorto-Right Ventricular fistula and aortic valve perforation: Surgical management
L. Montes (1) ; G. Prieto (1) ; JC. Villalba (1) ; F. Palencia (1)
Purpose Cardiac penetrating trauma has high mortality and morbidity, with only 6% of the patients surviving hospital transport as described in a few series. Aorto-cardiac fistulas still rare, and only a few reports of aorto-right ventricular fistulas have been published.
Methods We present the case of a 22 year-old man, who was admitted with a precordial stab wound. He was tachycardic, hypotensive, and the emergency echocardiogram showed cardiac tamponade. He was taken to the operating room, where general surgery performed a median sternotomy, an found a 3 cm right ventricular laceration. This was closed with silk suture and a thoracostomy tube was left. The patient went to the ICU where he had initially a good recovery, he was extubated and weaned off the vasopressors. However, he developed pleural effusions requiring right thoracostomy, signs of SIRS, superficial sternotomy wound infection and sternal dehiscence. An osteosynthesis closure of the sternum was performed followed by pulmonary decortication due to empyema and bilateral pneumonia.
Results He had torpid evolution and developed signs of heart failure. New TEE showed severe aortic regurgitation with an image suggestive of pseudoaneurysm vs root dissection and an aorto-right ventricular fistula. These was confirmed by CT angiography. 6 weeks after the initial injury, a new median sternotomy was performed with osteosynthesis extraction, subsequent extensive adhesiolysis and cardiopulmonary bypass. Aortotomy revealed a 6mm opening in the right sinus of Valsalva comunicating with the right ventricular outflow tract, perforation of 5x6mm of the right coronary cusp, and perforation of 5mm at the base of the non-coronary cusp.The aorto-right ventricular fistula was closed with a pericardial patch on the aortic aspect of the fistula.The aortic valve was repaired with a pericardial patch to the right coronary cusp and closure of the perforation at the base of the non-coronary cusp with double Gore-Tex suture.The aorta was closed and the clamp released.After hemodynamic conditions were suitable, cardiopulmonary bypass was stopped and TEE was performed showing trivial aortic regurgitation, good anatomic appearance, and no residual shunt.
Conclusions The patient had a good recovery,TTE confirmed the intraoperative findings,with good left and right ventricular function.3-weeks after surgery, the patient was discharged with a full recovery. At 2 months follow-up,the patient continues to be free of heart failure.
Aortic Valvular Replacement By Superior Hemisternotomy, First Approximation To Minimally Invasive Surgery In The South Of Col
G. Prieto (1) ; L. Montes (1) ; JC. Villalba (1) ; JE. Lopez (2) ; R. Riascos (2) ; A. Gonzales (3)
Purpose We aim to compare the results of our group of patients who had Aortic Valve Replacement (AVR) by superior hemisternotomy (SH) and our group of patients operated by conventional sternotomy (CS).
Methods Comparative study of retrosprective series of patients undergoing aortic valve replacement by CS or SH since January-2017 (when the minimally invasive program started), to August-2019. All performed by the same surgeon in a institution in the south of Colombia.
Results 86 patients (35 CS/51 SH)had AVR, mostly men (74.3% / 72.5%) with mean age of 57.11+/-15.9 and 62.7+ / -11.6 years. Main indication was severe aortic stenosis(77.1% vs. 80.4%. p = 0.401). Perioperative mortality was 8.6%(3) vs 2%(1) p = 0.363. There was no significant difference in the presence of postoperative excessive bleeding(22.9% vs. 13.7% p = 273), major bleeding reintervention(14.3% vs. 7.8% p = 0.548), postoperative renal insufficiency(14.7% vs. 10% p = 0.33), length of stay in ICU (3.2 +/- 4, 2 vs. 3.06+/1.95 days, p = 0.834) and length of hospitalization(7.65 +/- 4.9 vs. 6.45 +/- 3 days). AVR by SH had lower blood transfusions(2.71 +/- 2.46 vs. 1.69 +/- 2.2 IU p = 0.017) and plasma use(1.17 +/- 2 vs. 0 , 35 +/- 1.3 IU p = 0.006). They had lower serum creatinine peak in the postoperative period(1.3 +/- 0.76 vs 1.07 +/- 0.54 mg / dL p = 0.009 ). CPB (75.2 +/- 27.8 vs. 88.6 +/- 24.8 min p = 0.02) and aortic clamp times (53.9 +/- 18.7 vs. 62.9 +/- 14.9 min p = 0.014) were longer.
Conclusions In our series, AVR by SH showed similar results to those obtained with the usual CS, but, requires less blood and plasma transfusions despite longer CPB and aortic clamp times. We expect that as the number of cases and the experience of the surgical team will grow, results will be progressively better.
Surgical Ablation of Atrial Fibrillation and Left Appendage Occlusion by a Totally Videothoracoscopic Approach: 18 Months of Follow up in a Low Volume Center
C. Rodrigues, (1) ; M. Silva (2) ; R. Cerejo (1) ; G. Portugal (3) ; R. Rodrigues (1) ; M. Oliveira (3) ; J. Fragata (4)
(1) Cardiothoracic surgery, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisbon , Portugal; (2) Cardiothoracic surgery, Hospital de Santa Marta, Lisboa, Portugal; (3) Cardiology, Santa Marta Hospital, Lisboa, Portugal; (4) Cardiothoracic surgery, Hospital Santa Marta / Cardiothoracic Department, Lisbon, Portugal
Purpose Atrial Fibrillation leads to increased morbidity and mortality. Pharmacological and catheter therapies are unsatisfactory and with serious adverse effects. Cox- Maze III/IV, with the highest rates of success, had not been widely adopted because of complexity and low reproducibility.
Methods We performed a descriptive analysis of the 15 patients that have been submitted to surgical ablation of atrial fibrillation and occlusion of the left appendage by a totally thoracoscopic approach, since we started using this technique in November 2017. We describe the surgical technique and our results, including duration of surgery, hospital stay, complications and conversion to sinus rhythm immediately after surgery, at one month, 6, 12 and 18 months of follow-up. We aim to evaluate if the results in our institution are comparable with the results of high volume centers.
Results Of 15 patients, with ages between 39 and 75 years old, 53% (n=8) are female. The mean time since the diagnosis of atrial fibrillation was 5,75 years. All had been submitted to prior catheter ablation (mean of 2 attempts). The mean diameter and volume of left atrium was 42 mm and 70 ml (43 ml/m2). The mean duration of surgery was 2hours and 22 minutes. In only one patient we had to convert to a median sternotomy. The mean hospital stay was 4,8 days. Mean time of follow-up is 12 months. All patients were maintained on anti-coagulation after the surgery. At one month of follow-up, 91% were in sinus rhythm. At 6 months follow- up, 90% were in sinus rhythm. At one year, 5 patients were recorded during 7 days and 80% were in sinus rhythm. The 4 patients that completed 18 months of follow-up, 3 are in sinus rhythm.
Conclusions We believe it represents a real benefit for those with multiple attempts of catheter ablation without success. It is a reproducible technique and it has a fast learning curve with promising results, even in low volume centers.
Full recovery after 45´ CPR and Left ventricle free wall perforation repair as a complication of pulmonary veins ablation
CA. LATORRE DAVILA (1) ; O. Flores-Calderon (1) ; IMG. Andres (1) ; DSR. Oscar (1)
(1) CONGENITAL HEART SURGERY, INSTITUTO NACIONAL DE CARDIOLOGIA IGNACIO CHAVEZ, Mexico City, Mexico
Purpose We would like to demonstrate that, the decision to stop a CPR can never rest on a single parameter, such as duration of it. Here we want to emphasize that clinical judgment and respect for human dignity must enter into decision making.
Methods We present a 51 y/o survival patient who underwent a catheter ablation of pulmonary veins for paroxismal atrial fibrilation, who had cardiac tamponade as a consecuence of a LV perforation and dissecting subepicardial hematoma; went into cardiac arrest in the operating room and received 45 minutes of cardiopulmonar resuscitation.
