Cross-clamping Research Articles

550 Robotic Totally Endoscopic Mitral Valve Surgeries Within a Comprehensive Robotic Cardiac Program

BackgroundIn 2013, we initiated a comprehensive multispectrum robotic cardiac surgery program with emphasis on the totally endoscopic approach. We reviewed the outcomes of mitral valve (MV) procedures within this context. MethodsA retrospective review of 1714 robotic endoscopic cardiac surgeries performed at our institution between September 2013 and February 2024 was conducted. Of these, outcomes of 550 consecutive heterogeneous patients undergoing robotic totally endoscopic MV operations were analyzed. Data were collected according to the Mitral Valve Academic Research Consortium definitions. ResultsThe mean age was 63 years, and 217 patients (39%) were female. The mean Society of Thoracic Surgeons risk of mortality was 2.1% (range, 0.15%-19.4%). MV repair occurred in 98% of patients with degenerative mitral regurgitation (MR). Concomitant procedures included Cox-maze cryoablation in 127 (23%) patients, tricuspid valve repair in 54 (9.8%), septal myectomy in 15 (2.7%), totally endoscopic coronary bypass in 6 (1.1%), and aortic valve replacement in 3 (0.5%). Endoaortic balloon occlusion was used in 392 patients (71%), ventricular fibrillatory arrest in 114 (21%), and transthoracic aortic clamp in 44 (8%). Observed to expected 30-day mortality was 0.6. Mean length of hospital stay was 2.8 days. MV repair 30-day surgical success was 95.9% and procedural success was 93.0%. Postoperative echocardiography revealed no or trace residual MR in 95% and mild residual MR in 5%. Five-year freedom from reoperation for recurrent MR was 95.7%. ConclusionsRobotic endoscopic MV surgery is feasible within the context of a comprehensive multispectrum robotic cardiac surgery program.

Prophylactic Left Atrial Appendage Ligation During CABG: A Propensity Score-Matched Analysis

To evaluate short-term outcomes and statewide practice patterns of prophylactic left atrial appendage ligation (P-LAAL) in coronary artery bypass grafting (CABG) patients without pre-operative atrial fibrillation (AF). Adult patients who underwent an on-pump CABG (2017 - 2023) within a regional collaborative were identified. Patients with a history of AF, previous cardiac surgery, or non-device based LAAL were excluded. Patients were stratified by LAAL status and were propensity score matched. Univariable analysis was used to compare short-term clinical outcomes. Of 16,547 patients examined, 442 underwent P-LAAL. The propensity score matched cohort (439 P-LAAL, 439 No P-LAAL) was compared and had no significant differences in pre-operative CHA2DS2-VASc scores or operative variables. The P-LAAL group had longer cross clamp time (82 vs 76 minutes, p=0.001), ICU hours (72 vs 66, p=0.001), length of stay (6.0 vs 6.0 days, p=0.010), increased post-operative AF (35% vs 24%, p<0.001), and more discharge on anticoagulation (17% vs 8.2%, p<0.001). There were no significant differences in post-operative stroke (1.1% vs 2.1%, p=0.423), readmission (13% vs 9.6%, p=0.118), operative mortality (2.5% vs 1.6%, p=0.480), or readmission for thrombotic or bleeding complications (0.7% vs 1.1%, p=0.724). Hospitalization costs were significantly higher for P-LAAL patients ($43,478 vs $40,645, p<0.001). The rate of P-LAAL during CABG increased from 1.61% (2017) to 5.65% (2023) (p<0.001). Despite higher rates of post-operative AF, discharge on anticoagulation, and hospitalization costs in patients undergoing P-LAAL during CABG, there was no difference in short-term clinical endpoints including stroke and operative mortality.

Comparative efficacy of totally thoracoscopic, mini-thoracotomy, and mini-sternotomy approaches in aortic valve replacement

Aortic valve replacement (AVR) is a critical procedure for patients with aortic valve diseases. This study compares the effectiveness of three minimally-invasive surgical approaches for AVR: totally thoracoscopic (TT), right anterior mini-thoracotomy, and upper mini-sternotomy. We analyzed retrospective data from 130 patients who underwent one of these surgeries, focusing on various factors such as duration of hospital stay, operation time, times for cardiopulmonary bypass and aortic cross-clamping, postoperative complications, levels of cardiac biomarkers, pain intensity using the Visual Analog Scale, and mid-term survival rates. Results show that while the TT method had the longest operation times, it also had the shortest hospital stays and faster pain reduction post-surgery. Although the TT group initially showed higher cardiac biomarker levels after surgery, these levels normalized by the third day, similar to the other groups. There were no significant differences in mid-term survival and major adverse cardiac and cerebrovascular event (MACCE) rates among the groups. These findings suggest that the TT method, despite longer surgical times, offers a quicker initial recovery, making it a viable option for AVR.

