Cross-clamping Research Articles

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.

The safety and prognostic evaluation of subsequent aortic surgery after thoracic endovascular aortic repair: a retrospective cohort study.

Thoracic endovascular aortic repair (TEVAR) is a widely employed clinical procedure for treating various aortic pathologies. However, some patients require subsequent surgical interventions post-TEVAR, particularly due to life-threatening complications such as aortic dissection. This study aimed to evaluate the safety and prognosis associated with additional aortic surgeries following TEVAR. A retrospective analysis was conducted on 21 patients who underwent aortic surgery after TEVAR at Guangdong Provincial People's Hospital between September 2016 and August 2020. By compiling and reviewing perioperative data, we assessed surgical-related complications and survival rates. Among the 21 patients, 95.2% were male, with an average age of 53 years. Preoperative comorbidities included hypertension in 15 individuals, abdominal aortic aneurysm in one patient, and coronary heart disease in two patients. The primary complications of TEVAR were stent leakage and retrograde aortic dissection, with the latter being the predominant type in subsequent aortic surgeries. The mean duration of aortic clamping during surgery was 130.0 minutes, with a deep hypothermic circulatory arrest time of 8.5 minutes. Postoperatively, two patients suffered in-hospital mortality, one developed renal dysfunction, four required re-entry into the operating room for further treatment, and the average length of hospital stay was 20 days. Following discharge, 14.3% of patients experienced complications, with central nervous system symptoms being the most prevalent. Kaplan-Meier survival analysis indicated a 5-year survival rate of 85.7%. Aortic surgical intervention following TEVAR is a safe therapeutic approach that can improve patient prognosis. However, meticulous management of the perioperative period is crucial for reducing the risk of complications and improving survival rates. This study provides valuable insights into aortic surgery post-TEVAR, but large-scale research is needed to validate these findings.

Total aortic arch debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR) in acute non-A non-B aortic dissection

BackgroundThe surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios when thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention.Case presentationWe present a 38-year-old patient with a physically demanding lifestyle as a professional wrestler, uncontrolled hypertension due to history of medical non-adherence, and family history of aortic dissection who presented with acute non-A non-B aortic dissection. He was spared a total arch replacement by undergoing a hybrid approach of complete aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of aortic cross clamp, circulatory arrest, and hypothermic circulation.ConclusionsThis patient’s unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention that would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR.

Early and Long-Term Results of Minimally Invasive Mitral Valve Repair in Young and Middle-Aged Patients

The aim. To analyze the early and long-term results of minimally invasive mitral valve repair in young and middle-aged patients and compare the outcomes with mitral valve repairs performed through standard sternotomy. Materials and methods. From 2016 to 2021, 128 patients with mitral insufficiency were operated in the Ukrainian Children’s Cardiac Center. Exclusion criteria included patients under 18 or over 59 years old and patients with concomitant pathology of the aortic valve, aorta, and coronary arteries. Results. In the investigated group, the average duration of cardiopulmonary bypass and aortic cross-clamping time was longer than in the comparative group. However, the average duration of mechanical ventilation, average time in theintensive care unit, and average length of hospitalization were shorter in the investigated group. Patients in the investigated group less frequently required red blood cell transfusion (5.6% vs. 14.6%) and plasma transfusion (9.4% vs. 14.6%). The percentage of postoperative complications was almost half lower in the investigated group (3.6% vs. 6.6%). None of the patients in the investigated group showed a severe degree of mitral insufficiency, while two patients in the comparative group had severe mitral insufficiency. Conclusions. Minimally invasive mitral valve repair is associated with a lower percentage of postoperative complications. Early and long-term observation results indicate the high effectiveness and safety of the minimally invasive method.

Endograft Thrombosis as an Indication for Open Conversion after Endovascular Aneurysm Repair in a Multicenter Experience over 25 Years

To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The end points were as follows: 30-day mortality and major postoperative complications. Follow-up data included survival and aortic-related complications. Sixteen patients (mean age: 68.6±8.5years) were included. The median elapsed time between EVAR and OC was 26.46months (interquartile range: 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, and complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were aorto-bi-iliac grafts in 8 cases (50%), 7 aortobifemoral bypass grafts (43.8%), and 1 aortoaortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). The overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1year, 62.5% at 2years, and 41.7% at 3years. OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seems to be associated with high short-term mortality.

