Cross-clamping Research Articles

Intra- and early postoperative predictors of delirium risk in cardiac surgery: results from the prospective observational FINDERI study.

Postoperative delirium (POD) is a severe complication following cardiac surgery and is associated with increased morbidity and mortality. The impact of intra- and early postoperative factors on the occurrence of POD following cardiac surgery remains controversial. To close this gap, we investigated intra- and early postoperative factors and their predictive values for POD. We performed a prospective observational study that aimed to FIND DElirium RIsk factors (FINDERI) for patients undergoing elective cardiac surgery. POD was assessed using the Confusion Assessment Method (CAM) algorithm. Intra- and early postoperative factors were extracted from electronic medical records and reviewed by cardiac surgeons. To identify potential predictors of POD, we used univariate and multivariate logistic regression along with machine learning (ML) with tenfold cross-validation. In our study cohort of 490 patients, 106 screened positive for POD (21.6%). In the multivariate analysis, we found a positive association between POD occurrence and age (p<0.001), duration of surgery (p=0.027), combined (versus isolated) surgical procedures (p=0.024), opening of the cardiac chambers (p=0.046), and ventilation time (p<0.001). The ML-based decision tree identified a two level-algorithm including ventilation time and aortic cross-clamping time, with an AUC of 0.7116 (p=0.0002) in the validation set. In the ML-based LASSO regression analysis, we identified ventilation time, administration of erythrocyte concentrates (EC), and usage of cardiopulmonary bypass (CPB) as predictors of POD, with an AUC of 0.7407 (p<0.0001) in the validation set. The results of this analysis highlight the associations between ventilation time, aortic cross-clamping time, administration of EC, and usage of CPB and POD. Additionally, they suggest that the optimization of surgical protocols has the potential to reduce POD risk in individuals undergoing cardiac surgery.

Comparison of cold and tepid modified delnido cardioplegia on myocardial protection in open heart surgery patients

Objectives: Cardioplegia is a crucial component of myocardial protection during aortic cross-clamping and cardiopulmonary bypass. It has been reported to provide effective myocardial protection and improved clinical outcomes with enhanced surgical flow in adult cardiac procedures. This study investigates the efficacy and safety of cold-modified Del Nido cardioplegia versus tepid blood cardioplegia in adult cardiac surgery patients using Myotherm, a device mainly used in cardiac surgery to monitor and manage the myocardial temperature during surgery. Methods: After obtaining approval from the ethics committee and establishing entry criteria that included age, type of heart surgery, and absence of cardioplegic contraindications, the researchers defined exclusion criteria-such as previous heart surgery or significant comorbidities. Seventy patients were randomly divided into two groups: Group A received a cold solution at 4°C( n=35), while Group B received a tepid solution at 28°C (n=35).The amount of cardioplegia was 10 to 15 cc/kg and was injected with a pressure of 70 to 90 mm Hg in an anterograde manner. The temperature of cardioplegia was also adjusted with a Myotherm device. The day before the surgery, a written consent form was obtained from the patients, and the patients were informed about the study method. The sampling method is a double-blind clinical trial to achieve minimal bias, ensuring the reliability of the results and reducing influences on it. This study was conducted in Afshar Hospital in Yazd during 2023 and 2024. Results: There were no significant differences between the two groups in terms of the need for an intra-aortic balloon pump (p=1.0), intraoperative and postoperative inotropic support (p=0.26), and postoperative pacemaker (p=0.49). Also, there were no significant differences between the two groups in terms of troponin I level after surgery (p=0.50), left ventricular ejection fraction after discharge (p=0.34), time to return of spontaneous heart rhythm (P=0.25), cross-clamp time (P=0.30), cardiopulmonary bypass time (P=0.07), and length of stay in the ICU (P=0.21). Conclusions: The result showed that both techniques provide similar results. Although the time of cross-clamp and cardiopulmonary bypass was shorter in the group using tepid solution, these differences were not statistically significant. In other words, cold and tepid solutions are equally effective and safe to protect the myocardium, and doctors can use both types of solutions during open heart surgery.