Machine Learning Analysis of Predictors for Inhaled Nitric Oxide Therapy Administration Time Post Congenital Heart Disease Surgery: A Single-Center Observational Study.

Background Congenital heart disease (CHD) is a structural deformity of the heart present at birth. Pulmonary hypertension (PH) may arise from increased blood flow to the lungs, persistent pulmonary arterial pressure elevation, or the use of cardiopulmonary bypass (CPB) during surgical repair. Inhaled nitric oxide (iNO) selectively reduces high blood pressure in the pulmonary vessels without lowering systemic blood pressure, making it useful for treating children with postoperative PH due to heart disease. However, reducing or stopping iNO can exacerbate postoperative PH and hypoxemia, necessitating long-term administration and careful tapering. This study aimed to evaluate, using machine learning (ML), factors that predict the need for long-term iNO administration after open heart surgery in CHD patients in the postoperative ICU, primarily for PH management. Methods We used an ML approach to establish an algorithm to predict 'patients with long-term use of iNO' and validate its accuracy in 34 pediatric postoperative open heart surgery patients who survived and were discharged from the ICU at Kagoshima University Hospital between April 2016 and March 2019. All patients were started on iNO therapy upon ICU admission. Overall, 16 features reflecting patient and surgical characteristics were utilized to predict the patients who needed iNO for over 168 hours using ML analysis with AutoGluon. The dataset was randomly classified into training and test cohorts, comprising 80% and 20% of the data, respectively. In the training cohort, the ML model was constructed using the important features selected by the decrease in Gini impurity and a synthetic oversampling technique. In the testing cohort, the prediction performance of the ML model was evaluated by calculating the area under the receiver operating characteristics curve (AUC) and accuracy. Results Among 28 patients in the training cohort, five needed iNO for over 168 hours; among six patients in the testing cohort, one needed iNO for over 168 hours. CPB, aortic clamp time, in-out balance, and lactate were the four most important features for predicting the need for iNO for over 168 hours. In the training cohorts, the ML model achieved perfect classification with an AUC of 1.00. In the testing cohort, the ML model also achieved perfect classification with an AUC of 1.00 and an accuracy of 1.00. Conclusion The ML approach identified that four factors (CPB, in-out balance, aortic cross-clamp time, and lactate) are strongly associated with the need for long-term iNO administration after open heart surgery in CHD patients. By understanding the outcomes of this study, we can more effectively manage iNO administration in postoperative open heart surgery in CHD patients with PH, potentially preventing the recurrence of postoperative PH and hypoxemia, thereby contributing to safer patient management.

Mid-term outcomes of minimally invasive surgery for partial atrioventricular septal defect in children

Objective: This study aims to describe the mid-term outcomes of minimally invasive surgery for partial atrioventricular septal defect in children. Summary: Partial atrioventricular septal defect is one of the three types of atrioventricular septal defect, accounting for about 3.5% of congenital heart disease. Traditionally, complete repair has been performed via sternotomy. However, with the advancement of minimally invasive surgical techniques in treating congenital heart conditions, we conducted this study to assess the feasibility and mid-term outcomes of this approach. Subjects and methods: This descriptive study spanned from January 2018 to December 2023, involving 30 patients diagnosed with partial atrioventricular septal defect who underwent minimally invasive complete repair. The cohort comprised 12 males and 18 females, with an average age of 18 months and average weight of 10.3 kg. The mean diameter of the primary atrial septal defect was 15 mm. Eight patients (26.7%) exhibited moderate to severe mitral regurgitation, and the average pulmonary artery pressure was 37 mmHg. Results: The average durations of cardiopulmonary bypass and aortic cross-clamp were 82 minutes and 58 minutes, respectively. None of the patients required sternotomy. The average time of artificial ventilator post-surgery was 6.9 hours, with a mean hospital stay of 7.6 days. Postoperative echocardiography showed promising results: complete closure of atrial septal defect, with 90% of patients having absent or mild mitral valve regurgitation, only 10% experienced moderate mitral valve regurgitation. The average follow-up period was 38 months, during which there were no postoperative fatalities. One patient required reoperation due to severe mitral regurgitation from an anterior cleft. Conclusion: Minimally invasive surgery for partial atrioventricular septal defect in children can be safely performed, yielding favorable mid-term outcomes during follow-up.

