Cross-clamping Research Articles

Hybrid Arch Aneurysm Repair With Ascending Aortic Wrap and TEVAR.

Management of patients with large aortic arch aneurysms who are considered high risk for frozen elephant trunk technique have been challenging, especially when they have a dilated ascending aorta (AA) that precludes total endovascular branched repair (arch BEVAR). A viable option in our armamentarium is wrapping of the AA (AW), and zone 0 Ishimaru TEVAR. Retrospective analysis of our aortic database from 2013 to 2024 to select high-risk patients with aortic arch aneurysm that had an AW and TEVAR. We performed CTA analysis before and after wrapping and TEVAR, and last available CTA. The primary end points were 30-day mortality and stroke. A total of 12 patients had AA wrap and TEVAR, with supra-aortic vessels (SAVs) debranching (open or endovascular). In 9 patients, the indication for treatment was a large arch atherosclerotic aneurysm, and in 3 patients a dissecting arch aneurysm depicted during follow-up of AW initially performed for acute type A dissection (51.5 months on average between the wrap and the TEVAR). Average age was 72.9 years. Ascending aorta wrap and TEVAR were performed concomitantly in 3/12 patients, including 2 patients with rupture. It was staged in the other 9 patients. The average diameter of the AA pre-wrap was 47.7 (41.3-57), and post-wrap 35.6 (31.9-43) mm. The wrap provided an average seal length of 68.5 (38.4-97.4) mm. A total of 34 SAV were successfully debranched. No type 1 or 3 endoleaks were depicted on completion angiogram. Within the first 30 days, no strokes were diagnosed, and 1 patient with Horton disease died of cardiac arrest on postoperative day 7. Three patients required early reinterventions, including redosternotomy in 2 patients. Mean follow-up (FU) was 28 months (1-75). During FU, 1 patient developed a left vertebral artery steal phenomenon requiring a carotid subclavian bypass, and another patient died of an unknown cause. Ascending aorta wrap technique with debranching of the SAVs and zone 0 TEVAR might be a good option in patients at high risk for open replacement of the AA and with unfavorable proximal seal zone for a total endovascular repair. In the current study, we describe the treatment of aortic arch aneurysms in patients considered at high risk for open replacement of the aortic arch and also not candidate for complete endovascular arch repair (arch BEVAR). Ascending aorta wrap with surgical or endovascular debranching of SAVs and zone 0 TEVAR was performed in 12 patients with favorable outcomes. It should thus be considered a treatment option in this subset of fragile patients with unfavorable proximal seal zone for total endovascular repair. This technique does not require cardiopulmonary bypass (CPB) support, neither aortic cross-clamping.

Preoperative Non-Invasive Mapping for Targeted Concomitant Surgical Ablation of Non-Paroxysmal Atrial Fibrillation (PreMap Study)

Background/Objectives: The present study introduces our targeted approach for concomitant surgical ablation (CSA) using non-invasive phase mapping (NIPM) and describes its effectiveness regarding freedom from atrial fibrillation (AF). Methods: This retrospective study included cardiac surgical patients undergoing preoperative NIPM for CSA guidance. The primary outcome was freedom from AF six months after surgery. Key secondary outcomes were freedom from AF at hospital discharge and three months, frequency of biatrial ablation, feasibility and safety, the rate of CSA, complications, and levels of biomarkers. The control group consisted of patients undergoing CSA without NIPM. Results: Forty-four patients (Control: n = 31/NIPM: n = 13) were included. The NIPM group was younger (64 vs. 71 years [p = 0.044]), had a lower EuroSCORE II (2.6 vs. 3.4 [p = 0.041]), and a smaller left atrial size (46 mm vs. 54 mm [p = 0.025]). Surgery duration was longer in the NIPM group (285 vs. 230 min [p = 0.037]) with similar aortic cross-clamp times. Preoperative NIPM resulted in an effective frequency of CSA of 93%. CSA was more extensive in the NIPM group, with biatrial ablation performed in 54% vs. 26% of patients (p = 0.09). Conclusions: Routine preoperative NIPM in patients with non-paroxysmal atrial fibrillation might aid in increasing the number of patients receiving concomitant surgical ablation and developing a personalized CSA approach for every patient.