Early Outcomes of Repeat Cardiac Surgery at a Newly Established Cardiac Center in a Developing Country

Objective: The primary objective of this study is to evaluate the early clinical outcomes of repeat cardiac surgery performed at a newly established cardiac center in a developing country. Study Design: This is prospective observational cohort study setting: This study was performed between January 2021 and July 2024 at cardiac surgery department of Peshawar Institute of Cardiology. Methods: A total of 25 consecutive patients aged 18 years or older who had any previous cardiac surgery with and without the use of cardiopulmonary bypass were included. Elective, urgent, emergent, and salvage cases were all there. Patients who had incomplete records were excluded. Our study utilized SPSS (Statistical Program of Social Science) version 20 for analysis of our dataset Results: The average cardiopulmonary bypass (CPB) time was 193.48 minutes (±72.8), while the average duration of aortic clamp time was 136.20 minutes (±73.6). Regarding complications, 16% of patients (n=4) required re-intubation, 12% (n=3) needed re-exploration, 16% (n=4) experienced renal failure, and 4% (n=1) suffered a stroke. Additionally, 16% of patients (n=4) were readmitted, and 4% (n=1) died within 30 days following surgery. Conclusion: This study showed that new cardiac centers are safe for commencing complex cases like repeat cardiac surgeries with comparable results to other established centers.

Propensity score matching analysis of valve-sparing versus aortic root replacement in type A aortic dissection patients

This study compared long-term survival and reintervention rates between Valve-Sparing Root Replacement (VSRR, n = 244) and Aortic Root Replacement (ARR, n = 499) in 743 patients undergoing Type A acute aortic dissection (AAD), given the lack of prospective comparative data. Multivariable analysis is identifying advanced age, high Body Mass Index (BMI), Marfan syndrome, severe aortic regurgitation, bicuspid aortic valve, increased aortic root diameter, and reduced aortic cross-clamp time (ACC) as significant factors associated with ARR. After Propensity Score Matching (PSM), VSRR is showing significantly higher 5-year survival rates than ARR (80.2% vs. 64.1%, P = 0.001), validated by Inverse Probability of Treatment Weighting (IPTW) analysis. Reintervention rates are being found comparable, with endocarditis more prevalent in ARR and aortic regurgitation in VSRR. Subgroup analysis indicated that patients aged less than 60 years and those with a BMI greater than 24 in the VSRR group exhibited significantly improved survival probabilities compared to the ARR group. These findings support the wider utilization of valve-sparing root replacement (VSRR) in appropriately selected patients, highlighting its potential advantages for suitable candidates.

Factors Associated with Prolonged Mechanical Ventilation in Late Repair of Tetralogy of Fallot.

Research establishing factors associated with duration of mechanical ventilation after Tetralogy of Fallot repair, is mainly based on population presenting at early infancy. There are fewer reports regarding repair after infancy, during childhood and preadolescence. To compare two groups of late TOF repair based on post-operative invasive mechanical ventilation duration and explore associations with pre-operative clinical markers of severity of right ventricular outflow tract obstruction. A single-center retrospective cohort study based on medical charts review of patients older than 12months who underwent primary complete TOF repair between 2017 and 2023. Patients younger than 12months or those who had distinct anatomical variants were excluded. Pre-operative characteristics reflecting the severity of right ventricular outflow tract obstruction were collected, including baseline oxygen saturation, the occurrence of hypercyanotic spells, maximum right ventricular outflow tract pressure gradient. Perioperative variables included repair type, cardiopulmonary bypass and aortic cross-clamp duration, and rates of residual lesions. 280 patients from 27 countries were screened; 181 remained eligible and were significantly older than previously reported. 129 (71%) were extubated early post-operatively, while 52 (29%) had a longer ventilation course. In a multivariate analysis, only baseline oxygen saturation and repair type maintained a significant association with length of mechanical ventilation. In distinctly older patients undergoing TOF repair, those with lower base line saturation undergoing a non-valve preserving repair are more likely to have a longer course of mechanical ventilation. Other clinical markers reflecting the severity of right ventricular outflow tract obstruction were not independently associated with mechanical ventilation duration.