Evaluate the results of anesthesia and resuscitation of minimally invasive surgery for pediatric patients with ventricular septal defect at Cardiovascular Center, E hospital in 2022

Objective: Minimally invasive surgery has recently been implemented safely and effectively on children. The study aimed to evaluate the results of anesthesia and resuscitation in pediatric patients with ventricular septal defects (VSD) undergoing minimally invasive surgery. Methods: A cross-sectional study from January 1, 2021 to June 30, 2022 on 65 patients underwent minimally invasive surgery to repair ventricular septal defect, at Cardiovascular Center, E Hospital. Result: A toltal of 65 children aged from 1 month to 34 months, mean weight of 9.0 ± 6.3kg, mean height of 73.6 ± 22.1cm, with main clinical symptoms of slow weight gain (62.5%) and grade I heart failure (87.7%). The most common VSD location was perimembranous VSD (67.7%) with an mean size of 5.7±2.6 mm. The mean surgical time was 175 minutes with cardiopulmonary bypass time and aortic cross-clamp time of 77.5 and 53.0 minutes, respectively. Postoperative hemodynamic parameters changed statistically significantly compared to pre-operation: blood pressure decreased, heart rate increased, lactate level increased, P/F ratio decreased, blood potassium level decreased. The patient mainly needed to use 1 vasopressor, 1 type of sedative analgesic, continuous diuresis, and prophylactic antibiotics with a vasopressor withdrawal time of 34.2 hours, a sedation withdrawal time of 13.35 hours, and a sedative withdrawal time of 13.35 hours. Intubation time of 20.8 hours (minimum 2 hours) and length of stay ICU was 3.8 days. Postoperative complications were low, mainly pneumonia (9.2%) and residual shunt (9.2%), and no death was observed. Conclusion: Minimally invasive ventricular septal defect surgery showed that the anesthesia and surgical process did not change much, with relatively fast post-operative recovery results, short medication time, quick recovery, and no recording severe complications.

Case Series of First Microinvasive Fully Endoscopic Use of a New Mitral Prosthesis.

The use of bioprostheses is increasing in younger patients, but it is associated with the risk of later valve deterioration, especially in the mitral position. A new bioprosthesis for mitral valve replacement offers possible longer-term durability and improved hemodynamics. Objectives: Here, we report the implantation of the novel Edwards MITRIS RESILIA mitral valve (Edwards Lifesciences Inc., Irvine, CA, USA) through microinvasive fully endoscopic access as an innovative surgical approach based on a series of twelve patients. Methods: Contrast-based ECG gated CT was preoperatively performed in all patients to determine the intravascular calcifications and vascular parameters, as well as to assess noticeable problems during the operation. CT software for cardiac interventions (3Mensio Medical Imaging BV) was used to simulate surgical prostheses digitally inside the native annulus. With this, a digital LVOT and neo LVOT was created, and the difference between the valve prostheses was measured. Implantation of the MITRIS RESILIA valve was performed in 12 patients according to the instructions for use through microinvasive access in a fully endoscopic fashion using 3D visualization. Results: The mean patient age was 56.50 years, and 7/12 (58.33%) were redo procedures. All patients survived the first 30 days after the procedure, the mean aortic cross-clamp time was 40.17 ± 13.72 min. and mean postoperative transvalvular gradient was 4.45 ± 1.74 mmHg. The neo LVOT in the CT-based simulation was measured with an average area of 414.98 ± 88.69 mm2. The average difference between the LVOT and neo LVOT area was 65.35 ± 34.99 mm2. There was no case of paravalvular leakage or obstruction of the left ventricular outflow tract. Conclusions: The novel MITRIS RESILIA valve is a promising new bioprosthesis for mitral valve replacement that offers improved features as compared to other prostheses. The ease of implantation is increased by this prosthesis by the improved pliability of the sewing cuff and the inward folding of the struts, which was confirmed by short operative times in our series.

Lymphocyte Levels and Morbidity and Mortality in Cardiovascular Surgery With Cardiopulmonary Bypass.