Results After the ablation procedure in the operation room, the patient became hemodynamically unstable with sudden evolution to shock, identifying tamponade as a consecuence of a LV perforation and dissecting subepicardial hematoma; went into cardiac arrest and received 45 minutes of cardiopulmonar resuscitation and pericardiocentesis, draining about of 1400 ml of blood with return of spontaneous circulation. Management was initiated with crystalloid, blood components and vasopressors. Because of persistence of bleeding, is assessed by the cardiothoracic surgeons, and median sternotomy was performed for exploration
Conclusions We describe a patient who suffered cardiogenic shock during a catheter ablation procedure leading to a long-term CPR; a rapid surgical exploration with resolution of cardiac tamponade and LV repair with a favorable hemodynamic and neurological postoperative evolution
Coronary Artery Disease
On pump beating heart Coronary Artery Bypass Grafting Surgery in High Risk underserved patients. Results of a Cardiac Surgery Center in Southern Chile
JC. BAHAMONDES (1) ; M. Peña, (1) ; O. Cherres, (2) ; R. Trujillo, (2) ; J. Arellano, (2)
Purpose The mortality of conventional coronary artery bypass grafting after acute myocardial infarction remains high. This study report the clinical outcomes of patients undergoing on-pump beating-heart coronary artery bypass grafting and evaluated the efficacy of an on-pump beating-heart technique for the surgical treatment of these critically ill patients.
Methods Between November 2014 and July 2019, 18 patients underwent coronary artery bypass grafting with the on-pump beating-heart procedure without cardioplegic arrest because of a recent myocardial infarction with clinical or hemodynamic instability,left ventricular ejection fraction < 30% or an operation on a emergent setting.
Results Mean age was 64.8 ±2.54 years (42-80 years).13 patients were men (72.2%). Mean predicted mortality risk calculated by using EuroSCORE was 9.6 (+/- 1.6). 15 patients presented with angina at the time of surgery, 14 with a recent myocardial infarction, 4 had severe atheromatous disease of the ascending aorta not suitable for cross clamping, 4 patients had an AFib. CABG surgery was performed with the standard cannulation plus a vent catheter on the ascending aorta. 8 patients had an ejection fraction < 30% (20 – 50%). Mean extracorporeal circulation time was 56.6 ±5.3 minutes (14 – 109 min). All patients received a mean of 2.33 bypass (1 – 3) per patient. 1 patient died early in the postoperative period because of multiorganic dysfunction at day seven. 1 patient died (5.5%) in the follow up period due to a brain hemorrhage. Postoperatively, there were 3 patients with acute renal failure requiring sustitution therapy, 2 patients presented an AFib and 1 patient had a non complicated myocardial infarction.
Conclusions On-pump beating-heart coronary artery bypass grafting has the possibility to eliminate intraoperative global myocardial ischemia and to be an acceptable surgical option for acute myocardial infarction associated with lower postoperative mortality and morbidity.
Coronary Artery Disease
Minimally Invasive Hybrid Coronary Revascularisation as Standard Cost Effective Therapy using a Staged Approach- Early Experience
MM. Yusuf (1) ; K. Damodharan (2) ; G. Sengootuvel (2) ; R. Sowkathali (2) ; R. Dheeraj (1) ; B. Karthikeyan (1) ; V. Srinivasan (2)
(1) Ctvs, Apollo Hospitals, Greams Road, Chennai, India; (2) Interventional cardiology, Apollo Hospitals, Greams Road, Chennai, India
Purpose A combination of Minimally Invasive CABG and Percutaneous Coronary Intervention (PCI) is increasingly performed as a hybrid approach. We present our early experience using this approach in low and high-risk patients requiring coronary revascularization.
Methods Fifty-two patients with multivessel coronary artery disease (CAD) were treated by Minimally Invasive Hybrid Coronary Revascularisation(MIHCR) over a 15 month period. Suitable patients were assessed by our heart team and we adopted a 2 stage approach which can be performed without the need for an expensive Hybrid Operating theatre. Minimally Invasive CABG is performed on day 0 using single or bilateral Internal Thoracic Artery (ITA). On post-op day 2, PCI is performed using drug-eluting stents. Angiography is routinely performed during PCI to assess ITA graft patency. Patients are usually discharged home on post-op day 4 after complete coronary revascularization.
Results Total number of patients in our study were 52. Both left ,and right ITA was used in 12 patients who were below 60 years of age. Left ITA alone was used in the remaining 40 patients. During PCI 3 Drug-eluting stents (DES) were inserted in 3 patients, 2 DES in 31 patients and the remaining 18 required only one stent. Twelve patients in the group were at high risk with Euroscore II above 5. These high risk patients stayed in hospital up to 7 days in the postoperative period but had much fewer complications compared to similar patients undergoing conventional CABG. Two patients were taken back to theatre for bleeding/ tamponade in the early post-op period.
Conclusions MIHCR is a safe procedure and can be considered as standard, cost-effective therapy in low and especially high-risk patients. Early recovery and getting back to work following MIHCR is proving to be a huge financial benefit to the patients and their families.
Coronary Artery Disease
Perioperative Outcome and Graft Patency of Minimally Invasive Approach in Patients with Single Vessel Coronary Artery Disease
M. Elbatarny (1) ; A. Alsagheir (2) ; T. Sheth, (3) ; A. Dyub (2)
(1) Division of cardiovascular surgery, University of Toronto, Toronto, Canada; (2) Cardiac surgery, McMaster University, Hamilton, Canada; (3) Cardiology, McMaster University, Hamilton, Canada
Purpose Mini-throacotomy CABG (mini-CABG) may be associated with reduced pain, recovery time, infection rate and improved cosmesis. However, technical complexity and decreased graft patency concerns limit current adoption. We therefore report a prospective series of patients undergoing mini-CABG including Perioperative and graft patency data within 1 year.
Methods Adults undergoing elective/urgent mini-CABG for LAD grafting by a single surgeon were prospectively recruited. History of prior PCI was included. Patients with unfavourable anatomy for mini-thoracotomy access, prior sternotomy, urgent operation, critical left main, or the need for concomitant operations were excluded (N=65). Baseline demographic, intraoperative, and early postoperative data were collected and retrospectively analyzed. Primary outcomes were in-hospital mortality and graft patency assessed by angiogram or CT angiography between 3 to 12 months postoperatively. Other outcomes were: in-hospital myocardial infarction (MI), stroke, and infection by clinical criteria, as well as admission duration, and need for readmission.
Results Mean age was 66±12 years; 20 (31%) were female. Most (n=31, 48%) had Canadian Cardiovascular Society (CCS) Class II angina and Grade I left ventricles (n=55 85%). Five were operated on an urgent basis. History of MI was present in 17 (26%) and prior PCI in 16 (25%). Two grafts were performed in 5 patients (8%); all others received a single bypass. Seven patients were converted to sternotomy (11%). The majority were extubated in the operating room (83%, n=53). All survived to discharge with mean hospital stay of 3.7±2.2 days. No in-hospital cases of postoperative MI, stroke, or renal failure occurred. Four required transfusion (6%). Graft patency data were available for 44 patients: 40 had fully patent grafts (91%), 4 had only 1 of 2 grafts patent (9%). Wound infections were mostly superficial and occurred in 8 patients (12%). Seven patients required re-admission (11%).
Conclusions This single-centre series demonstrates that mini-CABG may be performed in appropriate patient candidates safely without excessive risk of mortality or perioperative adverse events. Graft patency within one year appears to be excellent for those undergoing single-grafting procedures.
Coronary Artery Disease
Neighborhood Socioeconomic Status Is Significantly Associated With Short and Long-term Outcomes After Coronary Artery Bypass Grafting
W. Patrick (1) ; M. Bojko, (2) ; J. Han (1) ; A. Iyengar (1) ; M. Helmers, (1) ; M. Williams, (3)
(1) Surgery, University of Pennsylvania, Philadelphia, United States of America; (2) Division of cardiovascular surgery, University of Pennsylvania, Philadelphia, United States of America; (3) Surgery, Hospital of the University of Pennsylvania, Philadelphia, United States of America
Purpose The relationship between social economic status (SES) and outcomes after CABG is poorly understood. Current studies fail to robustly determine SES. We used a validated index of 17 measures at the block group level called the Area Deprivation Index (ADI) to better understand this relationship.