Right ventricle-arterial coupling as a prognostic factor in patients with severe aortic stenosis who underwent surgical aortic valve replacement

Abstract Background In patients with aortic stenosis (AS), the extent of extravalvular cardiac damage has a prognostic impact. Recent studies demonstrated that the coupling between the right ventricle and the pulmonary artery assessed as the relationship between the systolic excursion of the tricuspid annulus and pulmonary artery systolic pressure (TAPSE/PSAP) was a more effective predictor of mortality than conventional echocardiographic parameters in patients undergoing trans-catheter aortic valve implantation. Purpose The study aimed to evaluate the prognostic significance of right ventricular decoupling (TAPSE/PSAP index &amp;lt;0.36 mm/mmHg) in patients with severe AS who underwent surgical aortic valve replacement (AVR). Methods This was an observational, longitudinal, and retrospective study of patients with severe AS who underwent surgical AVR between January 2016 and May 2023 in the National Institute of Cardiology Ignacio Chávez with a follow-up until December 2023. A composite of death and rehospitalization at 3 months was the endpoint. Survival analysis was performed with the generation of Kaplan Meier curves according to the TAPSE/PSAP value dichotomized at 0.36 mm/mmHg to assess survival and rehospitalization and was compared with the Log-rank statistical test. Results A total of 222 patients were included in the analysis, median age was 59 years (19-84), 36.9% were women, 27% had diabetes, 41% had arterial hypertension, and 24% had hyperlipidemia. Most patients (85%) were in NYHA functional class II. The median left ventricle ejection fraction was 58% (20-77). Patients were at low risk for surgical replacement according to EuroScore (median 1.1 [0.3-9.6) points] and Society of Thoracic Surgeons (STS) score (median 1.1 [0.04-5.8) points]; 26 patients (12%) died during follow-up. Figure 1 shows the echocardiographic characteristics, perioperative variables, and outcomes according to survival. There was no significant difference in the baseline, demographic, and clinical characteristics. Regarding echocardiographic parameters, the survival group had a higher right atrium volume [(27 (11-88) vs 22.5 (10-72) ml/m2, p=0.026] without significant differences in the size and function of the right and left ventricles, PSAP, and TAPSE/PSAP. As expected, the cardiopulmonary bypass time, aortic clamping time, blood cell transfusion, hours of intubation, and the incidence of postoperative complications were higher in the group of patients who died. There was no relation between the ventricle-arterial coupling and mortality, according to the dichotomic established value &amp;lt;0.36mmHg (Figure 2). Conclusion In the present study, the right ventricle uncoupling did not predict clinical outcomes. Our findings could be explained because the extent of extravalvular cardiac damage in the majority of these patients was in Généreux stages 0 to 2 since the median values of RV function and PSAP was normal in both groups. Figure 1 Figure 2

Beating-Heart Coronary Artery Bypass grafting (BH-CABG) in patients with End-Stage Renal Disease (ESRD): comparison of the Society of Thoracic Surgeons (STS) predicted risk with actual outcomes