A year ago, in a sample of 113 patients, our research group found that a high number of lymphocytes in the immediate postoperative period was correlated to a poor prognosis in cardiovascular surgeries. This study is an expansion of the initial study in order to confirm this finding. We analyzed the data of 338 consecutive patients submitted to cardiovascular surgeries with cardiopulmonary bypass performed at Hospital Universitário Ciências Médicas (Belo Horizonte/Brazil) from 2015 to 2017. We analyzed 39 variables with the outcomes death, hospital stay, and intensive care unit stay. The value of lymphocytes in the immediate postoperative period > 2175.0/mm³ was an indicator of poor prognosis in this sample (P<0.001). The variables female sex, age, high level of European System for Cardiac Operative Risk Evaluation II, increased stay in the intensive care unit and in the ward, elevation of creatinine in the preoperative period and at intensive care unit discharge, elevation of the percentage of immediate postoperative period segmented neutrophils, high immediate postoperative period neutrophil/lymphocyte ratio, fasting hyperglycemia, preoperative critical condition, reintubation, mild or transient acute renal failure, surgical infection, cardiopulmonary bypass, and aortic cross-clamping and mechanical ventilation durations also had an impact on the mortality outcome. The value of lymphocytes in the immediate postoperative period > 2175.0/mm3 was an indicator of poor prognosis in cardiovascular surgery with cardiopulmonary bypass.

Hypothermic Ventricular Fibrillation in Redo Minimally Invasive Mitral Valve Surgery: A Promising Solution for a Surgical Challenge.

Background: Minimally invasive mitral valve surgery (MIMVS) is a treatment for severe mitral valve pathologies. In redo cases, especially after coronary artery bypass grafting (CABG) surgery with patent mammary bypass grafts, establishing aortic clamping followed by antegrade cardioplegia application might be challenging. Here, we present the outcome of hypothermic ventricular fibrillation as an alternative to conventional cardioprotection. Methods: Patients who underwent MIMVS either received hypothermic ventricular fibrillation (study group, n = 48) or antegrade cardioprotection (control group, n = 840) and were observed for 30 postoperative days. Data were retrospectively analyzed and collected from January 2011 until December 2022. Results: Patients in the study group had a higher preoperative prevalence of renal insufficiency (p = 0.001), extracardiac arteriopathy (p = 0.001), insulin-dependent diabetes mellitus (p = 0.001) and chronic lung disease (p = 0.036). Furthermore, they had a longer surgery time and a lower repair rate (p < 0.001). No difference, however, was seen in postoperative incidences of stroke (p = 0.26), myocardial infarction (p = 1) and mitral valve re-operation (p = 1) as well as 30-day mortality (p = 0.1) and postoperative mitral valve insufficiency or stenosis. Conclusions: The patients who underwent redo MIMVS with hypothermic ventricular fibrillation did not have worse outcomes or more serious adverse events compared to the patients who received routine conventional cardioprotection. Therefore, the use of hypothermic ventricular fibrillation appears to be a promising cardioprotective technique in this challenging patient population requiring redo MIMVS.

Minimally Invasive Surgery through Right Mini-Thoracotomy for Mitral Valve Infective Endocarditis: Contraindicated or Safely Possible?

Background: Mitral valve infective endocarditis (IE) still has a high mortality. Minimally invasive mitral valve surgery (MIMVS) is technically more challenging, especially in patients with endocarditis. Here, we compare the early postoperative outcome of patients with endocarditis and other indications for MIMVS. Methods: Two groups were formed, one consisting of patients who underwent surgery because of mitral valve endocarditis (IE group: n = 75) and the other group consisting of patients who had another indication for MIMVS (non-IE group: n = 862). Patients were observed for 30 postoperative days. Data were retrospectively reviewed and collected from January 2011 to September 2023. Results: Patients from the IE group were younger (60 vs. 68 years; p < 0.001) and had a higher preoperative history of stroke (26% vs. 6%; p < 0.001) with neurological symptoms (26% vs. 9%; p < 0.001). No difference was seen in overall surgery time (211 vs. 206 min; p = 0.71), time on cardiopulmonary bypass (137 vs. 137 min; p = 0.42) and aortic clamping time (76 vs. 78 min; p = 0.42). Concerning postoperative data, the IE group had a higher requirement of erythrocyte transfusion (2 vs. 0; p = 0.041). But no difference was seen in the need for a mitral valve redo procedure, bleeding, postoperative stroke, cerebral bleeding, new-onset dialysis, overall intubation time, sepsis, pacemaker implantation, wound healing disorders and 30-day mortality. Conclusions: Minimally invasive mitral valve surgery in patients with mitral valve endocarditis is feasible and safe. Infective endocarditis should not be considered as a contraindication for MIMVS.