Methods Patients who underwent isolated CABG in our health system between 2002 and 2018 with a valid home address were assigned an ADI based upon their corresponding 2010 Census block group. The association between ADI and commonly reported operative outcomes was assessed with univariable analysis using a Wilcoxon rank sum test with continuity correction. A multivariable logistic regression model was created for CABG outcomes which included ADI. Long-term mortality was evaluated using a linkage to the Social Security Death Index as well as institution records. Long-term mortality was compared using the Log-rank test. Of note, higher ADI indicates poorer SES.
Results The6,751 patients who met the inclusion criteria were from 19 states with a median ADI of 31 (IQR 17 to 50). ADI was significantly associated with stroke (p = 0.03), renal failure (p < 0.01), prolonged ventilation (p < 0.01), reoperation (p = 0.05), and composite morbidity and mortality (p < 0.01) in univariable analysis. When included in a multivariable model ADI was significantly associated with renal failure (p = 0.02), prolonged ventilation (p < 0.01), and composite morbidity and mortality (p < 0.01). Before adjusting for baseline characteristics, survival 10 years after CABG for ADI quartiles one, two, three, and four was 87.2% (95% CI 85.4% to 89.1%), 84.8% (95% CI 82.8% to 86.8%), 85.2% (95% CI 83.3% to 87.2%), and 80.5% (95% CI 78.4% to 82.7%), respectively (Figure 1). Log-rank test demonstrated a significant difference in long-term survival between ADI quartiles (p < 0.01).
Conclusions SES as measured by ADI is significantly associated with operative morbidity and mortality as well as long-term survival following CABG. Further study is necessary to understand the cause(s) of this relationship and how to address it.
Coronary Artery Disease
Association of Perioperative Whole Blood Transfusion With Troponin I Release After Off-pump Coronary Artery Bypass Surgery
Ibrahim Cardiac Hospital & Research Institute, Dhaka, Bangladesh
Purpose High Troponin I (TnI) after OPCABG can often be observed in patients in the absence of significant perioperative hemodynamic instability. Biancari (2012) found that Red Blood Cell transfusion was associated with increased TnI release. This study was conducted to assess whether Whole Blood Transfusion resulted in increased release of TnI
Methods A total of 40 patients (34 males and 6 females) undergoing OPCABG were consecutively enrolled in the study, 20 patients in the transfusion recipient group and 20 patients in the non-transfusion recipient group. The groups were compared for pre-operative baseline characteristics and co-morbidities, per-operative techniques and events, and postoperative or end-point variables including Postoperative TnI level measured 12 hours at the end of surgery and a number of other clinical outcomes.
Results Both transfusion recipient and non-transfusion recipient groups had statistically indifferent baseline characteristics, co-morbidity counts, operative techniques and operative events. No significant difference (p = 1.000) was noted in case-counts with increased Postoperative TnI level between the groups (85% in the transfusion recipient group versus 90% in the non-transfusion recipient group). All other clinical outcomes were also found to be similarly distributed with no statistical difference between the groups.
Conclusions In contrast to Red Blood Cell transfusion in several other studies, perioperative Whole Blood transfusion was not associated with increased postoperative Troponin I (TnI) release after isolated off-pump coronary artery bypass grafting (OPCABG) operation.
Coronary Artery Disease
The routine use of epicardial pacing wires in cardiac surgery does not improve patient outcomes
MS. Thet (1) ; AMA. Shafi (1) ; WI. Awad (1)
(1) Cardiothoracic surgery, St Bartholomew's Hospital, London, United Kingdom
Purpose Temporary epicardial pacing wires are frequently used in cardiac surgery. They are almost always placed in patients undergoing valve surgery, and increasingly placed routinely in patients undergoing non-valve surgery. The aim of this study is to explore whether the use of epicardial pacing wires in cardiac surgery influences patient outcomes.
Methods This is a retrospective study of 2,114 patients, who underwent cardiac surgery at our institution from January to December 2018. Four groups of patients were investigated depending on the procedure undertaken: isolated CABG, isolated valve, CABG + valve and other procedures. Within each group, patients were divided into those who had pacing wires inserted and those who did not at the initial procedure. Outcomes, including in-hospital mortality, complication rates, length of ITU and total post-operative hospital stay, were compared within each group. Chi-Square test and Mann-Whitney-U Test were used for statistical analysis.
Results 1,751/2114 (82.8%) patients undergoing cardiac surgery had epicardial pacing wires inserted and within 4 groups of procedures as follows: isolated CABG in 777/954 (81.4%) patients, isolated valve in 528/582 (90.7%), CABG+valve in 211/234 (90.2%) and other procedures in 235/344 (68.3%). Overall mortality rate was similar in patients who had pacing wires versus those without (3.3% vs 3.6%, p=0.75) as was resternotomy (4.0% vs 3.3%, p=0.55), stroke (2.1% vs 1.7%, p=0.58) and renal dysfunction (4.7% vs 4.4%, p=0.79). Mortality and complication rates were also similar within all 4 operation groups between patients with and without pacing wires. However, in the isolated CABG group only, total post-operative length of stay was longer in patients who had epicardial pacing wires (8.4±8.1 vs 7.4±7.5 days, p=0.02), although ITU length of stay was similar, as were total post-operative and ITU stay in the remaining groups, regardless of whether patients had epicardial pacing wires or not.
Conclusions The routine use of epicardial pacing wires appears to have no positive impact on survival or complication rates. In isolated CABG cases, insertion of pacing wires is associated with longer post-operative hospital stays only. The use of epicardial pacing wires in isolated CABG procedures should be reserved for selected patients.
Coronary Artery Disease
Hybrid Coronary Revascularization – who can benefit most? A pilot study
A. Kędziora (1) ; J. Konstanty-Kalandyk, (1) ; J. Piatek (1) ; W. Zajdel (2) ; J. Legutko (2) ; B. Kapelak, (1)
(1) Department of cardiovascular surgery and transplantology, John Paul II Hospital, Krakow, Poland; (2) Department of interventional cardiology, John Paul II Hospital, Kraków, Poland
Purpose Hybrid coronary revascularization (HCR - MIDCAB combined with PCI) allows avoiding the burden of open-chest procedure and can be an effective alternative that diminishes risk and grants complete revascularization. The study prospects for the enhancement of available data on HCR and identification of the subgroup with the utmost clinical benefit.
Methods Retrospective analysis of consecutive patients undergoing HCR (MIDCAB LIMA-LAD combined with PCI to non-LAD coronary lesions). The safety and effectiveness assessment included diminishing periprocedural risk and granting complete revascularization. Within the analysis, 3 subgroups were identified: group A – elective PCI then elective CABG (1 patient required CABG date acceleration due to unstable angina); group B – elective/urgent CABG then elective PCI, group C – ACS PCI then elective/urgent CABG. The subgroups were tested for clinical benefit of HCR approach. The outcome was evaluated for 30-day post-surgery period.
Results To date, 32 consecutive patients were enrolled into the study. Within the analysis, 3 subgroups were identified: group A – elective PCI then elective CABG (1 patient required CABG date acceleration due to unstable angina); group B – elective/urgent CABG then elective PCI, group C – ACS PCI then elective/urgent CABG. The PCI target vessel differed among the groups (A: 66.7% RCA, 33.3% Cx or Mg or Cx/Mg; B: 33.3% RCA, 44.4% LM/Cx, 11.1% RCA + Cx; C: 58.8 % RCA, 35.3% Cx or Mg or Cx/Mg, 5.9% RCA + Cx). Similarly were the contraindications to multivessel CABG, as a composite of inability to achieve complete revascularization and contraindications to full median sternotomy (A: 66.7%; B: 100%; C: 23.5%). Overall, no deaths and 1 case of MACCE (1 patient, group B: preoperatively - LM stenosis with inability to achieve complete revascularization with CABG due to Cx anatomical characteristics, postoperative MI with sudden cardiac arrest and successful emergent LM/Cx PCI) were reported. The observed mortality was lower than predicted by the EuroSCORE II (A: 1.33%; B: 2.9%; C: 1.23%).