Impact of Preventive Intravenous Amiodarone on Reperfusion Ventricular Fibrillation in Patients With Left Ventricular Hypertrophy Undergoing Open-Heart Surgery: Randomized Controlled Clinical Trial.

Ventricular fibrillation (VF) is a vicious arrhythmia usually generated after removal of the aortic cross-clamp (ACC) in patients undergoing open-heart surgery, which could damage cardiomyocytes, especially in patients with left ventricular hypertrophy (LVH). Amiodarone has the prominent properties of converting VF and restoring sinus rhythm. However, few studies concentrated on the effect of amiodarone before ACC release on reducing VF in patients with LVH. The study was designed to explore the effectiveness of prophylactic intravenous amiodarone in reducing VF after the release of the ACC in patients with LVH. A total of 54 patients with LVH scheduled for open-heart surgery were enrolled and randomly divided (1:1) into 2 groups-group A (amiodarone group) and group P (placebo-controlled group). Thirty minutes before removal of the ACC, the trial drugs were administered intravenously. In group A, 150 mg of amiodarone was pumped in 15 minutes. In group P, the same volume of normal saline was pumped in 15 minutes. The primary outcome was the incidence of VF 10 minutes after removal of the ACC. The incidence of VF was lower in group A than in group P (30% vs 70%, P=.003). The duration of VF, the number of defibrillations, and the defibrillation energy were also lower in group A than in group P (P<.001, P=.002, and P=.002, respectively). After the end of cardiopulmonary bypass, the heart rate and mean arterial pressure were lower in group A, and the mean pulmonary arterial pressure and the dose of vasoactive drugs were higher than those in group P (P<.001, P<.001, P=.04, and P=.02, respectively). However, there were no significant differences in the use of vasoactive-inotropic agents and hemodynamic status between the 2 groups before the end of surgery. In patients with LVH who undergo open-heart surgery, amiodarone can be safely used to reduce the incidence of VF, the duration of VF, the frequency of defibrillation, and the energy of defibrillation after ACC removal.

Unsupervised machine learning model for phenogroup-based stratification in acute type A aortic dissection to identify postoperative acute gastrointestinal injury

ObjectiveWe aimed to explore the application value of unsupervised machine learning in identifying acute gastrointestinal injury (AGI) after extracorporeal circulation for acute type A aortic dissection (ATAAD).MethodsPatients who underwent extracorporeal circulation for ATAAD at the First Hospital of Lanzhou University from January 2016 to January 2021 were included. Unsupervised machine learning algorithm was used to stratify patients into different phenogroups according to the similarity of their clinical features and laboratory test results. The differences in the incidence of perioperative AGI and other adverse events among different phenogroups were compared. Logistic regression was used to analyze the high-risk factors for AGI in each phenogroups and random forest (RF) algorithms were used to construct diagnostic models for AGI in different phenogroups.ResultsA total of 188 patients were included, with 166 males and 22 females. Unsupervised Machine Learning stratified patients into three phenogroups (phenogroup A, B, and C). Compared with other phenogroups, phenogroup B patients were older (P &amp;lt; 0.01), had higher preoperative lactate and D-dimer levels, and had the highest incidence of AGI (52.5%, P &amp;lt; 0.001) and in-hospital mortality (18.6%, P = 0.002). The random forest model showed that the top four risk factors for AGI in phenogroup B were cardiopulmonary bypass time, operation time, aortic clamping time, and ventilator time, which were significantly different from other phenogroups. The areas under the curve (AUCs) for diagnosing postoperative AGI of phenogroup A, B, and C were 0.943 (0.854–0.992), 0.990 (0.966–1.000), and 0.964 (0.899–0.997) using the RF model, respectively.ConclusionPhenogroup stratification based on unsupervised learning can accurately identify high-risk populations for postoperative AGI in ATAAD, providing a new approach for implementing individualized preventive and therapeutic measures in clinical practice.