Rapid deployment aortic valve implantation in complex patients with infective endocarditis or aortic valve insufficiency

BackgroundNew prosthetic valves and surgical approaches that shorten operation time and improve the outcome of patients with aortic valve (AV) infective endocarditis (IE) and AV insufficiency (AVI) are crucial. The aim of this study was to evaluate the outcome of patients with AV IE or AVI treated with the EDWARDS INTUITY Rapid-Deployment AV prosthesis for this off-label indication.MethodsThis single-centre retrospective study analyzed data from patients who underwent AV replacement with the EDWARDS INTUITY Rapid-Deployment AV prosthesis for AV IE or regurgitation. (n = 8 for IE and n = 6 for AVI).ResultsHeart-lung machine times were significantly shorter in the AVI group (111.3 ± 20.7 min) compared to the IE group (171.9 ± 52.4 min) (p = 0.02). Aortic cross-clamp followed a similar trend (73.7 ± 9.9 min for AVI vs. 113.4 ± 35.6 min for IE) (p = 0.02). The length of ICU stay was also shorter in the AVI group (3.8 ± 2.6 days) compared to the IE group (16.9 ± 8.9 days) (p = 0.005). Postoperative echocardiography revealed no paravalvular leakage or significant valvular dysfunction in any patient. One patient died postoperatively from aspiration pneumonia.ConclusionThe INTUITY valve demonstrates as a safe option for complex AV IE and AVI surgery. Further prospective studies with larger patient cohorts are necessary to confirm these findings and explore the long-term benefits of this approach.

Comparative analysis of del Nido cardioplegia versus blood cardioplegia in isolate coronary artery bypass grafting

BackgroundThis study examined the efficacy of del Nido cardioplegia compared with traditional blood cardioplegia in adult cardiac surgery for isolated coronary artery bypass grafting by evaluating the early postoperative outcomes.MethodsA total of 119 patients who underwent isolated conventional coronary artery bypass grafting were enrolled and divided into two groups (del Nido cardioplegia group [n = 36] and blood cardioplegia group [n = 50]) based on the type of cardioplegia used. This study compared the preoperative characteristics, intraoperative data, and early postoperative outcomes. Further subgroup analyses were conducted for high-risk patient groups.ResultsThe 30-day mortality and morbidity rates were not significantly different between groups. The del Nido cardioplegia group exhibited advantageous myocardial protection outcomes, demonstrated by a significantly smaller rise in Troponin I levels post-surgery (2.8 [-0.4; 4.2] vs. 4.5 [2.9; 7.4] ng/mL, p = 0.004) and fewer defibrillation attempts during weaning off of cardiopulmonary bypass (0.0 ± 0.2 vs. 0.4 ± 1.1 times, p = 0.011) when compared to the blood cardioplegia group. Additionally, the del Nido group achieved a reduction in surgery duration, as evidenced by the reduced aortic cross-clamping time (64.0 [55.5; 75.5] vs. 77.5 [65.0; 91.0] min, p = 0.001) and total operative time (287.5 [270.0; 305.0] vs. 315.0 [285.0; 365.0] min, p = 0.008). Subgroup analyses consistently demonstrated that the del Nido cardioplegia group had a significantly smaller postoperative increase in Troponin I levels across all subgroups (p < 0.05).Conclusionsdel Nido cardioplegia provided myocardial protection and favorable early postoperative outcomes compared to blood cardioplegia, making it a viable option for conventional coronary artery bypass grafting. Establishing a consensus on the protocol for Del Nido cardioplegia administration in adult surgeries is needed.

Effects of Fibrinogen Concentrate Supplementation on Postoperative Bleeding in Infants Undergoing Complex Cardiac Surgery.