Conclusions Patients qualified for hybrid coronary revascularization due to contraindications to multivessel CABG benefit most in terms of 30-day mortality, when compared to estimated outcome based on EuroSCORE II. Further data acquirement and analysis is warranted in order to develop the qualification protocol for hybrid revascularization, according to EBM standards.
Coronary Artery Disease
Increased number of vasa vasorum in saphenous veins as compared with internal mammary arteries: a possible explanation for better performance of arterial conduits
A. Frolov (1) ; L. Bogdanov (2) ; R. Mukhamadiyarov (2) ; A. Kutikhin (2)
(1) Laboratory for vascular reconstructive surgery, division of atherosclerosis research, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia; (2) Laboratory for vascular biology, division of experimental and clinical cardiology, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
Purpose Internal mammary arteries demonstrate higher long-term patency after CABG surgery than saphenous veins, yet the pathophysiological basis for better performance of arterial conduits is lacking. Here we evaluated intimal hyperplasia and expansion of vasa vasorum, both recognised as surrogate markers of vascular inflammation, in arterial and venous grafts.
Methods Segments of internal mammary arteries (IMA) and saphenous veins (SV) (n = 13) were excised in pairs during CABG surgery, fixed with 10% formalin, postfixed with osmium tetroxide, dehydrated, stained with uranyl acetate, and embedded into epoxy resin with subsequent grinding, polishing, and counterstaining with lead citrate. Samples were then sputter coated with carbon and visualised by means of backscattered scanning electron microscopy. Intimal hyperplasia was measured as thickest-to-thinnest neointima ratio and percent stenosis. Quantification of intimal hyperplasia as well as area and number of vasa vasorum, which were additionally normalised to the area of adventitia, was performed using ImageJ.
Results Intimal hyperplasia correlated with total number (Spearman r = 0.47) and area (Spearman r = 0.45) of vasa vasorum suggestive of their possible role in vascular inflammation. Further, intimal hyperplasia (thickest-to-thinnest neointima > 5) was more prevalent in SV (9/13, 69.2%) than in IMA (7/13, 53.8%), although this difference did not reach statistical significance. Median number of vasa vasorum in SV exceeded that in IMA (60 (interquartile range 34.5-87) and 18 (16-23.5), respectively, p = 0.0005), and these differences remained significant after the adjustment by the area of adventitia (one vessel per 26,201 (21,314-37,495) and 65,079 (45,248-85,263) µm2 of adventitia in SV and IMA, respectively, p = 0.0266).
Conclusions In comparison with IMA, SV contain significantly higher number of vasa vasorum that correlates with the development of intimal hyperplasia. This might be considered as a possible factor contributing to low-grade chronic inflammation potentially affecting long-term CABG surgery outcomes and possibly elucidating the reason for better performance of IMA.
Coronary Artery Disease
Long Segmental Reconstruction of Diffusely Diseased Left Anterior Descending Coronary Artery using Left Internal Thoracic Artery
H. abdelmohty (1) ; A. Bakry (2) ; W. Abdelaziz (3)
(1) cardiothoracic surgery, mansura university hospitals, Mansoura, Egypt; (2) Cardiothoracic surgery, Zagazig University, Zagazig, Egypt; (3) Cardiothoracic surgery, Faculty of Specific Education Mansoura - University, Mansoura, Egypt
Purpose The diffusely diseased left anterior descending coronary artery (LAD) remains a challenge for both interventional cardiologists and cardiac surgeons. In this study, we assessed the surgical outcomes obtained from coronary artery reconstruction, with or without endarterectomy, for a diffusely diseased LAD.
Methods Two hundred and fifty patients were treated with an extended LAD reconstruction, with or without endarterectomy, as part of coronary artery bypass grafting to achieve complete revascularization.
Results The left internal thoracic artery (LITA) was used to reconstruct the LAD in all patients. There were 197 men and 53 women. The mean age was 65.1±9.0 years. Coronary artery reconstruction was performed without endarterectomy in 183 patients (73.2%) and with endarterectomy in 67 patients (26.8%). The operative mortality was 1.6%. Perioperative myocardial infarction was observed in 6.4% of the patients. The mean LAD incision length was 9.3±1.7 cm. The patency rate of the LITA to LAD was 98.6% by 1st year postoperative angiographic examination (mean, 8.5±3.9 postoperative months). There were 3 late cardiac related deaths at a mean follow-up of 11.2±5.7 months. The actuarial survival was 92.0% at 24 months. Freedom from death or cardiac events was 89.1% at 36 months.
Conclusions Coronary artery reconstruction, with or without endarterectomy, using the left internal thoracic artery for a diffusely diseased LAD can be performed with encouraging early and midterm results.
Coronary Artery Disease
Crawling in MIDCAB, Mansoura experience
cardiac surgery, Prince Sultan Heart Center, Najran, Saudi Arabia
Purpose Minimally invasive direct coronary artery bypass grafting (MIDCAB) is an operation which doesn’t need special infrastructure. It avoids sternotomy and cardiopulmonary bypass and preserve durability of surgical revascularization.
Methods From December 2015 to January 2018, (49) patients were operated on with MIDCAB. Myocardial territories approached through (5-6-cm) left forth intercostal thoracotomy. Stabilizer are introduced through the same incision, the left internal mammary artery (LIMA) is used to graft LAD, and saphenous vein segments are used to graft the lateral myocardial territories. Proximal anastomoses are performed directly onto the aorta, left subclavian or from LIMA as a (T or Y) graft.
Results The mean age was (52.3±10.7) years, 2 patients were female. In all cases LIMA was used, patients has single vessel disease (n=35), 2 vessel disease (n=10) and 3 vessel disease (n=4). Most of the cases done via off-pump surgery (n=29) and 6 patients were done via on pump surgery.
Hybrid approach was used in 3 cases; one on table and 2 during the hospital stay. 2 cases had low EF, one cases with renal failure and one patient had liver transplantation. ICU stay was (12 hours - 2 days) and hospital stay from 2-7 days
Complication were haemothorax in 2 patients, pericardial effusion in one case , conversion in 2 cases.
One year follow up by MSCT coronary or coronary angio in 20 cases showed graft patency in 18 patients and one patient with thrombosed Y graft subjected to redo CABG and one patient with distal occlusion which managed conservatively. We have one case of mortality related to preoperative low left ventricular function.
Conclusions MIDCAB is feasible and has excellent procedural and short-term outcomes. This operation could potentially replace CABG as it is safe, effective, less destructive and rapid recovery.
First Experience with Veno-Arterial Extracorporeal Membrane Oxygenation in Peru
A. Zevallos (1) ; C. Soplopuco (2)
(1) Cardiovascular surgery, INSTITUTO NACIONAL CARDIOVASCULAR, Lima, Peru; (2) Perioperative cardiology, INSTITUTO NACIONAL CARDIOVASCULAR, Lima,
Purpose Despite the increase of centers with ECMO programs in the world, Latin America has the less than 1% of ECMO case reports. The aim of the present study was to describe our first experience as the single center with an ECMO program in Peru.
Methods From January 2014 to June 2019, 22 patients who received VA-ECMO support were reviewed. Demographic and preoperative data, indications of ECMO support and configuration, and also postoperative outcomes are presented.
Results Twenty (90.9%) patients were male and the mean age of patients was 46.7 ± 14.08 years. Pre implantation causes were shock postcardiotomy (n=10, 45.45%), primary graft dysfunction (n=5, 22.72%), ischemic heart disease (n=5, 22.72%), one case of advanced heart failure (4.54%) and one case (4.54%) of pulmonary embolism. The indications were bridge to recuperation (n=17, 77.27%), bridge to bridge (n=4, 18.18%) and bridge to surgery (n=1, 4.54%). Twelve patients (54.54%) had a peripherial access: eleven (91.66%) were femoral and one (8.34%) was axillar. All patients with femoral access had intra-aortic balloon pump and prophylactic distal perfusion catheter. Ten patients (45.46%) were central: nine (90%) had a venting cannula in left atrium. Fourteen (63.63%) patients were weaned from ECMO successfully. Totally, 45.45% of the study population survived to hospital discharge. The complications were surgical side bleeding (n=12, 50%), dialysis required (n=8, 36.36%), sepsis (n=9, 40.9%), limb complications (n=3, 13.63%) and cerebrovascular event (n=4, 18.18%).