Primary surgical repair of tetralogy of fallot at the Uganda Heart Institute: a ten-year review of 30day mortality and morbidity

BackgroundTetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) worldwide. It accounts for 7% of CHD cases in Uganda and leads to fatal outcomes in the long term without surgery. Surgery is often delayed in developing countries like Uganda due to limited resources.ObjectiveThis study aimed to determine the early surgical outcomes of patients with TOF who underwent primary intracardiac repair at the Uganda Heart Institute (UHI) and to identify factors associated.MethodologyThis retrospective chart review evaluated outcomes of primary TOF repair patients at UHI from February 2012 to October 2022. Patient outcomes were assessed from surgery until 30 days post-operation.ResultsOut of the 104 patients who underwent primary TOF repair at UHI, records of 88 patients (84.6%) were available for review. Males accounted for 48.9% (n = 43). The median age at the time of operation was 4 years (with an interquartile range of 2.5-8.0 years), ranging from 9 months to 16 years. Genetic syndromes were present in 5/88 (5.7%). These included 2 patients with trisomy 21, 2 with Noonan’s, and 1 with 22q11.2 deletion syndrome. Early postoperative outcomes for patients included: residual ventricular septal defects in 35/88 (39.8%), right ventricular dysfunction in 33/88 (37.5%), residual pulmonary regurgitation in 27/88 (30.7%), residual right ventricular outflow tract obstruction in 27/88 (30.0%), pleural effusion in 24/88 (27.3%), arrhythmias in 24/88(27.3%), post-operative infections in 23/88(26.1%) and left ventricular systolic dysfunction in 9/88 (10.2%). Out of the children who underwent surgery after one year of age, 8% (7 children) died within the first 30 days. There was a correlation between mortality and post-operative ventilation time, cardiopulmonary bypass (CPB) time, aortic cross-clamp time, preoperative oxygen saturations, RV and LV dysfunction and the operating team.ConclusionThe most frequent outcomes after surgery were residual ventricular septal defects and right ventricular failure. In our study, the 30-day mortality rate following TOF repair was 8%. Deceased patients had lower pre-operative oxygen levels, longer CPB and cross-clamp times, longer post-operative ventilation, RV/LV dysfunction, and were more likely operated by the local team.

Robotic Mitral Valve Repair: Impact of Experience on Results and Complex Mitral Disease Treatment.

Background/Objectives: Robotically assisted mitral valve (MV) surgery is the least invasive surgical approach to the MV. The aim of the present study is to report our experience with robotically assisted MV repair, trying to define how experience could impact on postoperative results. Methods: This is a retrospective study on 144 patients who underwent robotic MV repair from November 2011 to March 2023. Patients were divided in two groups: Group 1, including 39 patients (November 2011-January 2013) operated using the Da Vinci Si system, and Group 2, including 105 patients operated (February 2020-March 2023) using the new Da Vinci Xi system. Results: Mean age was 58 ± 10 years. Increased use of external aortic clamp was observed in Group 2. A significant reduction of surgical times was observed: cardiopulmonary bypass time was 155 ± 44 min in Group 1 and 121 ± 36 min in Group 2 (p = 0.002), whereas cross-clamp time was 112 ± 25 min in Group 1 and 68 ± 39 min in Group 2 (p < 0.001). In-hospital mortality was 0.7%, and 10-year survival was 96 ± 2%. Freedom from reoperation was 100%. A higher percentage of complex and most complex MV repairs were performed in Group 2 (36% in Group 1 vs. 52% in Group 2, p = 0.001). Conclusions: Robotic-assisted MV repair is associated with excellent results. Experience is a key element to overcome the limitations of this technology. Finally, the robotic platform could improve results in difficult MV repair.

Evaluating the relationship between lactate levels during coronary artery bypass graft surgery and postoperative renal dysfunction.

Postoperative Acute renal failure related to cardiac surgery is a common complication due to cardiac surgery and is estimated to influence up to 30% of patients. Serum lactate is a famous biomarker of tissue ischemia and is regularly checked during surgery. In this retrospective observational research, the records of 395 patients undergoing CABG were examined. Patients were classified into 4 groups based on the difference between the maximum lactate level measured during surgery and its baseline level. Also creatinine and urea levels, blood sugar, hemoglobin, and hematocrit pre, postoperative were recorded. The intraoperative and postoperative use of inotropes and the durations of surgery, cardiopulmonary bypass pump, and aortic cross-clamping were also recorded. According to the results, pre, post and 24-hour postoperative blood urea nitrogen were not significantly related to intraoperative lactate changes. Also, pre and 24-hour postoperative creatinine had no significant relationship with intraoperative lactate changes, while postoperative creatinine was significantly associated with intraoperative lactate changes (P value=0.05). The duration of cardiopulmonary bypass (P value=0.02), intraoperative inotrope infusion (P value=0.03), inotrope infusion during the first six hours in ICU (P value=0.049), and receiving packed cell (P value=0.006) and receiving platelets during surgery (P value=0.04) were significantly related to intraoperative lactate changes. Furthermore, no significant relationship was observed between the duration of hospitalization in the ICU and the hospital and intraoperative lactate changes. According to the results, blood lactate level is an unreliable marker for predicting renal dysfunction postoperative.