BackgroundEnd-Stage Renal Disease (ESRD) is an independent risk factor in outcomes for traditional coronary artery bypass grafting (TRAD-CAB) utilizing aortic cross-clamping and cardioplegic arrest. In order to determine if Beating-Heart CABG (BH-CABG) techniques offer benefit in patients with ESRD, an analysis of the Society of Thoracic Surgeons (STS) predicted risk versus the actual outcomes was performed.MethodsBetween March 2017 - October 2023, all ESRD patients underwent BH-CABG by a single surgeon at a single institution. Patients were kept normothermic, ventilation was maintained, and intra-coronary shunts with flow-probe graft assessment were utilized during the procedure. The STS predicted risk calculator was used to compare outcomes with actual results.ResultsThere were 55 patients– 37 men and 18 women with a mean age of 61.5 years (41–77 years). Co-medical conditions consisted of the following: HTN (100%), DM (85%), Pulmonary HTN (49%), PVD (45%), CVD with CVA (18%), and COPD (9%). Fifty-one patients underwent Pump-Assisted Direct Coronary Artery Bypass Grafting (PADCAB) and four underwent Off-Pump CABG (OP-CAB). There were 16 Elective, 35 Urgent, and 4 Emergent cases. Case presentation included: 24 NSTEMI, 4 STEMI, 6 Unstable Angina, 7 CHF, 1 Cardiac Arrest, and 13 with a positive exercise stress test (EST) for renal transplant screening. The mean EF was 47% (range: 15–75%). The mean number of grafts was 2.4 (1–4) and CPB time was 78 min (34–128 min) for the PAD-CAB group. Nine of the thirteen patients (69%) listed for kidney transplant underwent the transplant, one of whom was a combined liver-kidney. There was 1 hospital mortality (1.8%) compared to a predicted 6.2%. There was 1 stroke (1.8%) compared to a predicted 3.3%. There was 1 prolonged ventilation (1.8%) compared to a predicted 20.2%. There were no return to OR and no sternal wound infections. Prolonged Lengths of Stay occurred in 3 patients (5.5%) compared to a predicted 16.9%. One-year mortality occurred in 8 patients (14.5%). The observed-to-expected outcomes was < 1 in all categories.ConclusionsThe BH-CABG appears to demonstrate superior outcomes compared to the STS predicted risk for CABG. The Beating-Heart technique may offer advantages by avoidance of aortic cross-clamping and cardioplegia, maintenance of normothermia and ventilation, as well as preservation of coronary blood flow during construction of bypass grafting.

Outcomes of RDAVR with Coronary Revascularization: 3-year Results from the German INCA Registry.

The long-term outcomes of combined rapid-deployment aortic valve replacement (RDAVR) with coronary artery bypass graft surgery (CABG) are not well explored. We report 3-year results from the INCA registry on combined RDAVR with CABG. INCA is a prospective, multicenter registry that enrolled 224 patients undergoing RDAVR with CABG at 10 cardiac institutions in Germany. Prosthetic valve hemodynamics, clinical outcomes, and quality of life (QoL) up to 3 years were assessed. The mean age of patients was 73.6 ± 6.1 years, and the mean logistic EuroSCORE was 7.8 ± 6.0%. The mean number of distal arterial and venous anastomoses was 3.13 ± 1.56, aortic cross-clamp time was 79.4 ± 24.1 minutes, cardiopulmonary bypass time was 109.6 ± 34.5 minutes, and operation time was 224.2 ± 62.7 minutes. The majority of implanted valve size was 25 mm. At baseline, 11 patients (4.9.%) had a permanent pacemaker. Postoperatively, 17 patients (7.6%) required a new pacemaker implantation (5.4% valve-related). All-cause mortality at 30 days was 2.2%, and 11.2% at 3 years. Patient QoL (SF-12v2) was significantly restored and maintained for up to 3 years (p < 0.001). Five patients (0.9%) underwent reoperation related to endocarditis. The postimplant mean gradient was 9.2 ± 3.7 at discharge and 8.9 ± 4.6 mm Hg at 3 years. Combined RDAVR with CABG procedure is safe and effective over time. It offers stable and low transvalvular gradients with satisfactory clinical outcomes at 3 years. The pacemaker rate appears to be slightly increased, with no significant clinical effect at 3 years.

Simple vs Complex Aortic Arch Repair in Acute Type A Aortic Dissection.