Conclusions Extracorporeal membrane oxygenation is an effective therapy that is constantly growing in our country despite economic limitations. Our single-center experience presented results in survival comparable with ELSO registry report and showed the feasibility in different clinical scenarios.
The comparison of two surgical classifications in prediction of outcome after Pulmonary Endarterectomy
J. Lindner (1) ; M. Niznansky (1) ; T. Prskavec (1) ; D. Ambroz (2) ; P. Jansa (3)
(1) 2nd department of surgery – department of cardiovascular surgery, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic; (2) 2nd medical department – department of cardiolofgy and angiology, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic; (3) 2nd department of internal cardiovascular medicine, First faculty of medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
Purpose The aim of this study was to compare two surgical classification in prediction of residual pulmonary hypertension, morbidity and mortality of patient with chronic tromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA) in a single CTEPH centre.
Methods Jamieson CTEPH perioperative classification (used in our centre from the beginning of our PEA program in 2004) and new UCSD classification (used from 2013) were compared in prediction of outcome after PEA. For statistics analysis we used Pearson Correlation coefficient.
Results We retrospectively analysed 150 patients, who underwent PEA between 2010 and 2018. Patients characteristics: mean age 60,9±11 years, 40 % females. TAB. 1 (Click on image to left)
Conclusions UCSD classification is more predictive regarding pulmonary vascular resistence (PVR), serious pulmonary haemorrhage, 30- day mortality and survival. Cumulative correlation shows that UCSD classification is more predictive that Jamieson classification, but results is not statistically significant (p=0.25 vs p=0.72).
Peripherial versus Central Veno Arterial Extracorporeal Membrane Oxygenation in a Center of Latinoamerica
A. Zevallos (1) ; C. Soplopuco (2)
(1) Cardiovascular surgery, INCOR, Lima, Peru; (2) Perioperative cardiology, INSTITUTO NACIONAL CARDIOVASCULAR, Lima, Peru
Purpose Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) application is increasing in Latinamerica. Nevertheless, there are no reports of the best configuration of VA- ECMO in centers of Latin America. The aim of the present study was to compare the outcomes between peripherial and central VA ECMO configurations in a single center.
Methods A retrospective analysis of twenty two consecutive patients from January 2014 to June 2019 who underwent ECMO by central (right atrial to ascending aorta) or peripheral cannulation (femoral vein to femoral artery or axillary artery) was performed. Survival, cerebrovascular events, limb complications, bleeding requiring reoperation, sepsis, dialysis requirement and transfusions were assessed in both groups.
Results Twelve patients (54.54%) had a peripherial access: eleven (91.66%) were femoral and one (8.34%) was axillar. All patients with femoral access had intra-aortic balloon pump and prophylactic distal perfusion catheter. Ten patients (45.46%) were central: nine (90%) had a venting cannula in left atrium. The main pre implantation cause of central cannulation was the shock postcardiotomy (n=7, 70%) and in peripherial cannulation was isquemic heart disease (n=5, 41,66%). The survival to hospital discharge in central ECMO was two patients (20%) and in peripherial was eight (66.7%) with statistical difference (p=0.043). Peripheral cannulation was associated with a significant reduction in the risk of bleeding (p = 0.002) and sepsis (p=0.027). No statistical differences were found between peripheral and central VA-ECMO with regard to cerebrovascular events, limb complications, dialysis requirement and transfusion of red blood cells units, fresh frozen plasma units, platelets units and cryoprecipitate units.
Conclusions Peripheral VA-ECMO configuration showed a better inhospital survival compared with central configuration. The risk of bleeding and sepsis was significantly lower with the peripheral cannulation strategy.
Determining the optimal mode of mechanical cardiopulmonary support for right heart recovery: the effects of veno-venous configuration
R. Ukita (1) ; A. Tumen (1) ; J. Stokes, (2) ; Y. Tipograf, (1) ; R. Donocoff, (3) ; E. Berman-Rosenzweig, (4) ; K. Cook, (5) ; M. Bacchetta, (1)
(1) Thoracic surgery, Vanderbilt University Medical Center, Nashville, United States of America; (2) General surgery, Vanderbilt University Medical Center, Nashville, United States of America; (3) Institute of comparative medicine, Columbia University Medical Center, New York, United States of America; (4) Pediatrics, Columbia University Medical Center, New York, United States of America; (5) Biomedical engineering, Carnegie Mellon University, Pittsburgh, United States of America
Purpose Extracorporeal membrane oxygenation (ECMO) may be an effective strategy to bridge pulmonary hypertension patients to right heart recovery or lung transplantation. However, there is little work studying the benefits and risks of differing ECMO configurations. Here, we present our initial work on the effects of veno-venous ECMO on right heart recovery.
Methods Two 70-80 kg sheep with chronic PA banding underwent veno-venous (VV) ECMO using dual-lumen Crescent cannula with an adult Quadrox oxygenator. The circuit was started at blood flow of 1.5 L/min, and right heart failure was induced with a pulmonary vascular occluder to decrease cardiac output by 40-50%. The support was continued for 3 hours, increasing ECMO blood flow rate by 1 L/min per hour. Hemodynamic and biochemical data were collected during the 3-hour support. Thereafter, sheep were euthanized and necropsies were performed.
Results The initial cardiac outputs for Sheep 1 and 2 were 2.9 and 4.2 L/min, respectively, and they dropped to 1.8 and 1.7 L/min from further PA banding and decreased steadily over the 3 hours of VV ECMO. After acute banding, CVP remained elevated in both sheep, especially in Sheep 2. VV ECMO offered oxygenation to the animal, as PaO2 returned to normal after the initial drop at 0h. There was a rising trend in blood lactate level but more notably in Sheep 2, reaching as high as 4.6 mmol/L. Sheep 1 survived the entire duration, but Sheep 2 died at 3 h of support from RV failure. Ventricular weight ratios (RV:LV+S) were 0.55 and 0.45, indicating extensive RV hypertrophy for Sheep 1 and 2, respectively.
Conclusions VV-ECMO is not an effective mode for right ventricular recovery or support. Future studies will investigate the benefits of other cannulation strategies, including central VA-ECMO and pumpless pulmonary artery-to-left atrium configurations.
Result of Pulmonary Thromboendarterectomy in the management of chronic thromboembolic pulmonary hypertension in high-altitude center
N. Federico (1) ; D. Ruben (2) ; R. Sandra (3) ; H. Santos (1) ; V. Caicedo (1) ; A. Sergio (4) ; A. Dario (1) ; P. Sonia (5)
Purpose Bilateral pulmonary thromboendarterectomy is the definitive therapy for chronic thromboembolic pulmonary hypertension (HPTEC). The exact incidence of HPTEC is unknown, but it has been reported in 0.57 to 3.8 percent of survivors of acute pulmonary embolism and in more 10% of those with recurrent pulmonary embolism.
Methods Retrospective, observational, cross-sectional study, period June 2008 to June 2019.
Results 63 patients taken to bilateral pulmonary thromboendarterectomy, mean age 47 years, male sex 54%, history: 54% deep vein thrombosis, 63.5% thrombophilia, 21% hypothyroidism, 7.9% vena cava filter, 1.6% cancer . Use of preoperative pulmonary antihypertensives: 100% bi or triconjungado pulmonary vasodilators. Symptoms of admission: 100% dyspnea CF III-IV, 39.7% precordial pain, 6.3% hemoptysis, 20.6% syncope. Signs compatible with pulmonary hypertension on chest x-ray 87%, electrocardiographic changes 82% and 100% by pulmonary gammagraphy, angiotac or angiography. Grade III - IV preoperative tricuspid insufficiency in 64%. Walk test of 6 minutes preoperative average of 250, average preoperative PAP 70 mmHg (35-133), preoperative RVP average 600 dynas (300-1300). Associated surgeries 30%, Global mortality 10%, 100% of patients are found with tricuspid insufficiency I-II and 90% in functional class I-II. Complications: ECMO required in 22%, neurological lesion 0%. The main mortality risk factor was the use of ECMO, a statistically significant correlation with p 0.000 mortality.