OFF-PUMP CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH CORONARY ARTERY DISEASE AND CONCOMITANT MITRAL VALVE REGURGITATION

HighlightsThe review presents a retrospective analysis of data of patients who underwent combined coronary artery bypass grafting and mitral valve repair/replacement.The authors comparatively assessed outcomes of off-pump coronary artery bypass grafting (OPCABG) and on-pump CABG (ONCABG) in patients with combined valvular pathology. AbstractAim. To evaluate the benefits of off-pump coronary artery bypass grafting (OPCABG) in patients with coronary artery disease and concomitant mitral valve (MV) regurgitation.Methods. The study included 50 patients with coronary artery disease and concomitant MV disease who underwent simultaneous CABG and correction of MV regurgitation. Patients were divided into 2 groups: group 1 (n = 26) included patiens with on-pump CABG (ONCABG), group 2 (n = 24) included patiens with OPCABG.Results. In the OPCABG group there was shorter aortic cross-clamping time (85,5 [71,25; 105,25] vs 119 [99,25; 132,25] min, compared with the ONCABG group, p &lt; 0,05), shorter duration of CPB (136,5 [119,25; 158,5] vs 168,5 [142,75; 186,25] min, p &lt; 0,05), and overall duration of the operation (292,5 [252,5; 360] vs 340 [287,5; 385] min, respectively, p = 0,15). Moreover, in this group there was a lower need for transfusion of blood and its components: freshly frozen plasma (2 [2; 3] vs 3 [3; 3], p &lt; 0,05), RBC mass (2 [1; 2] vs 2 [2; 2], respectively, p = 0,4), and lower number of bed-days during hospital stay (20 [13,5; 26,25] vs 23,5 [17,5; 26] days, p &lt; 0,05).Conclusions. Off-pump CABG in patients with combined valvular pathology is a safe and reproducible technique that provides shorter aortic cross-clamping time, on-pump time and operation duration. The need for blood transfusion and the length of hospital stay are reduced as well.

Effect of del Nido cardioplegia in patients with reduced left ventricular ejection fraction: A meta-analysis.

Research on the safety and efficacy of del Nido cardioplegia in adult patients with reduced left ventricular ejection fraction (LVEF) is limited. We evaluated the effect of del Nido cardioplegia on early outcomes of cardiac surgery in this cohort. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched through August 2024 to conduct a meta-analysis comparing del Nido to other cardioplegia in adult patients with reduced LVEF (≤50%). Primary endpoint was early mortality, and secondary endpoints included morbidities, aortic cross-clamp time and postoperative LVEF before discharge. A random-effect model was used to estimate the pooled effect size. Seven studies met our eligibility criteria, including three propensity score-matched studies with a total of 1160 patients. Conventional blood cardioplegia was used exclusively as a control solution in the included studies. The incidence of early mortality was similar between the del Nido and control groups, with a pooled odds ratio of 0.94 [95% confidence interval: 0.52; 1.71] (p = .822). Postoperative stroke (p = .680), renal failure (p = .832), atrial fibrillation (p = .412), and aortic cross-clamp time (p = .153) were also comparable between the two groups. Postoperative LVEF was significantly higher in the del Nido group compared to the control group, with a standardized mean difference of 0.52 [95% confidence interval: 0.07; 0.96] (p = .034). In adult patients with reduced LVEF undergoing cardiac surgery, del Nido cardioplegia provides comparable mortality and morbidity rates compared to conventional blood cardioplegic solutions, with the potential to offer protective effects on myocardial function.

Myocardial Protection Using Antegrade Cardioplegia Alone Compared to Antegrade Combined with Vein Cardioplegia in On-Pump Coronary Artery Bypass Graft Surgery

Cardioplegia is an integral component of myocardial protection. Standard delivery of cardioplegia includes antegrade and retrograde method. Retrograde technique may cause injury to the coronary sinus and inadequate right ventricular protection while antegrade alone may be inadequate especially delivery of cardioplegia through very stenotic vessels. Therefore, in this study we compare myocardial protection using antegrade cardioplegia alone compared to combination of antegrade and vein cardioplegia in on pump coronary artery bypass graft surgery. This is a cross sectional retrospective study. Two groups of patients (antegrade combined with vein cardioplegia-study group and antegrade cardioplegia alone- control group) were studied. The study group consists of 42 patients while the control group consists of 39 patients. Study population are patients aged between 30-80 years old between 1 January 2019 and 30 April 2023. Intraoperative characteristics such as cardiopulmonary bypass time, aortic cross clamp time, cardioplegia volume, number of post-operative inotropes, ventricular tachycardia and fibrillation after aortic unclamping and postoperative characteristics such as hospital stay, ICU stay, mortality, intra-aortic balloon pump insertion, chest reopen for bleeding and postoperative atrial fibrillation were compared. The results of this study showed that cardiopulmonary bypass time, hospital stay, mortality, postoperative IABP insertion and postoperative arrhythmia rate for both groups were similar, however not statistically significant. The study group required less inotropes before transfer to ICU. (2.83 VS 3.10, P=0.04). The primary finding of this study shows that there is no difference in terms of myocardial protection with antegrade combined with vein cardioplegia as compared antegrade cardioplegia alone.