The use of allogeneic blood products to restore hemostasis during pediatric cardiac surgery is associated with major risks. Consequently, there has been a growing interest in new patient blood management strategies, such as those based on the use of fibrinogen concentrate (FC). Accumulating evidence has shown FC supplementation to be safe and effective. Nevertheless, no guidelines are available on using FC in the pediatric setting, and few objective evaluations have been provided in clinical practice. The endpoint of this monocenterretrospective study was the hemostatic effect of additional FC in infants undergoing complex cardiac surgery with cardiopulmonary bypassto manage persistent clinically relevant bleeding. After weaning from cardiopulmonary bypass and after protamine administration, patients were transfused with conventional allogeneic products such as packed red blood cells, fresh frozen plasma (FFP), and platelets. In the case of redo surgery, according to the institutional protocol, patients also received tranexamic acid. In case of clinically persistent relevant bleeding, according to the anesthesiologist's judgment and thromboelastography, patients received FC supplementation (group with FC) or further FFP transfusions without receiving FC supplementation (group without FC). The primary endpoint was the hemostatic effects of FC. Secondary endpoints were the functional hypofibrinogenemia threshold value (expressed as maximum amplitude fibrinogen, MA-Fib) and postoperative MA-Fib, fibrinogenemia, intraoperative transfusions, and adverse events (AEs). In total, 139 patients who underwent cardiac surgery with CPB and aged less than 2 years were enrolled: 70 patients received allogeneic blood products and FC supplementation (group FC); 69 patients received allogeneic products without FC supplementation (group without FC). Patients that received FC supplementation were characterized by a significantly longer time of extracorporeal circulation (p < 0.001) and aortic cross-clamping (p < 0.001), a significantly lower minimum temperature (p = 0.011), increased use of concentrated prothrombin complex (p = 0.016) and tranexamic acid (p = 0.010), and a significantly higher amount of packed red blood cells, platelets (p < 0.001) and fresh frozen plasma (p = 0.03). Postoperative bleeding and severe bleeding were not statistically different between patients treated with FC and those not treated with FC supplementation (p = 0.786 and p = 0.695, respectively); after adjustment, a trend toward reduced bleeding can be observed with FC (p = 0.064). Overall, 88% of patients with severe bleeding had MA-Fib < 10 mm; a moderate association between severe bleeding and MA-Fib (odds ratio 1.7, 95% CI 0.5-6.5, p = 0.425) was found. Increased MA-Fib and postoperative fibrinogen were higher in the FC group (p = 0.003 and p < 0.001, respectively) than in FFP. AEs in the FC group were comparable to those observed in less complicated surgeries. Our results suggest a potential role of FC in complex surgery in maintaining postoperative bleeding at a level comparable to less complicated surgical procedures and favoring the increase in postoperative MA-Fib and fibrinogen.

The absolute lactate levels versus clearance for prognostication of post-cardiotomy patients on veno-arterial ECMO.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving procedure for supporting patients with cardiogenic shock after cardiac surgery. This work aimed to analyse the impact of changes in blood lactate levels on the survival of patients on post-cardiotomy ECMO (PC-ECMO) and whether lactate clearance (LC) performs better than absolute lactate levels. We retrospectively analysed the data of adult patients who received PC-ECMO at our centre between 2016 and 2022. The primary outcome was the in-hospital mortality rate. Arterial lactate levels were measured at ECMO initiation, peak and 12 and 24h after VA-ECMO support. LC was calculated at 12 and 24h. Out of 2368 patients who received cardiac surgeries, 152 (median age, 48years; 57.9% of them were men) received PC-ECMO. Of them, 48 (31.6%) survived and were discharged, while 104 (68.4%) died during the index hospitalization. Non-survivors had higher frequencies of atrial fibrillation (41.35% vs. 12.5%, P<0.001), chronic kidney disease (26.9% vs. 6.3%, P=0.004), prolonged cardiopulmonary bypass (237 vs. 192min, P=0.016) and aortic cross-clamping times (160 vs. 124min, P=0.04) than survivors. Non-survivors had a significantly higher median Sequential Organ Failure Assessment (SOFA) score at ECMO initiation (13.5 vs. 9, P<0.001) and a lower median Survival After Veno-arterial ECMO (SAVE) score (-3 vs. 3, P<0.001) with higher SAVE classes (P<0.001) than survivors. After 12h of VA-ECMO support, the blood lactate level was negatively correlated with LC in survivors (r=-0.755, P<0.001) and non-survivors (r=-0.601, P<0.001). After 24h, the same negative correlation was identified between survivors (r=-0.764, P<0.001) and non-survivors (r=-0.847, P<0.001). Blood lactate levels measured at 12h to determine hospital mortality [>8.2mmol/L, area under the receiver operating characteristic curve (AUROC): 0.868] and 24h (>2.6mmol/L, AUROC: 0.896) had the best performance, followed by LC-T12 (<21.94%, AUROC: 0.807), LC-T24 (<40.3%, AUROC: 0.839) and peak blood lactate (>14.35mmol/L, AUROC: 0.828). The initial pre-ECMO blood lactate (>6.25mmol/L, AUROC: 0.731) had an acceptable ability to discriminate mortality but was less than the following measurements and clearance. Kaplan-Meier curves demonstrated that LC of <21.94% at T12h and <40.3% at T24h was associated with decreased survival (log-rank P<0.001). Cox proportional hazards regression analysis for mortality revealed that LC of <21.94% at T12h had an adjusted hazard ratio (HR) of 2.73 [95% confidence interval (CI): 1.64-5.762, P<0.001] and LC of <40.3% at T24h had an adjusted HR of 1.98 (95% CI: 1.46-4.173, P<0.001). The predictors of hospital mortality after PC-ECMO were the lactate level at 12h [odds ratio (OR): 1.67, 95% CI: 1.121-2.181, P=0.001], initial SOFA score (OR: 1.593, 95% CI: 1.15-2.73, P<0.001), initial blood lactate (OR: 1.21, 95% CI: 1.016-1.721, P=0.032) and atrial fibrillation (OR: 6.17, 95% CI: 2.37-57.214, P=0.003). Bivariate models using lactate levels and clearance at the same points revealed that blood lactate levels performed better than the clearance percentage. Serial measurements of arterial blood lactate and LC help in obtaining early prognostic guidance in adult patients supported by VA-ECMO after cardiac surgery. Absolute lactate levels, compared with LC at the same time points, demonstrated better performance in differentiating mortality.