The purpose of this study is to evaluate the clinical outcomes of patients undergoing a simpler (hemiarch) vs complex (zone 2 arch) aortic repair for acute type A aortic dissection (TAAD). Adults (≥18 years) who underwent hemiarch or zone 2 arch repair for acute, hyperacute, or acute on chronic TAAD at a single institution between January 2018 and April 2024 were reviewed. Disabling stroke was defined as modified Rankin scale ≥4. Statistical analysis included univariate comparisons, Kaplan-Meier analysis, and multivariable modeling. Two hundred eighty-three acute TAAD patients underwent hemiarch (44.5%, n=126) and/or zone 2 arch (55.5%, n=157) repair. Hemiarch patients were older (63.3±14.1 vs 56.3±12.2 years, P<0.001), but had lower rates of preoperative cerebrovascular disease (11.1%[n=14] vs 21.7%[n=34], P=0.03), chronic kidney disease (16.7%[n=21] vs 33.1%[n=52], P=0.003), and previous sternotomy (13.5%[n=17] vs 35.0%[n=55], P<0.001). Cardiopulmonary bypass and cross clamp times were shorter in hemiarch patients (214±78.5 vs 261±62.3 minutes, P<0.001; 135±54.4 vs 182±60.0 minutes, P<0.001, respectively). Postoperatively, there was no difference in the rate of disabling stroke (4.5%[n=13], P=0.12), tracheostomy (14.8%[n=43], P=0.15), pneumonia (17.2%[n=50], P=0.24), or renal failure requiring permanent dialysis (6.2%[n=18], P=0.47). In multivariable analysis, older age (HR 1.05, 95% CI=1.02-1.08) was a risk factor for longitudinal mortality, while complex aortic arch repair did not confer increased risk (HR 0.68, 95% CI=0.35-1.31). Complex aortic arch reconstruction provides a framework for down-stream endovascular procedures for the remaining aorta and can be performed in acute TAAD without increased risk of morbidity or mortality compared with a simpler repair.

Ventricular Fibrillation after Aortic Declamping During Open-Heart Surgery: Incidence and Risk Factors? Assessment in a Sub-Saharan Country

Ventricular fibrillation (VF) is a complete desynchronization of ventricular fibers due to multiple reentry wavelets. The aim of our study was to determine the frequency as well as the risk factors for the occurrence of VF after aortic decompression intraoperatively in cardiac surgery. This was a prospective observational study, conducted over a period of 06 months at the CHU de Fann cardiac center. All patients scheduled for cardiac surgery under extracorporeal circulation were included. Exclusion criteria were patients with incomplete preoperative and/or intraoperative data. Our study included 105 patients with a mean age of 24.5 years and a sex ratio of 0.98. All patients underwent scheduled surgery with compensated cardiac status. Intraoperatively, all patients had received general anesthesia with tracheal intubation. The mean duration of aortic clamping was 93.8 min, and half the patients received a single dose of cardioplegia. The incidence of VF after aortic reperfusion was 16.2%, with the main risk factors being valve surgery, preoperative sildenafil use, left ventricular ejection fraction &lt; 50%, severe pulmonary hypertension with systolic pulmonary artery pressure &gt; 80mmHg. VF is one of the most dreaded complications of cardiac surgery. Preventive treatment with amiodarone or lidocaine before releasing the aortic clamp would seem to reduce its incidence. Hence the importance of recommending this measure in our daily practice.

Early and late outcomes of emergency coronary bypass grafting in non-ST-segment elevation acute myocardial infarction

The majority of patients undergoing emergency coronary artery bypass grafting for non-ST-segment elevation myocardial infarction are of advanced age and have many comorbidities, which pose challenges for operation. This study aimed to determine the early and midterm outcomes of this subgroup. The study conducted a retrospective analysis on 89 patients who experienced non-ST-elevation acute myocardial infarction and underwent emergency coronary artery bypass graft surgery at Hanoi Heart Hospital in Hanoi, Vietnam, between January 1, 2020, and December 31, 2022. The primary outcome variable was in-hospital mortality, and the secondary outcome variable was midterm mortality. The mean age of the cohort was 66.4 years. Female accounted for 31.46%. Over half of patients (53.9%) were operated on within 24 hours from the onset of symptoms. The average European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 10.55%. The number of coronary bypasses was 3.4. Aortic cross-clamp and cardiopulmonary bypass times were 64.2 and 94.4 minutes. The in-hospital mortality rate was 10.11%. Significant predictors determining in-hospital mortality were the EuroSCORE II score. The mean follow-up time was 28.2±12.2 months. Survival rates at 1 year and 2 years were 97.5% and 96.02%, respectively. Emergency coronary bypass surgery in patients with non-ST segment elevation myocardial infarction had poor early but good midterm outcomes. A high EuroSCORE II score was a predictor of in-hospital mortality.