The cardioprotective effects of HTK solution and conventional blood cardioplegia in patients with atrial fibrillation undergoing valvular replacement and Cox maze III procedure.

The study was to assess the myocardial protection effects of the histidine-tryptophan-ketoglutarate (HTK) solution and the 4:1 blood cardioplegia (BC) in patients with atrial fibrillation (AF) who were subjected to valvular replacement concomitant with the Cox maze III surgery. A cohort of 148 individuals afflicted with AF, who received valve replacement surgery in conjunction with the Cox maze III procedure at our clinic within the period extending from 2015 to 2023, were enrolled. Subsequent to adjustment by propensity score matching (PSM), the patients were categorized into two distinct groups: the HTK group and the BC group. The primary end points assessed inotropic support requirements, complications, troponin trend, mechanical ventilation time and the intensive care unit stay. Arrhythmias, aortic cross-clamp and cardiopulmonary bypass times, and other clinical perioperative variables were considered as secondary end points. No substantive disparities were observed concerning mortality rates, arrhythmias, neurological events, or renal complications. The duration of cardiopulmonary bypass and the aortic cross-clamp time did not demonstrate any marked variations between both groups, with p-values of 0.71 and 0.05, respectively. The time required for weaning from mechanical ventilation and the length of postoperative hospitalization were notably less in the group receiving HTK solution (p < 0.001 and p = 0.03, respectively). While inotropic support need was higher in the BC group (p = 0.02). Conversely, the dosage and frequency of perfusions were considerably increased in the BC group (p < 0.001 for each parameter). Within subgroups stratified by longer than 150min of aortic cross-clamping duration, those in the BC cohort had significantly elevated peaks of cardiac troponin I (cTnI) (p = 0.01), whereas individuals in the HTK group experienced less mechanical ventilation time (p = 0.002) and shorter durations of intensive care unit admission (p < 0.001). The LVEF value in the HTK group was higher compared to that in the BC group in the 3-month follow-up data (p = 0.02). Both the HTK and 4:1 blood cardioplegia could be used safely in patients with AF who were subject to valvular replacement and Cox maze III procedure. However, the utilization of HTK conferred a greater advantage in diminishing the duration of mechanical ventilation weaning and the duration of postoperative hospitalization. HTK may be a better myocardial protection in patients with long cross-clamp time. The follow-up data indicated that HTK might be superior to 4:1 blood cardioplegia in the short-medium term cardiac function.

Prolonged Time from Cross Clamp until Normothermic Machine Perfusion Start is Associated with Increased Risk of Early allograft Dysfunction Following DCD Liver Transplant

Prolonged Time from Cross Clamp until Normothermic Machine Perfusion Start is Associated with Increased Risk of Early allograft Dysfunction Following DCD Liver Transplant

Comparative analysis of clinico-metabolic profiles between St Thomas and del Nido cardioplegia solutions: A pilot study.

Cardioplegia (CP) is integral to myocardial protection during cardiac surgery. Two standard cardioplegic solutions viz. Del Nido solution (DNS) and St Thomas solution (STS) are widely used in cardiac surgeries. The DNS is a single-dose CP that offers superior myocardial protection in adults, and studies have claimed myocardial injury in STS patients. The elevated circulatory level of citric acid cycle intermediate, succinate is a metabolic hallmark of ischemia. Its rapid oxidation after reperfusion causes ischemia-reperfusion (IR) injury through mitochondrial reactive oxygen species production. Succinate has been identified as an early marker of IR injury through blood plasma/serum-based clinical metabolomics studies. The primary objective of the study was metabolomic profiling of succinate from the coronary sinus and venous blood. Two blood samples each were obtained from coronary sinus (CS) & venous reservoir from patients before the application of aortic cross-clamp and after the release of aortic cross-clamp from 22 patients divided into two groups. The blood-serum metabolic profiles were measured by 800 MHz NMR spectrometer and compared using univariate statistical analysis methods. The study also compared the two groups' cardiopulmonary bypass variables and left ventricle functions. DNS leads to increased serum levels of succinate in the coronary sinus blood after the reperfusion compared to STS. The results of our study are consistent with a previous study that found DNS administration (90minutes) increases the inflammatory response in the myocardium. NMR-based serum metabolomics revealed significantly increased circulatory succinate in coronary sinus blood of patients administered with DNS cardioplegia in comparison to STS cardioplegia. URL- https://ctri.nic.in/Clinicaltrials/login.php.