Long-Term Outcomes of Surgical Repair of Supracardiac Total Anomalous Pulmonary Venous Connection.

The conventional surgery (CS) of supracardiac total anomalous pulmonary venous connection (TAPVC) is not always effective particularly in the setting of complex anatomy such as the mixed variety of TAPVC. This study aimed to analyze the outcomes of surgical treatment of supracardiac TAPVC and determine the optimal strategy. From December 2009 to December 2023, patients with supracardiac TAPVC undergoing surgical repair in our institution were included. The Kaplan-Meier curve was used to demonstrate the survival estimates. The Cox proportional hazard model was used to identify risk factors for death and postoperative pulmonary venous obstruction (PVO). One hundred and eighty-three patients with supracardiac TAPVC underwent surgical repair [CS group, n = 102; modified L-shaped incision technique (MLIT) group, n = 81]. There were 8 in-hospital deaths and 16 late deaths. The survival rates at 1, 5, and 10 years were 89.0%, 85.0%, and 85.0%, respectively in the whole cohort. Multivariable analysis showed that lower weight (P = 0.031), prolonged CBP time (P = 0.007), preoperative PVO (P = 0.020), and emergency surgery (P = 0.001) were incremental risk factors for death, but using the MLIT was a protective factor for death (p = 0.028). In the CS group, patients with emergency operation had worse survival than patients with elective surgery (P < 0.001). However, in the MLIT group, patients with emergency operation had comparable survival to patients with elective surgery (P = 0.332). Postoperative PVO occurred in 30 patients. Fourteen patients underwent PVO-related reintervention. In the whole cohort, freedom from postoperative PVO at 1, 5, and 10 years were 87.5%, 80.6%, and 80.6%, respectively. Patients who underwent MLIT repair had a lower incidence of postoperative PVO (P < 0.001), and PVO-related reintervention (P = 0.019). Neonates(P = 0.033), aortic cross-clamp time (P = 0.012), preoperative PVO (P = 0.002), and using the CS (P = 0.005) were associated with postoperative PVO. In terms of postoperative PVO, MLIT had a protective effect compared with CS. In the CS group, Infant and Children patients had better freedom from postoperative PVO than Neonate patients (P < 0.001). However, in the MLIT group, Neonate patients had comparable freedom from postoperative PVO to Infant and Children patients (P = 0.332). The MLIT can achieve satisfactory outcomes for supracardiac TAPVC repair. Compared with CS, the MLIT was significantly associated with decreased death, postoperative PVO, and PVO-related reintervention. It is especially significant in improving the survival rate of patients undergoing emergency surgery and reducing the incidence of postoperative PVO in neonatal patients.

Adverse Technical Events During Aortic Root Replacement

BackgroundAlthough adverse technical events during aortic root replacement (ARR) are not uncommon and are extremely challenging, there is scant literature to help surgeons prepare for such situations. We describe our experience of outstanding technical events during ARR. MethodsThis is a retrospective study of 830 consecutive ARRs at a single center from 2012 to 2022. Technical events were defined as intraoperative events that led to an unplanned cardiac procedure, need for mechanical circulatory support, or additional aortic cross-clamping. Logistic regression identified factors associated with operative mortality and technical events. ResultsTechnical events occurred in 90 patients (10.8%) and were attributed to bleeding (n = 26), nonischemic ventricular dysfunction (n = 23), residual valve disease (n = 20), myocardial ischemia (n = 19), and iatrogenic dissection (n = 2). Prior sternotomy (odds ratio [OR], 2.38; 95% CI, 1.36-4.19; P = .002) and complex aortic valve disease (OR, 3.09; 95% CI, 1.09-8.75; P = .03) were associated with technical events. Patients with technical events had higher rates of operative mortality (6.7% vs 2.3%, P = .03) and all major postoperative complications. Surgical indications of dissection (OR, 13.57; 95% CI, 4.95-37.23; P < .001) and complex aortic valve disease (OR, 14.09; 95% CI, 3.67-54.02; P < .001) but not adverse technical events (OR, 2.42; 95% CI, 0.81-7.26; P = .11) were associated with operative mortality. ConclusionsAdverse technical events occurred in 10.8% of ARRs and were associated with reoperative sternotomies. Technical events are associated with increased postoperative complications.