Impact of Body Mass Index on the Initial Phase of a Minimally Invasive Aortic Valve Program.

In obese patients, minimally invasive surgical aortic valve replacement (MIS-AVR) presents challenges, and the risk of patient-prosthesis mismatch (PPM) is elevated. This retrospective single-center study evaluates the impact of body mass index (BMI) on the outcome of an initial MIS-AVR program. A total of 307 patients underwent MIS-AVR between January 2013 and December 2015, the initial phase of our MIS-AVR program. They were divided into normal/overweight (BMI <30 kg/m2) versus obese patients (BMI ≥30 kg/m2). Primary endpoints included 30-day and 2-year mortality and stroke. Secondary endpoints comprised type 3 bleeding, PPM, paravalvular leakage, wound healing disorders (WHDs), and pacemaker rates. In all 191 patients exhibited a BMI <30 kg/m2, while 116 patients had a BMI ≥30 kg/m2. The BMI groups did not differ in baseline characteristics, excepting a higher peripheral arterial disease incidence among obese patients (15.7% vs. 26.7%; p = 0.01). Aortic clamp time (75 ± 29 min vs. 87 ± 37 min; p = 0.001), cardiopulmonary bypass (104 ± 36 min vs. 124 ± 56 min; p = 0.0002), and ventilation times (26 ± 6 h vs. 44 ± 8 h; p = 0.03) were longer in obese patients. They demonstrated a higher risk for bleeding (2.6% vs. 9.5%; p = 0.008) but lower pacemaker rates (9% vs. 3%; p = 0.02). PPM, paravalvular leakage, and WHD exhibited no group differences. No BMI-related differences revealed in 30-day mortality (4.7% vs. 3.4%) and stroke rates (2% vs. 2.6%), as well as 2-year mortality (12.6% vs. 11.2%) and stroke rates (2.1% vs. 2.6%). In the initial phase of an MIS-AVR program, the 30-day mortality may be elevated. Despite longer operative times and an increased risk for bleeding in obese patients, no influence of BMI on postoperative morbidity, mortality, or stroke rates was observed.

Early and Long-Term Outcomes of Patients Undergoing Surgery for Native and Prosthetic Valve Endocarditis: The Role of Preoperative Neutrophil-to-Lymphocyte Ratio, Neutrophil-to-Platelet Ratio, and Monocyte-to Lymphocyte Ratio.

Background/Objectives: Previous studies evaluated the prognostic role of hematological parameters in predicting outcome in patients with infective endocarditis (IE). However, only a few studies evaluated the role of hematological parameters in patients undergoing surgery for IE. The aim of this study was to review our 20-year experience with the treatment of native (NVE) and prosthetic (PVE) valve endocarditis and to evaluate the role of neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-platelet ratio (NPR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), neutrophil-to monocyte ratio (NMR), and systemic inflammatory index (SII) on early and long-term outcomes of patients undergoing surgery for NVE and PVE. Methods: All adult patients undergoing surgery for NVE and PVE at our institution between January 2001 and December 2022 were included in the study. Preoperative NLR, NPR, PLR, MLR, NMR, and SII were calculated using hemograms with complete blood count. Results: During the study period, 503 patients, 371 (74%) males, median age 65 (52-73) years, underwent surgery for NVE (n = 337, 67%) or PVE (n = 166, 33%). Patients with PVE had significantly more aortic annulus abscess (95 (57%) vs. 51 (15%); p < 0.001), longer CPB (180 (131-235) vs. 105 (84-145) min; p < 0.001) and aortic cross-clamping times (129 (96-175) vs. 82 (64-114) min; p < 0.001), and received more aortic homografts (47 (28%) vs. 28 (9%); p < 0.001) and postoperative pacemaker implantation (25 (15%) vs. 20 (6%); p < 0.001 compared to patients with NVE. Preoperative NLR was 3.7 (2.4-6.1), NPR was 23 (16-37), PLR was 159 (106-210), NMR was 8.4 (6.6-12), MRL was 0.41 (0.29-0.62], and SII was 790 (485-1396). NLR, NPR, and MLR were significantly lower in patients with NVE compared to patients with PVE and in survivors compared to non-survivors. Overall mean survival time was 12.2 ± 0.5 years, with patients with NVE having better early and late survival compared to patients with PVE. Patients with preoperative NLR < 3.8, NPR < 30.9, and MLR < 0.4 had significantly better mean survival time compared to patients with preoperative NLR > 3.8, NPR > 30.9, and MLR > 0.4, respectively. Conclusions: In patients undergoing surgery for IE, preoperative higher NLR, NPR, and MLR are associated with increased early and long-term mortality.