Conclusions Pulmonary thromboendarterectomy is a safe procedure that allows an immediate and sustained decrease in PAP, RVP and the degree of tricuspid insufficiency, with improvement of the functional class. The procedure can be performed in cities located at great heights with results comparable to published series.
The Simulus Mitral Ring: initial results of a new semi-rigid ring
M. Saccocci (1) ; A. Messina (2) ; E. Villa (3) ; N. Del Zanna (1) ; M. Cirillo, (3) ; M. Dallatomba (3) ; M. Campana (4) ; G. Troise (2)
(1) Department of cardiac surgery, Poliambulanza Foundation Hospital, Brescia, Italy; (2) Department of cardiovascular surgery, Poliambulanza Foundation / Cardiac Surgery Unit, Brescia, Italy; (3) Cardiac Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; (4) Cardiology, Poliambulanza Foundation Hospital, Brescia, Italy
Purpose The aim of this study is to describe and analyze intraoperative performance and short term results of isolated MV repair using the Medtronic Simulusmitral ring in both Barlow and Fibro Elastic Deficiency valves.
Methods From April 2016 to April 2019 we have performed more than 400 isolated or concomitant mitral valve repair using different types of technique, prosthetic rings and surgical access. We selected 67 consecutive patients who underwent isolated MVR using the Simulus ring associated to “resect” or “respect” technique; Follow-up 15,68 ± 10,58months
POST-operative results: No MR 53 (79,10%); Mild MR 14 (20,9); More than mild MR 0 (0%); no intraoperative mortality.
FOLLOW-UP: Time (months)15,68 ± 10,58; Lost at Follow-up0 (0%);Overall Survival100%; Freedom from recurrency100%; MR more than mild 0%;NYHA > I 0%
Conclusions MVR with the Simulus ring is safe and feasible and permit to achieve excellent results in all kind of valve dysfunctions showing a tremendous efficacy to restore leaflet coaptation even in extremely dilated annuli. Short terms results confirm the durability of MVR with no evidence of MR recurrence and complete freedom from reoperation.
Robotic Assited Cardiac Surgery in Colombia
D. Andrade (1) ; J. Parra (1) ; F. Nuñez (1) ; E. Sepulveda (2) ; H. Balkhy (3)
(1) Cardiac surgery, Fundación Clínica Shaio, Bogota, Colombia; (2) Cardiac surgery, Clínica Las Condes, Las Condes, Chile; (3) Cardiac surgery, University of Chicago Medicine, Chicago, United States of America
Purpose This paper aims to analyze the postoperative clinical outcomes of patients who were treated with robotic cardiac surgery for cardiac surgical heart disease at a referral institution between 2017 and 2019 in Bogota, Colombia.
Methods This is an observational, descriptive, case series study. We performed a retrospective review of electronic medical records from 2017 to 2019 of patients undergoing cardiac robotic surgery at a referral institution. We evaluated: sex, age, origin, surgical technique, associated procedures, associated surgical pathologies (valvulopathies or coronary disease), preoperative and postoperative ventricular function, use of blood transfusions ,ICU and hospitallength of stay, complications and, early and late mortality at 1 year.
Results 7 cases (100%) were successfully completed robotically, three cases of mitral valve repair and two of atrial septal defect closure; the range of ages was between 55 and 59 years, 60% were male. Average aorta cross-clamping time were 70 ± 40 minutes in atrial septal defect closure and in mitral valve repair was 114 ± 90 minutes. The median time of cardiopulmonary bypass was 228.4 min. The median length of stay was between 2 and 4 days. Early mortality (30 days) rate and Late mortality (1 year) was 0%. There were no changes in ventricular function in postoperative state, measured by echocardiography. None of the patients needed reoperation for bleeding or any other cause. Non-lethal postoperative complications were observed. None of our patients developed renal injury. 100% of the patients were in sinus rhythm after discharge and in the postoperative control. All our patients were discharged with only acetaminophen for pain control and they began their activities on average 8 days after surgery.
Conclusions Clinical experience with robot-assisted surgery shows that it is a feasible technique for cardiac surgery in our country. It is important to mention that Columbia is a third world country with significant limitations in applying this technique because of cultural economic, and health insuranceconsiderations.
MIMVS + PCI as a One-Stage Hybrid Procedure
B. Ferreira (1) ; AG. Everding (2) ; HR. Diaz (2) ; A. Gutierrez (2)
(1) Instituto Cardiovascular de Mínima Invasión, Zapopan, Mexico; (2) Cardiocirugia, Instituto Cardiovascular de Mínima Invasión, Zapopan, Mexico
Purpose Currently there are multiple therapeutic options for combined pathologies of heart valves + ischemic heart disease. Here we present our approach using MIMVS (minimally invasive mitral valve surgery) + PCI (percutaneous coronary intervention) in a one-stage hybrid procedure. This procedure being feasible and reproducible.
Methods Male, 65 years old, history of HTN, AMI treated with thrombolysis. ETT showing dyskinesia in multiple areas of the LV. LVEF 45%. Severe mitral regurgitation. Myocardial perfusion study with thallium 201 reports multiple areas of necrosis. Cateterism: multivessel disease (LAD 90%, CX 100% and RC 70%).
The Heart-team concluded: MIMVS + PCI as a one-stage hybrid procedure. The surgical approach by Minitoracotomy. Preservation of the subvalvular apparatus and MVR with biological valve # 29. PCI with medicated stents (Everolimus) of: LAD, CX and RC.
Conclusions Performing concomitant CABG + MVR, STS score shows a 9.8% mortality risk and a significantly greater occurrence of post-operative complications. An alternative is to divide the operation into two lower risk procedures: PCI + MIMVS. Hypothesized the risk would decrease. More studies are need to confirm this hypothesis.
The features of surgical treatment of children with hypertrophic cardiomyopathy: Ukrainian experience
K. Rudenko (1) ; V. Lazoryshynets (2) ; A. Krykunov (3) ; A. Rusnak (1) ; O. Chyzhevska (4) ; L. Nevmerzhytska (4) ; P. Danchenko (5)
(1) Department of surgical treatment of heart failure and heart and lung mechanical support, Amosov Heart Institute, Київ, Ukraine; (2) Surgery for newborns and children, Amosov National Institute of Cardio-vascular surgery, Kiev, Ukraine; (3) Department of surgical treatment of infective endocarditis, National Institute of Cardio-vascular surgery named after M.M. Amosov, Kyiv, Ukraine; (4) Department of surgical treatment of heart failure and heart and lung mechanical support, Amosov National Institute of Cardiovascular Surgery, Kyiv, Ukraine; (5) Surgery department №4, Bogomolets National Medical University, Kyiv, Ukraine
Purpose The objective of this study is to identify the features of surgical correction of HOCM in children and define the mandatory surgical steps needed to be performed for successful clinical outcome.
Methods The study involves 226 patients among which 12 (5,8%) were children from 8 months to 18 years old. The following steps of surgical correction were conducted in all patients: extended septal myectomy; resection of anomalous chordal attachments (secondary chordae); papillary muscles mobilization; plication of the MV leaflets (75% of the cases) was performed to reduce the length of the oversized structure and thus reduce the risk of post-operative systolic anterior motion (SAM) effect. A mandatory intraoperative echocardiographic control was conducted using transesophageal echocardiography.
Results The average LVOT systolic pressure gradient decreased from 95,6 ± 37,2 mmHg to 23,5 ± 9,1 mmHg (measured at the discharge from the hospital). All patients remained in NYHA class I after surgery. The were no major complications (such as ventricular septal defect, acute cerebrovascular event, cardiogenic shock, conduction impairments etc.) registered in the pediatric group. According to the echocardiographic findings, the 77% of the patients (n=10) who had moderate MR before the surgery, had mild degree of mitral insufficiency after surgical procedure. No patients were found to have SAM effect of post-operative echocardiography. 1 patient (7,6%) underwent implantation of the implantable cardioverter-defibrillator (ICD) in the post-operative period.