Benefit of minimally invasive extracorporeal circulation on minimally invasive aortic valve replacement through right lateral mini-thoracotomy using femoral cannulation: a propensity-matched analysis.

The objective of this study was to evaluate the impact of minimally invasive extracorporeal circulation on blood transfusion and asymptomatic brain injury in comparison to conventional extracorporeal circulation in the context of minimally invasive aortic valve replacement through right lateral mini-thoracotomy surgery. This was a retrospective observational study. Patients who underwent isolated aortic valve replacement through right lateral mini-thoracotomy surgery were divided into two groups: the minimally invasive extracorporeal circulation group and the conventional extracorporeal circulation group. Propensity matching was employed for further analysis. Of 242 patients, the minimally invasive group and conventional group comprised 166 patients and 76 patients, respectively. In the matched cohort of 71 pairs, the two groups had similar preoperative characteristics. Extracorporeal circulation time was similar between the minimally invasive and conventional groups: 113 and 115 min, respectively, as was aortic clamp time: 86 and 82 min, respectively. Estimated amount of haemodilution was lower in the minimally invasive group (16.8 vs. 18.8%, P = 0.006). Blood transfusion frequency during surgery was less than half of conventional in the minimally invasive group (12.7 vs. 31.0%, P = 0.01). There were no deaths or stroke in either group during the hospital stay. Asymptomatic brain injury rate was the same for the two groups (35.2 vs. 35.2%, P = 1.00). Minimally invasive extracorporeal circulation was associated with fewer patients requiring transfusion than conventional extracorporeal circulation without an increase of asymptomatic brain injury in minimally invasive aortic valve replacement through right lateral mini-thoracotomy surgery.

Application comparison of paediatric myocardial protection procedures in arterial switch surgery.

Reliable myocardial protection is essential for a good outcome after arterial switch operation. We evaluated 56 neonates with arterial switch operation in this retrospective study. Three types of cardioplegia were used: antegrade Custodiol® (CCC) n = 22, antegrade Custodiol® plus paediatric microplegia (mix) n = 14, and antegrade plus retrograde intermittently paediatric microplegia (blood) n = 20. We evaluated the extent of myocardial injury using troponin I, Creatine kinase (CK), CK-MB (CK in myocardial cells) and vasoactive inotrope score (VIS), immediately- and the first postoperative day, as well as outcome parameters. A statistical analysis was conducted using multiple linear regression, with adjustments made for the RACHS score and ischemia time, at a significance level of 5%. Preoperative data were comparable between the three groups. Aortic cross clamp time was significantly different between the three groups (CCC: 115 ± 26 min: mix: 162 ± 35 min: blood: 153 ± 31 min). We found significantly lower troponin I release in the blood group 14ng/mL [CI95 10; 18] versus CCC group 36ng/mL [CI95 27; 48] and versus mix group 27ng/mL [CI95 19; 38]; troponin I 24h blood group 8ng/mL [CI95 6; 11] versus CCC group 14ng/mL [CI95 10; 19]. No significant differences were found in CK, CK-MB, VIS, as well as in outcome parameters 30-day mortality, ventilation time, hospital stay or ECMO implantation. Intermittent paediatric microplegia led to a significantly lower release of troponin I, despite significantly longer ischemia times than after application of Custodiol®. Paediatric microplegia can be safely performed in neonates and also offers the advantage of miniaturization of the Cardiopulmonary bypass setup.