Barlow severe mitral regurgitation: respect vs resect approaches in minimally invasive valve repair

Introduction: Barlow’s disease represents the most severe form of degenerative mitral valve disease, with mitral regurgitation as its most common manifestation. According to current treatment guidelines, severe symptomatic mitral regurgitation warrants surgery, with mitral valve repair being preferred over replacement due to its favorable impact on patient prognosis. Mitral valve repair techniques are broadly classified into two main approaches: resect and respect. In Barlow’s disease, characterized by significant excess valve tissue, the choice between these two approaches in minimally invasive surgery remains controversial. This study aimed to compare the early outcomes of resect and respect approaches in minimally invasive mitral valve repair for patients with Barlow’s disease. Methods: This retrospective cohort study included all patients with severe mitral regurgitation and Barlow-type mitral valve who underwent minimally invasive mitral valve repair from 2020 to 2024 at the University Medical Center in Ho Chi Minh City, with complete data available for analysis. Results: A total of 61 patients met the inclusion criteria. Successful valve repair was achieved in 57 patients (93.4%), while 4 cases required valve replacement due to complex valve pathology. Among the 57 patients who underwent repair, 26 patients (45.6%) received mitral valve repair using the respect approach, while 31 patients (54.4%) were treated with the resect approach. The mean cardiopulmonary bypass time and aortic cross-clamp time were 146.1 ± 23.8 minutes and 84.6 ± 15.9 minutes, respectively. During the 30-day postoperative follow-up, no mortality or SAM (systolic anterior motion) complications were observed, with one case of moderate mitral regurgitation post-surgery. Additionally, no reoperations were required during the follow-up period. Conclusion: Minimally invasive mitral valve repair for Barlow’s disease shows favorable outcomes within the first 30 postoperative days. The resect and respect approaches yield comparable results.

Research on application of totally endoscopic surgery with Three- Dimensional system for congenital heart surgery in children

Objective: to evaluate the feasibility and results of implementing 3D total endoscopic surgery for congenital heart surgery in children. Abstract: Minimally invasive surgery is currently a widespread tendency in open heart surgery and particularly in congenital heart surgery. In particular, total endoscopic surgery with a 3D system has been applied to adult patients, bringing many benefits such as thoroughly resolving heart lesions, fast post-operative recovery and especially high aesthetic value with small surgical scars. The application of 3D endoscopic surgery for children still has many limitations due to their small body size. Therefore, we conducted this study to evaluate the feasibility and results of implementing this technique in children. Subjects and methods: From January 2018 to March 2024, patients weighing over 15 kilograms were operated using 3D total endoscopic methods. Total 127 patients included: 62 cases of atrial septal defect, 42 cases of ventricular septal defect, 18 cases of partial atrioventricular septal defect and 5 cases of partial anomalous pulmonary venous return. Average age: 8.73 years (3-15). Average weight: 21.34 kg (15-51). Results: All patients were established with peripheral extracorporeal circulation, no patient had to undergo sternotomy. The time of cardiopulmonary bypass for atrial septal defect, ventricular septal defect, partial atrioventricular septal defect, and partial anomalous pulmonary venous return were: 78 minutes, 115 minutes, 140 minutes, 91 minutes, respectively. Aortic clamping time for ventricular septal defect: 82 minutes; partial atrioventricular septal defect: 88 minutes; partial anomalous pulmonary venous return: 62 minutes. For the disease of atrial septal defect, the heart was left beating during the surgical process. No cases of fatality after surgery. Postoperative echocardiography demonstrates promising results. Postoperative complications included 1 patient with femoral artery occlusion at the site of arterial cannulation, this patient then underwent emergency femoral artery angioplasty; 1 patient with external iliac artery stenosis required reoperate after 3 months. The average postoperative follow-up time was 29 months (2 - 59), no fatality, no complications, stable echocardiography results, no patient needed to be reoperated during the follow-up period. Conclusion: 3D total endoscopic surgery can be performed routinely on children weighing over 15 kg, offering excellent early and long-term outcomes and evident cosmetic benefits.