Conclusions The combination of the mentioned mandatory surgical stages provides successful clinical outcome. For the better visualisation of the anatomical or anomalous structures the routine performance of MRI before the surgical intervention is recommended.
Mitral Valve Robotic Surgery. Single Centre Initial Experience And Evolution
A. Molina-Romo (1) ; D. Bouchard, (1) ; L. Revelli, (1) ; M. Pellerin (2)
(1) Chirurgie Cardiaque, Institut de Cardiologie de Montréal , Montréal , Canada; (2) Cardiac surgery, Montreal Heart Institute, Montreal, Canada
Purpose To share the initial experienice at our institution using the Da Vinci surgical system for mitral valve robotic assited surgery
Methods Single centre retrospective study, including 105 patients with mitral valve regurgitation. All surgeries were performed by the same 2 surgeons using the Da Vinci Surgical system.
Results From April 2017 to June 2019, a total of 105 patients where operated on using the Da Vinci Surgical system. 71%(74) male and 29%(31) female. 85%(89) had severe mitral regurgitation, while 15%(16) had moderate to severe MR. NYHA Functional class was II-III was present in most patients. Mean EF of the left ventricule was 61%. Mean cardiopulmonary bypass time was 129 min, mean crossclamping time was 94 min. Over 62% of mitral repairs were achieved by triangular resection of the prolapsing segment plus mitral annuloplasty. Succesful repair was achieved in 97.7%(102) There were no deaths associated with the procedure and no conversions to full sternotomy. There was 1 patient with post op CVA, 7% (7)of patients requiered reoperation for abnormal bleeding after surgery. Median ICU stay was 1 day.
Conclusions Robotic surgery is an effective and safe approach to correct MR. Operative mortality/morbidity is low, while having an excellent anatomical exposure.
The rate of repair is excellent and equivalent to standard approaches.
Team work and experience play a fundamental role in optimizing results.
Effect of Scheme Therapy (ET) on the resilience of parents of children with congenital heart disease
(1) Cirugía Cardiovascular, Instituto Nacional de Pediatria, Ciudad de México, Mexico
Purpose Congenital heart diseases are one of the leading causes of death in pediatric populations. The elective treatment is the cardiovascular surgical procedure in which there is a high risk of death, which generates an impact in the parents cognitition, activating early maladaptive patterns that will impact intensified emotions and self-destructive behaviors.MethodsThis is a quasi-experimental study of pretest-posttest type with a non-equivalent control group. 12 subjects were included in the study, six from the experimental group and six from the control group, who underwent a TE intervention of 8 psychological sessions. The Young’s Schema Questionnaire and the Mexican Resilience Scale (RESIM) were applied to identify the changes.ResultsThe experimental group presented significant changes in the negativity scheme (p = 0.030) and in the RESIM scale the strength ability in itself was increased (p = 0.043). In the emotional deprivation schemes (p = 0.075), self-sacrifice (p = 0.054) and approval search (p = 0.054) there is an important difference, although no statistical significance was found.ConclusionsAt the end of the TE intervention, changes were observed in the negativity schemes, emotional deprivation, self-sacrifice and search of approval of congenital heart disease patients caregivers and the development of self-perception in strength of self is favored.
Treatment of Cor Triatriatum Dexter, An Unusual Case
D. Miranda, (1) ; M. Vera, (2) ; DB. Ortega Zhindón (3)
(1) Pediatric cardiothoracic surgery department, National Institute of Cardiology Ignacio Chavez, Ciudad de México, Mexico; (2) Cardiovascular surgery department, Hospital Pediatria Centro Medico Siglo XXI, Mexico City, Mexico; (3) Cardiothoracic Surgery Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
Purpose The cor triatriatum dexter is an uncommon finding, which can produce hemodynamic alterations by itself or in conjunction with the defects to which it is associated. There are reports of isolated cases, so an incidence of 0.025% of all congenital heart diseases is estimated.
Methods A 10 years old patient, at 4 years diagnosed with heart murmur, without follow-up. At 9 years, osteum secundum interatrial communication plus bicameral right atrium is diagnosed by membrane presence. The contrasted echocardiogram reported preferential flow to the right ventricle, with little passage of bubbles through the membrane to the upper portion of the right atrium and to the second beat bubbles that reach the left atrium, with a 13 mm inferior vena cava, left atrium 23 mm, 12mm osteum secundum interatrial communication, bidirectional short circuit, QP: QS 1.7:1.
Results This technique is performed through a conventional approach with median sternotomy, aortic and bicaval cannulation. It is entered through a right atriotomy to identify each of the structures and the remnant membrane that is located between the coronary sinus and the inferior vena cava and goes in the direction of the interatrial septum at the margin of the oval fossa. The resection of the cephalic membrane at caudal is then performed with a Metzenbaum scissors and with special care not to open the left atrium roof, to later identify again the existing structures and defects. Finally, reinforcement was made in the roof of the left atrium with continuous suture with polypropylene 6-0 USP and closure of the interatrial communication with continuous suture with polypropylene 5-0 USP.
Conclusions In the current literature, there is no description of the technique for the vestige of membrane, nor its limits; therefore, we present a simple and practical approach with extraction of the residual membrane and together the direct closure of the atrial septal defect is performed.
Preoperative Factors for Acute Lung Injury After Pediatric Open-Heart Surgery
T. Fukunishi (1) ; K. Miyaji (1)
(1) Department of cardiovascular surgery, Kitasato University School of Medicine, Sagamihara, Japan
Purpose In recent years, the neutrophil-to-lymphocyte ratio (NLR) has emerged as a sensitive inflammatory maker associated with poor outcomes in various clinical situations for adult cardiac surgery and heart disease. This study focuses on pediatric cardiac surgery and explores the preoperative factors for acute lung injury (ALI) after open-heart surgery.
Methods We performed a retrospective review of 70 cases (weighting; 5.6±1.3kg, age; 4.1±2.9months) that underwent ventricular septal defect (VSD) repair at Kitasato University Hospital from January 2012 to May 2018. We excluded preoperative mechanical ventilation from this study. ALI after pediatric cardiac operation was defined as PaO2/FiO2 (P/F) ratio less than 300. Univariate and multivariate regression were used to determine preoperative factors including elevated NLR for ALI. Receiver-operating-characteristic (ROC) was used to determine the cutoff value of predictors for ALI from multivariate analysis.
Results The incidence of ALI after pediatric cardiac surgery was 55.7% (39/70 cases). P/F ratio after operation and preoperative NLR was 306.1±70.1 and 0.40±0.18 on average, respectively. Univariate analysis revealed significant correlations between P/F ratio <300 and preoperative pulmonary resistance (Rp, p=0.03), LDH (p=0.03), NLR (p=0.005), and total protein (TP, p<0.001), although there was no correlation between P/F ratio and other preoperative factors, such as age, weight, Qp/Qs ratio, bilirubin, CPK, and CRP. Preoperative NLR (CO; -94.41, 95% CI; -181.33 to -7.5, p=0.04) and TP (CO; 39.20, 95% CI; 9.5 to 68.9, p=0.01) in the multivariate analysis emerged as each independent predictor of ALI after operation. The ROC analysis demonstrated that the cutoff value of preoperative NLR and TP for incidence of ALI after pediatric open-heart surgery was 0.36 (AUC=0.75, p <0.001) and 5.8 (AUC=0.74, p<0.001), respectively.
Conclusions Postoperative ALI is due to inflammatory ischemic reperfusion and microcirculatory insufficiency in cardiac surgeries. In this study, preoperative elevated NLR (>0.36) and low TP (<5.8) were identified as risk factors for postoperative ALI. Therefore, the value of preoperative NLR and TP are predictors for ALI after pediatric cardiac surgeries.