Association of Preoperative Oxygen Saturation and McGoon Ratio With Early Prognosis of Tetralogy of Fallot: A Propensity Score-Matched Analysis

Tetralogy of Fallot (TOF) is the most common cyanotic heart disease. This study aimed to demonstrate the effects of preoperative oxygen saturation on the early prognosis of TOF and identify risk factors associated with early complications. A cohort of 1,138 patients who were diagnosed and underwent one-stage surgical repair in this hospital were retrospectively included in this study. The cohort was divided into three groups according to preoperative oxygen saturation: group 1 (≤75%, n=275), group 2 (75%-85%, n=339), and group 3 (≥85, n=524). There were 16 early deaths (16 of 1,138) and no late deaths in this study. The total mortality rate was 1.41%, which was not significantly different among the three groups. Major adverse events (MAE)-including death, extracorporeal membrane oxygenation assistance, delayed sternal closure, and re-operation during hospitalisation-were reported in 11.81% of patients in group 1, 7.93% in group 2, and 5.61% in group 3 (p=0.008). Multivariable risk analysis showed that atrial septal defect fenestration (p=0.002), aortic cross-clamp time (p=0.027), and McGoon ratio (p=0.046) were associated with MAE. By propensity score matching, the lower McGoon ratio was significantly related to MAE. The surgical outcomes were acceptable, with low mortality and MAE rates. The McGoon ratio, not oxygen saturation, presented as a determining factor of MAE.

The Use of Arterial Blood Gases Analysis to Evaluate Lung Injury in Children with Congenital Heart Disease Disease who Undergo On-pump Cardiac Surgery

Abstract: congenital heart disease is a defect in the heart or great vessel discovered during infancy or later in life. Congenital heart disease is divided into acyanotic and cyanotic. Surgery is the main therapeutic option for any congenital heart disease. The cardiopulmonary bypass has advancements in open heart surgery. It provides circulatory and respiratory support. Aortic cross-clamp is necessary in most open heart surgeries to isolate the heart from circulation. Patients undergoing cardiac surgery on cardiopulmonary bypass often have disturbances in arterial blood gases, including partial pressure of oxygen, partial pressure of carbon dioxide, PH value, and bicarbonate. Aim of study: The study aimed to investigate the serial changes in arterial blood gases before, during, and after open heart surgery and to find the correlation between these changes and aortic cross-clamp time. Conclusion: This study finds the partial pressure of carbon dioxide is more predictive of lung injury after open heart surgery than the P/F ratio in cyanotic cases. While in acyanotic cases, the P/F ratio and partial pressure of carbon dioxide are important to determine lung injury. Also, this study finds that the prolonged cross-clamp time increases lung injury after open heart surgery.

Surgical treatment of retroperitoneal liposarcoma using the technology of endoprosthetic replacement of the abdominal aorta and left common iliac artery with an endoprosthesis

Soft tissue sarcomas are rare malignancies, accounting for approximately 1% of all malignancies in adults, with approximately 15–20% of all soft tissue sarcomas arising in the retroperitoneal space. Guidelines for the surgical treatment of retroperitoneal sarcomas are still lacking. Criteria for unresectability remain unclear, and indications and compliance with surgical treatment vary. A special focus is made on vascular resections in retroperitoneal sarcomas. Surgical intervention with resection of the main vessels in case of their involvement allows for a radical operation and naturally improves long-term results. However, only isolated cases of surgical interventions with resection of the main vessels for retroperitoneal sarcomas are described in the literature. The article describes a unique clinical case of a two-stage successful surgical treatment of a patient with retroperitoneal liposarcoma and invasion of the aorta and left common iliac artery. At the first stage, an intravascular graft stent was installed. The second stage was en bloc tumor removal, nephrectomy and left hemicolectomy, resection of the infrarenal segment of the abdominal aorta and left common iliac artery. The discussion provides an analysis of publications on the role of vascular resections in retroperitoneal sarcomas. The technique of two-stage surgical treatment using endoprosthetics of the main vessel at the first stage, compared to one-stage resection and prosthetics, used in our work has a number of advantages: no need for intraoperative prosthetics of the vessel; no clamping of the abdominal aorta and iliac arteries to form anastomoses; minimal blood loss and reduced surgery time; reduced risk of thrombosis and embolism. Taking into account the above advantages, this technique can be recommended for retroperitoneal sarcomas with invasion of the main vessels.

Implantation of a sutureless aortic valve into the ring of a mechanical valve: an extreme solution for extreme cases.