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.

Unveiling the role of risk factors and predictive models in acute type-a aortic dissection surgery: OI downregulation and its association with immune disorders.

Background and Objective: Acute type A aortic dissection (ATAAD) represents a critical and life-threatening condition requiring urgent surgical intervention, which is often life-saving. However, postoperative acute lung injury (ALI) has emerged as a prominent complication that significantly impacts patient outcomes and prognosis. This study aims to systematically analyze the risk factors associated with the development of severe ALI following ATAAD surgery, providing insights to improve postoperative management strategies. Methods: A retrospective analysis was conducted using a comprehensive database comprising 483 patients diagnosed with ATAAD. Patients were stratified into two groups based on the severity of postoperative ALI: severe ALI group (n = 182) and non-severe ALI group (n = 301). Clinical data were systematically collected and compared between the two cohorts. Binary logistic regression analysis was employed to identify independent predictors of severe ALI following ATAAD surgery. The diagnostic accuracy of these risk factors was assessed using receiver operating characteristic (ROC) curve analysis, with the area under the curve (AUC) serving as the metric for prognostic performance. Results: The severe ALI group exhibited a higher prevalence of preoperative oxygenation index (OI) ≤ 200 mmHg, smoking history, and coronary artery disease compared to the non-severe ALI group (P < 0.001, P = 0.032, and P = 0.039, respectively), while the prevalence of Marfan syndrome was lower (P = 0.033). Moreover, significant differences were observed in several clinical and intraoperative parameters, including body mass index (BMI), C-reactive protein (CRP), procalcitonin (PCT), D-dimer, white blood cell count (WBC), aortic cross-clamp time, moderate hypothermic circulatory arrest (MHCA) time, cardiopulmonary bypass (CPB) duration, and ICU length of stay (all P < 0.05). Multivariate logistic regression identified preoperative OI [P = 0.008, OR (95% CI): 0.002 (0.000-0.183)], BMI [P = 0.037, OR (95% CI): 1.569 (1.027-2.397)], CRP [P = 0.022, OR (95% CI): 1.292 (1.037-1.609)], D-dimer [P < 0.001, OR (95% CI): 3.841 (1.820-8.108)], MHCA time [P = 0.001, OR (95% CI): 3.306 (1.670-6.544)], and CPB duration [P = 0.017, OR (95% CI): 1.117 (1.020-1.223)] as independent predictors of severe ALI. ROC curve analysis revealed the diagnostic performance of preoperative OI, BMI, CRP, D-dimer, MHCA time, and CPB duration, with AUC values of 0.715, 0.844, 0.871, 0.955, 0.944, and 0.833, respectively (all P < 0.001). Conclusion: Preoperative oxygenation index, BMI, CRP, D-dimer levels, MHCA time, and CPB duration are independent risk factors for the development of severe ALI following ATAAD surgery. These findings underscore the importance of preoperative risk assessment and perioperative optimization to mitigate the risk of severe ALI and improve patient outcomes.

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

We 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). Patients 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. A 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 < 0.01), had higher preoperative lactate and D-dimer levels, and had the highest incidence of AGI (52.5%, P < 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. Phenogroup 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.