Controlled Reversible Visceral Arterial Ischemia, Venous Congestion and Combined Malperfusion via Midline Laparotomy in Rats.

Besides sepsis and malignancy, malperfusion is the third leading cause of tissue degradation and a major pathomechanism for various medical and surgical conditions. Despite significant developments such as bypass surgery, endovascular procedures, extracorporeal membrane oxygenation, and artificial blood substitutes, tissue malperfusion, especially of visceral organs, remains a pressing issue in patient care. The demand for further research on biomedical processes and possible interventions is high. Valid biological models are of utmost importance in enabling this kind of research. Due to the multifactorial aspects of tissue perfusion research, which include not only cell biology but also vascular microanatomy and rheology, an appropriate model requires a degree of biological complexity that only an animal model can provide, rendering rodents the obvious model of choice. Tissue malperfusion can be differentiated into three distinct conditions: (1) isolated arterial ischemia, (2) isolated venous congestion, and (3) combined malperfusion. This article presents a detailed step-by-step protocol for the controlled and reversible induction of these three types of visceral malperfusion via midline laparotomy and clamping of the abdominal aorta and caval vein in rats, underscoring the significance of precise surgical methodology to guarantee uniform and dependable results. Prime examples of possible applications of this model include the development and validation of innovative intraoperative imaging modalities, such as Hyperspectral Imaging (HSI), to objectively visualize and differentiate malperfusion of gastrointestinal, gynecological, and urological organs.

Successful open surgical treatment for persistent type II endoleak following thoracic endovascular aortic repair: a case report

BackgroundThe occurrence of type II endoleaks after endovascular repair of aortic aneurysm has gradually gained increasing attention. We present a case of a patient with an expanding aneurysm after thoracic endovascular aortic repair (TEVAR) for a type II endoleak, in which successful direct ligations of the intercostal artery were performed using a sac incision without cardiopulmonary bypass (CPB) or graft replacement.Case presentationA 62-year-old male patient, previously treated with TEVAR for a descending thoracic aortic aneurysm, presented with ongoing chest discomfort. Based on the diagnosis of a growing aneurysm and type II endoleak, the patient was prepared for CPB and aortic cross-clamping, as a precautions against the possibility of a type I endoleak. A longitudinal opening of the thoracic aortic aneurysm sac was performed following left thoracotomy. Visual confirmation identified the T5 level intercostal artery as the source of the endoleak, and after confirming the absence of a type I endoleak, multiple ligations were applied to the intercostal artery. Follow-up computed tomography confirmed the absence of endoleaks or sac growth.ConclusionIn a case involving TEVAR for a thoracic aortic aneurysm, open suture ligations were used to treat type II endoleaks without having to resort to CPB, resulting in successful outcomes.

789 Alternative Operative Procedures in Repeat Mitral Valve Surgery: A Systematic Review and Meta-Analysis

Abstract Aim Median sternotomy remains the gold standard redo mitral valve surgery. However, this can be physically demanding for patients and affect mortality and morbidity. Alternative procedures such as the right anterolateral mini thoracotomy have been explored to mitigate the risks of a re-sternotomy. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini thoracotomy (MT) in mitral valve surgery. Method A systematic, electronic search was performed according to PRISMA guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via an MS approach. Results Twelve studies were identified, enrolling 4,514 patients. Length of hospital stay (MD= -3.71, 95% CI[-4.92, -2.49]), 30-day mortality(OR = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure(OR=0.38, 95% CI [0.22, 0.65]) were statistically significant in favour of the MT approach. Infection rates(OR=0.56, 95% CI[0.25, 1.21]) and length of ICU stay (MD= -0.55, 95% CI[-1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time(MD=-2.33, 95% CI [-8.15, 3.50]), aortic cross-clamp time MD= -1.67, 95% CI[-17.07, 13.76]), and rates of stroke(OR=1.03, 95% CI[0.55, 1.92]). Conclusions Right MT offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis and hence, can be considered a safe alternative. This review calls for robust trials in the field to further strengthen the evidence.