Partial cardiopulmonary bypass through left thoracotomy for coarctation repair in children

BackgroundA left thoracotomy approach is anatomically appropriate for childhood aortic coarctation; however, the pediatric femoral arteriovenous diameters are too small for cardiopulmonary bypass cannulation. We aimed to determine the safety of a partial cardiopulmonary bypass through the main pulmonary artery and the descending aorta in pediatric aortic coarctation repair.MethodsWe retrospectively reviewed 10 patients who underwent coarctation repair under partial main pulmonary artery-to-descending aorta cardiopulmonary bypass with a left thoracotomy as the CPB group. During the same period, 16 cases of simple coarctation of the aorta repair, with end-to-end anastomosis through a left thoracotomy without partial CPB assistance, were included as the non-CPB group to evaluate the impact of partial CPB.ResultsThe median age and weight at surgery of the CPB group were 3.1 years (range, 9 days to 17.9 years) and 14.0 (range, 2.8–40.7) kg, respectively. Indications for the partial cardiopulmonary bypass with overlap were as follows: age > 1 year (n = 7), mild aortic coarctation (n = 3), and predicted ischemic time > 30 min (n = 5). Coarctation repair using autologous tissue was performed in seven cases and graft replacement in three. The mean partial cardiopulmonary bypass time, descending aortic clamp time, and cardiopulmonary bypass flow rate were 73 ± 37 min, 57 ± 27 min, and 1.6 ± 0.2 L/min/m2, respectively. Urine output during descending aortic clamping was observed in most cases in the CPB group (mean: 9.1 ± 7.9 mL/kg/h), and the total intraoperative urine output was 3.2 ± 2.7 mL/kg/h and 1.2 ± 1.5 mL/kg/h in the CPB and non-CPB group, respectively (p = 0.020). The median ventilation time was 1 day (range, 0–15), and the intensive care unit stay duration was 4 days (range, 1–16) with no surgical deaths. No major complications, including paraplegia or recurrent coarctation, occurred postoperatively during a median observation period of 8.1 (range, 3.4–17.5) years in the CPB group. In contrast, reoperation with recurrent coarctation was observed in 2 cases in the non-CPB group (p = 0.37).ConclusionsPartial cardiopulmonary bypass through the main pulmonary artery and descending aorta via a left thoracotomy is a safe and useful option for aortic coarctation repair in children.

Experience of urgent surgical thrombolectomy of high-risk acute massive pulmonary embolism under parallel cardiopulmonary bypass: a case report

Massive acute pulmonary embolism is a rare and life-threatening condition that cardiac surgeons may encounter in their clinical practice. Although systemic thrombolysis is often prescribed in critically ill patients to improve pulmonary perfusion and reduce right ventricular afterload, surgical treatment is an objective alternative when thrombolytic therapy is ineffective or impossible. Aim. Determining the expediency of pulmonary thromboembolectomy in the case of unavailability or impossibility of systemic thrombolysis to optimize treatment protocols for patients with high-risk pulmonary embolism accompanied by hemodynamic instability. Materials and methods. We present clinical cases of patients with high-risk pulmonary embolism as determined by multispiral computed tomography with Miller index determination. In both cases, the condition of the patients upon admission was critical, due to rapidly progressing hemodynamic instability, severe pulmonary hypertension, and right ventricular failure. Results. The patients were urgently brought to the operating room with severe desaturation, bradycardia, in a state of medical sedation and with pronounced hypotension. Taking into account the patients’ severe condition and the results of the tomography, we performed emergency pulmonary thromboembolectomy using a modified surgical technique using cardiopulmonary bypass without deep hypothermia or transverse aorta clamping. Conclusions. The complete clinical remission resulting from the clinical observations described in this study demonstrates the feasibility of performing open pulmonary thromboembolectomy in combination with anticoagulant therapy in patients with high-risk pulmonary embolism accompanied by hemodynamic instability based on clinical diagnosis in specific individual cases.

Cool-Shot Technique to Protect Spinal Cord during Thoracoabdominal Aortic Replacement.

Deep hypothermia helps protect the spinal cord, but is invasive. Here, we present a method to avoid reperfusion injury by selectively circulating cold blood under high pressure to the intercostal artery during reperfusion after intercostal artery reconstruction. Of the 23 patients who underwent thoracoabdominal aortic aneurysm open repair, one died. The motor evoked potential disappeared during aortic clamping in nine patients. Six patients recovered completely from aortic clamping release, two showed recovery >50% and one achieved full recovery 3 months later. Permanent motor impairment did not occur. This method could prevent reperfusion injury and paraplegia following thoracoabdominal aortic aneurysm surgery.