Reoperations due to dysfunction of artificial mechanical aortic valves represent a complex and high-risk surgical procedure, particularly for elderly patients. In this report, we present a case of an 81-year-old female patient where, due to structural degeneration of the mechanical valve, an emergency surgical procedure was indicated. After the removal of the valve leaflets, a sutureless aortic valve was implanted within the mechanical ring. In our case, we demonstrate that such an approach is a safe alternative for high-risk patients, who cannot undergo percutaneous procedures. By reducing the duration of cardiopulmonary bypass and aortic clamping, the surgical outcomes and complication rates can be significantly improved.

Growth Differentiation Factor 15 as a Biomarker for Risk Stratification in the Cardiothoracic Surgery Intensive Care Unit.

Growth Differentiation Factor 15 (GDF15) is an emerging biomarker that significantly increases during acute stress responses, such as infections, and is moderately elevated in chronic and inflammation-driven conditions. While evidence suggests that high levels of GDF15 in cardiac surgery are associated with worse outcomes, its utility as an evaluator of early postoperative complications remains unclear. This study aims to characterize the postoperative profile of GDF15 in patients undergoing isolated surgical aortic valve replacement, evaluating its association with short-term outcomes. Serum samples from patients undergoing cardiac surgery were collected preoperatively and at defined postoperative time points (1 h, 6 h, 12 h, 24 h, and 48 h) to measure GDF15 levels. GDF15 levels significantly increased after surgery, peaking at 6 h. A positive correlation was observed between GDF15 levels and both cardiopulmonary bypass and aortic cross-clamp times. Notably, patients who developed postoperative acute kidney injury (AKI) or required prolonged hemodynamic support had significantly higher GDF15 levels, with increased mechanical ventilation time and extended intensive care unit length of stay. Furthermore, GDF15 levels correlated with postoperative SOFA scores at 24 h after surgery. GDF15 may be a valuable biomarker for risk stratification and guiding therapeutic decisions in cardiac surgery patients. Higher GDF15 levels were significantly associated with prolonged hemodynamic support, postoperative AKI, and measures of illness severity.

The multi-center mid-term clinical outcomes of combined complete preservation of chordal structure mitral valve replacement with total anatomic complete arterial myocardial revascularization for coronary patients with moderate-to-severe or severe ischemic mitral regurgitation

Objective: To evaluate the clinical outcomes of combined complete preservation of chordal structure mitral valve replacement (C-MVR) with total anatomical arterial myocardial revascularization (TACR) in coronary patients with moderate-to-severe or severe ischemic mitral regurgitation (IMR). Methods: This is a retrospective multi-center case series study. Data were retrospectively collected from 127 patients with coronary artery disease with moderate to severe or severe IMR who received TACR with C-MVR from July 2015 to April 2024 in 13 hospitals in China. There were 90 males and 37 females, aged (56.5±10.7) years (range: 33 to 74 years). Perioperative data and follow-up data including left ventricular ejection fraction, left ventricular end-diastolic diameter, and patency rate of arterial grafts of patients were collected. Comparisons were made using paired sample t-test or χ2 test. Results: In this cohort of 127 patients, 67 underwent concurrent tricuspid valve repair. During surgery, 113 grafts of the left internal mammary artery (LIMA), 127 grafts of the left radial artery, 80 grafts of the right radial artery, and 110 grafts of the right internal mammary artery (RIMA) were harvested. The number of the distal anastomosis was 4.2±0.4 (range: 3 to 5). The aortic cross-clamp time and cardiopulmonary bypass time were (97.5±23.4) minutes (range: 90 to 161 minutes) and (145.4±19.2) minutes (range: 101 to 210 minutes), respectively. There was one operative death. Intraoperative placement of an intra-aortic balloon pump was performed in 21 patients to improve the left ventricular ejection. No sternal ischemic occurred. All patients completed follow-up, with a mean follow-up period of (64.3±7.5) months (range: 4 to 110 months). No major cerebrovascular events occurred during the follow-up period, and all patients survived. Left ventricular ejection fraction improved postoperatively (55.0%±5.3% vs. 41.0%±15.3%, t=17.23, P<0.01). The proportion of patients with New York Heart Association functional class ≤2 increased postoperatively (23.6% (30/127) vs. 87.3% (110/126), χ²=103.77, P<0.01). The proportion of patients with Canadian Cardiovascular Society Angina Classification ≤3 decreased postoperatively (4.8% (6/126) vs. 78.7% (100/127), χ²=142.19, P<0.01). The left ventricular end-diastolic diameter decreased postoperatively ((5.70±4.50) cm vs. (6.10±0.23) cm, t=12.15, P<0.01). Coronary multi-detector computed tomography angiography (MDCTA) follow-up was conducted for (60.5±11.7) months (range: 6 to 109 months) postoperatively. MDCTA confirmed the patency rates of the grafts: 96.4% (108/112) for the LIMA grafts, 88.9% (112/126) for the left radial artery grafts, 93.7% (74/79) for the right radial artery grafts, and 90.9% (100/110) for the free RIMA grafts. No significant differences in graft patency rates were observed between the arterial grafts (χ²=5.24, P=0.155). Conclusion: The results of this multi-centre study demonstrate satisfactory mid-term results of C-MVR with TACR for the treatment of coronary artery disease with moderate to severe or severe IMR.