997 Ascending Aorta Pseudoaneurysm 40 Years Following Surgical Atrial Septal Defect Repair

Abstract Background Ascending aorta pseudoaneurysm is a rare postoperative complication of cardiac surgery. It is often attributed to infection and dehiscence at sites of aortotomy, cannulation, cross-clamp placement, and proximal coronary anastomoses. Mortality risk is 29-46% and this requires prompt surgical intervention. Case summary A 48-year-old woman who underwent atrial septal defect repair at 8 years of age, presented with chest pain radiating to the right shoulder and dyspnoea. Cardiac-gated CT angiography demonstrated a 21mm pseudoaneurysm arising anteriorly from the proximal ascending aorta, 6mm above the right coronary artery ostium, likely the site of previous cardioplegia cannula. There was active blood flow from the aorta into the pseudoaneurysm sac. It was heavily calcified, apart from a thinned irregular wall inferiorly, from which rupture was imminent. She underwent emergency surgery. Using femoro-femoral cardiopulmonary bypass, the chest was safely re-entered. Under mild hypothermia and distal ascending aorta cross-clamping, the pseudoaneurysm was resected and aorta repaired using a Gelweave patch. The patient recovered uneventfully and was discharged home after one week. Discussion Accurate imaging, primarily via cardiac-gated CT angiography, is crucial for diagnosis and surgical planning in patients presenting with aortic pseudoaneurysm, particularly those close to the aortic valve and coronary arteries. Operative strategy, including need for deep hypothermic circulatory arrest and/or graft replacement of aorta, depends on pseudoaneurysm anatomy. It is recommended that preventative measures are taken during the primary operation, inserting the cardioplegia cannula tip through full-thickness purse-strings and/or addition of separate oversewing sutures after decannulation. Alternative techniques of pseudoaneurysm repair are also discussed.

A nomogram for predicting low cardiac output syndrome in older patients undergoing acute type A aortic dissection surgery.

Low cardiac output syndrome (LCOS) is a dangerous postoperative complication in patients with acute type A aortic dissection (ATAAD). This study aims to develop and evaluate a nomogram model that can reliably identify risk variables for postoperative LCOS in elderly patients suffering from ATAAD. In this retrospective study, a total of 310 elderly patients with ATAAD admitted to Fujian Medical University Union Hospital were included and categorized into the LCOS and non-LCOS groups. Stepwise logistic regression was used to analyze independent predictors of LCOS, and a nomogram was constructed. The best clinical decision points were found using decision analysis and a clinical impact curve. Postoperative LCOS occurred in 22 (7.1%) of elderly patients with ATAAD. Independent risk factors for postoperative LCOS were age, smoking history, aortic cross-clamp (ACC), coronary heart disease (CHD), and preoperative shock. The nomogram constructed based on the identified risk factors showed good performance. Our results suggest that preventive treatment can be administered when needed when the risk of LCOS in older patients with ATAAD after surgery is >60%. This study contributes to developing a methodology that may improve therapeutic decision-making in older patients and provides insights for assessing the risk of LCOS.

Endovascular Aortic Balloon control versus open Aortic cross Clamp in open ruptured abdominal Aortic aneurysm repair

To determine 30-day mortality of endovascular aortic balloon control compared to open aortic cross clamp in open surgical repair of ruptured abdominal aortic aneurysms. A retrospective cohort review was performed of all adult patients who underwent open surgical repair of an infrarenal rAAA between 2001 and 2018 at a single tertiary care center. 174 patients were identified, of which 21 patients received endovascular aortic balloon control and 137 patients received an open aortic cross clamp. Primary outcome was 30-day mortality. Two-variable multivariate logistic regression was adjusted for preoperative blood pressure and age. Endovascular aortic balloon control was non-significantly associated with lower mortality (adjusted OR = 0.75 [95%CI 0.24-2.38], p=0.63), and when placed under local anesthesia showed a trend towards improved mortality (adjusted OR = 0.34 [95%CI 0.06-1.77], p=0.19). Balloon placement under general anesthesia was non-significantly associated with worse mortality (adjusted OR = 2.50 [95%CI 0.35-9.13], p=0.46). There is no significant different in mortality with the use of endovascular aortic balloon control in rAAA patients undergoing open surgical repair, and it may be considered as an alternative approach to open aortic cross clamp in properly selected patients.