Axillary Incision; an option in the surgical approach of Scimitar Syndrome with Lugones Technique. Successful case report
HS. Diliz Nava (1) ; A. Palacios (2) ; F. Pérez (3) ; M. Barrera (4) ; V. Castañuela (5) ; K. Martínez (6)
(1) Cirugía cardiovascular, Instituto Nacional de Pediatria, Ciudad de México, Mexico; (2) Ciruguría cardiovascular, Instituto Nacional de Pediatria, Ciudad de México, Mexico; (3) Ecocardiografía pediátrica, Instituto Nacional de Pediatria, Ciudad de México, Mexico; (4) Anestesiología cardiovascular, Instituto Nacional de Pediatria, Ciudad de México, Mexico; (5) Terapia intensiva cardiovascular, Instituto Nacional de Pediatria, Ciudad de México, Mexico; (6) Cirugía Cardiovascular, Instituto Nacional de Pediatría, Mexico City, Mexico
Purpose Scimitar syndrome is a rare congenital anomaly; total or partial anomalous venous drainage of the right lung to the inferior vena cava. The operative approach for correction is variable. The traditional technique consists in the anastomosis of the anomalous vein with the wall of the right atrium through middle sternotomy.
Methods Tertiary paediatric centre, 5-year-old female with 3-year history of palpitations and recently chest pain. Diagnosis with chest x-ray and echocardiogram.
Surgical approach: selective left lung intubation, axillary incision, through 4th intercostal space, exposure of the pericardium, phrenic nerve, scimitar vein (SV). Pericardium is opened. Incision inferior to the phrenic nerve. Routine cannulation and cardiopulmonary bypass at 34ºC. SV is sectioned and IVC is repaired through incision in pericardium and anastomosis of SV with pericardium, a pericardium patch is over anastomosis SV-left atrial wall. Echocardiogram without obstruction to drainage. Extubation, admission to CVICU with milrinone. Hospital discharge in 5 days.
Results The technique of repair of Scimitar Syndrome has changed over time, with the main objective to prevent stenosis of the anastomosis of the pulmonary vein. Dr. Lugones describes the technique of redirecting venous flow through a patch of pericardium to the left atrium, to avoid direct anastomosis of the vein with the wall of the left atrium, with excellent medium and long-term results.
After performing multiple procedures through an axillary incision, we noticed the excellent exposure of the right side of the heart, the vena cava and the wall of both atria.
The SV has a lateral and posterior course to the right side of the heart. The axillary approach adequately exposes the lateral side of the heart.
One month follow-up: asymptomatic, echocardiogram without drainage obstruction.
Conclusions This approach exposes scimitar vein as well as the phrenic nerve, which is a reference in Lugones´s technique.
The postoperative evolution of the patient was satisfactory with a short time of hospital stay, a postoperative echocardiogram without obstruction, in addition to achieving better aesthetic results.
Quality and Outcomes Initiatives
Bedside PDA Ligation in Patient Less of 1kg in Cancún Quintana Roo. Why is it Extraordinary?
(1) Cardiac and pediatric cardiac surgery, Cancun General Hospital "Jesus Kumate Rodriguez", Cancún, Mexico; (2) Pediatric cardiology, Cancun General Hospital "Jesus Kumate Rodriguez", Cancún, Mexico; (3) Cardiac anestesiology, Cancun General Hospital "Jesus Kumate Rodriguez", Cancún, Mexico; (4) Pediatric anestesiology, Cancun General Hospital "Jesus Kumate Rodriguez", Cancún, Mexico; (5) Neonatology intensive care unit, Cancun General Hospital "Jesus Kumate Rodriguez", Cancún, Mexico
Purpose Demonstrate the need and beginnings of a program to congenital heart defects (CHD) in Cancun, Quintana Roo Mexico
Methods In Mexico the CHD are the second cause of mortality in children younger than 5 years old. Quintana Roo have 1´754,144 habitants, conformed mostly by young people with a high birth rate. The prevalence of CHD in Quintana Roo is expected to be higher in comparison whit the rest of the country: in 2017 the CHD was reported as 9.8 per 1000 live newborns increasing by 2018 when the estimate prevalence of the CHD was 14.8 per 1000 live newborns mostly because the diagnosis increased.
Results Our concern it that to date there’s no congenital heart service neither in public or private hospitals and still no pediatric medical center in the state. The high mortality index of CHD is because of the lack of timely treatment and the difficulty to carry out transfers to the overcrowded centralized hospitals.
Whit a new team in the state conformed by pediatric cardiologist, congenital heart surgeon, cardiac anesthesiologist and pediatric anesthesiologist we were able to perform the first time bedside PDA ligation of a 750g newborn in the Neonatal Intensive Care Unit.
The General Hospital’s plan is to obtain financial resources from the federal government starting 2020. The objective is to race 15 million Mexican pesos to do the first 100 cardiac surgeries in the state. At this moment we already begin the work whit several foundations to obtain infrastructure and money to help all the CHD patients in Quintana Roo.
Conclusions Our goals are to be able to open the PICU and begin whit the CHD integral program, one that includes newborn cardiac screening, prenatal diagnostic, cardiology attention and cardiac surgery, slowly increasing the complexity
Quality and Outcomes Initiatives
Postoperative Stroke in Cardiac Surgery
M. Silva (1) ; T. Silva (1) ; C. Rodrigues, (1) ; R. Cerejo (1) ; P. Coelho, (1) ; N. Banazol (1) ; J. Fragata (1)
(1) Cardiothoracic surgery, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisbon, Portugal
Purpose Neurological adverse events following cardiac surgery are some of the most worrisome complications, with increased morbidity and mortality. Stroke negatively impacts recovery and quality of life. We aim to study our center cohort of patients with neurological complications and analyse outcomes.
Methods Single center, retrospective study of 4153 adult patients who underwent aortic valve replacement (AVR), coronary artery bypass grafting (CABG) and combined procedures (AVR + CABG), between January 2008 and March 2017. Two groups (STROKE vs. NO STROKE) were compared; outcomes and association with in-hospital mortality were analysed.
Results Overall incidence of stroke was 2% (n=69). AVR was preformed in 1613 patients, 2160 patients underwent CABG and 380 had AVR+CABG, with stroke rate of 2%, 1% and 2%, respectively. The two groups, STROKE (n=69) and NO STROKE (n=4084), had similar baseline characteristics, except for older age (>70 years), higher incidence of arterial hypertension, diabetes, atrial fibrilation and cerebralvascular disease in STROKE group (p-value <0,05). Neurological adverse events were significantly associated with renal dysfunction, prolonged invasive mechanical ventilation (>24 hours), need for inotropic support over 48 hours, perioperative myocardial infarction, intra-aortic balloon pump, cardiac arrest, postoperative atrial fibrillation and need for temporary or definitive pacemaker (p-value <0,05). Overall in-hospital mortality was 2%; STROKE group had significantly higher in-hospital mortality (19% vs. 2% p<0,05).
Conclusions Postoperative stroke in cardiac surgery is devastating complication. Overall incidence in our study was similiar to other series published in the literature. A higher morbidity and a significant higher in-hospital mortality were asscociated with stroke.
Quality and Outcomes Initiatives
A Sex-Based Bibliometric Analysis of the European Journal of Cardio-Thoracic Surgery: Trends, Gaps, and Opportunities
D. Vervoort (1) ; S. Hirji, (2) ; J. Luc (3) ; A. Malarczyk (2) ; E. Percy, (3) ; M. Antonoff (4) ; O. Preventza (5)
(1) Program in global surgery and social change, Harvard Medical School, Boston, United States of America; (2) Department of cardiac surgery, Brigham and Women's Hospital, Boston, United States of America; (3) Division of cardiovascular surgery, University of British Columbia, Vancouver, Canada; (4) Department of thoracic and cardiovascular surgery, MD Anderson Cancer Center, Houston, United States of America; (5) Cardiothoracic surgery, Baylor College of Medicine,St Luke's Hospital,Texas Heart Institute, Houston, United States of America
Purpose Women remain underrepresented in cardiothoracic surgery, comprising <5% of American Board of Thoracic Surgery diplomats. Global representation of women among scholarly publications in our field is unknown. This study aimed to characterize female authorship of high-impact articles published in the European Journal of Cardio-Thoracic Surgery (EJCTS).
Methods The top 50 papers by Altmetric score from the EJCTS were included for years 2013, 2015, and 2017. The Altmetric score is a measure of attention and scholarly dissemination