Prolonged time from cross clamp until normothermic machine perfusion start is associated with increased risk of early allograft dysfunction following DCD liver transplant.

There is a paucity of data on the impact of cold ischemia time prior to the initiation of normothermic machine perfusion (NMP), particularly in more susceptible organs such livers from DCD donors. The present analysis aimed to investigate the impact of prolonged time from cross clamp until NMP start on early allograft dysfunction (EAD) and other peri-liver transplant (LT) outcomes. All DCD LT performed and placed on NMP at Mayo Clinic Arizona, Florida and Rochester from January 2022-March 2024 were included. The decision was made a priori to divide the population into 2 groups based on terciles: Typical Cross-clamp to On-pump time (lower 2 terciles) versus Prolonged Cross-clamp to On-pump Time (upper tercile; >2h 45.6min). 384 DCD LT undergoing NMP met the inclusion criteria. The rate of EAD was significantly higher in the Prolonged Cross-clamp to On-pump group (51.2%) compared to the Typical Cross-clamp to On-pump group (37.6%) (P=0.01). The Prolonged Cross-clamp to On-pump group also had higher rates of AKI and number of pRBCs transfused during LT. No significant difference in IC (2.0% vs. 1.5%;P=0.77) or graft survival at 12 months was seen between the Prolonged Cross-clamp to On-pump and Typical Cross-clamp to On-pump group, respectively. Following cross clamp, DCD liver grafts should be placed on the NMP pump as quickly as is safely and logistically possible. In cases where delays are unavoidable such as waiting for biopsy results or liver reallocation with another center, acceptable results can still be achieved and therefore livers with prolonged times should still be utilized.

Effect of lactate levels on extubation time in coronary artery bypass grafting surgery.

In current practice, fast-track protocols are gaining importance in patients undergoing cardiac surgery. For this purpose, besides different application techniques, biomarkers are frequently examined in the peri-operative period. We aimed to examine whether serum lactate levels at different peri-operative intervals had an effect on the extubation time. The patients were analysed in two groups according to the extubation time (early < 6 hours, and late extubation > 6 hours). Individual characteristics, co-existing diseases, blood transfusion, inotropic support, intra-aortic balloon pump, cardiopulmonary bypass time, aortic cross-clamp time, and the serial measurements of serum lactate levels were recorded. Correlations of serial measurements of lactate levels and the peri-operative variables with extubation times were analysed. No significant differences were observed between the groups in terms of co-existing diseases and individual characteristics. However, cardiopulmonary bypass, aortic cross-clamp times and all lactate levels after aortic cross-clamping were found to be significantly different (p = 0.001). A statistically significant correlation was found between the cut-off value of 1.7 for serum lactate levels after aortic-cross clamping (L2); 1.9 for levels after aortic cross-clamp removal (L3); 2.2 for levels after cardiopumonary bypass (L4); 2.1 for levels after intensive care admission (L5); 1.7 for levels after first postoperative hour in the intensive care unit (L6), and 1.8 for the difference between pre-operative levels (L0) and the peak level of lactate in the peri-operative period (ΔL) in predicting extubation time (p < 0.01). We concluded that cardiopulmonary bypass and aortic cross-clamp times, and intra-operative serum lactate levels were important in predicting early extubation after isolated coronary artery bypass graft surgery.