Cardioprotection in cardiovascular surgery.

Since the invention of cardiopulmonary bypass, cardioprotective strategies have been investigated to mitigate ischemic injury to the heart during aortic cross-clamping and reperfusion injury with cross-clamp release. With advances in cardiac surgical and percutaneous techniques and post-operative management strategies including mechanical circulatory support, cardiac surgeons are able to operate on more complex patients. Therefore, there is a growing need for improved cardioprotective strategies to optimize outcomes in these patients. This review provides an overview of the basic principles of cardioprotection in the setting of cardiac surgery, including mechanisms of cardiac injury in the context of cardiopulmonary bypass, followed by a discussion of the specific approaches to optimizing cardioprotection in cardiac surgery, including refinements in cardiopulmonary bypass and cardioplegia, ischemic conditioning, use of specific anesthetic and pharmaceutical agents, and novel mechanical circulatory support technologies. Finally, translational strategies that investigate cardioprotection in the setting of cardiac surgery will be reviewed, with a focus on promising research in the areas of cell-based and gene therapy. Advances in this area will help cardiologists and cardiac surgeons mitigate myocardial ischemic injury, improve functional post-operative recovery, and optimize clinical outcomes in patients undergoing cardiac surgery.

Minimal learning curve for minimally invasive aortic valve replacement.

Minimally invasive aortic valve replacement (MiAVR) is an established technique for surgical aortic valve replacement (AVR). Although MiAVR was first described in 1993 and has shown good results compared to full sternotomy AVR (FSAVR) only a minority of patients undergo MiAVR. We recently started using MiAVR via an upper hemisternotomy. We aimed to examine the early results of our initial experience with this technique. We compared 55 MiAVR to a historical cohort of 142 isolated FSAVR (12.2016-12.2022). The primary outcome was in-hospital mortality. Secondary outcomes included cardiopulmonary bypass (CPB) and cross clamp times, blood product intake, in hospital morbidity, and length of ICU and hospital stay. There was no significant difference in preoperative characteristics, including age, laboratory values and co-morbidities. There was no significant difference between the groups regarding in-hospital mortality (FSAVR 3.52% vs MiAVR 1.82%). There was no significant difference in CPB time (FSAVR 103.5 min [IQR 82-119.5] vs MiAVR 107 min [92.5-120]), aortic cross-clamp time (FSAVR 81 min [66-92] vs MiAVR 90 min [73-99]), and valve size (FSAVR 23 [21-25] vs MiAVR 23 [21-25]). The incidence of intraoperative blood products transfusion was significantly lower in the MiAVR group (10.91%) compared to the FSAVR group (25.35%, P=0.03). Our findings further establish the possibility of reducing invasiveness of AVR without compromising patient safety and clinical outcomes. This is true even in the learning curve period and without requiring any significant change in the operative technique and dedicated equipment.

Accuracy of a deep learning-based algorithm for the detection of thoracic aortic calcifications in chest computed tomography and cardiovascular surgery planning.

To assess the accuracy of a deep learning-based algorithm for fully automated detection of thoracic aortic calcifications in chest computed tomography (CT) with a focus on the aortic clamping zone. We retrospectively included 100 chest CT scans from 91 patients who were examined on second- or third-generation dual-source scanners. Subsamples comprised 47 scans with an ECG-gated aortic angiography and 53 unenhanced scans. A deep learning model performed aortic landmark detection and aorta segmentation to derive eight vessel segments. Associated calcifications were detected and their volumes measured using a mean-based density thresholding. Algorithm parameters (calcium cluster size threshold, aortic mask dilatation) were varied to determine optimal performance for the upper ascending aorta that encompasses the aortic clamping zone. A binary visual rating served as a reference. Standard estimates of diagnostic accuracy and inter-rater agreement using Cohen's Kappa were calculated. Thoracic aortic calcifications were observed in 74% of patients with a prevalence of 27% to 70% by aorta segment. Using different parameter combinations, the algorithm provided binary ratings for all scans and segments. The best-performing parameter combination for the presence of calcifications in the aortic clamping zone yielded a sensitivity of 93% and a specificity of 82% with an area under the receiver operating characteristic curve of 0.874. Using these parameters, the inter-rater agreement ranged from κ 0.66 to 0.92 per segment. Fully automated segmental detection of thoracic aortic calcifications in chest CT performs with high accuracy. This includes the critical preoperative assessment of the aortic clamping zone.