Avoidance Of Cardiopulmonary Bypass Research Articles

Hybrid Perventricular Ventricular Septal Defect Device Closure in a 3-Months Old Infant with Severe Failure to Thrive

We report a case of successful hybrid device closure of large mid muscular Ventricular Septal Defect (VSD) in an infant for the very first time in Pakistan. Increasing collaboration between pediatric cardiac interventionalists and congenital cardiac surgeons has resulted in introduction of various hybrid procedures in the management of Congenital Heart Diseases (CHD). Advantages of hybrid procedures include complex interventions by using minimally invasive methods, avoidance of cardiopulmonary bypass, shorter procedure and recovery time leading to subsequent decrease in complications. A large VSD in an infant carries an increased risk of morbidity including failure to thrive, congestive cardiac failure, and recurrentrespiratory tract infections. Timely and safely the successful perventricular closure of large VSD using hybrid approach is a milestone in the management of VSDs in infants.

RETROSPECTIVE STUDY OF GLENN SHUNT WITHOUT CARDIOPULMONARY BYPASS

The bidirectional Glenn shunt improves systemic arterial oxygen saturation without increasing ventricular work or pulmonary vascular resistance (1).BDG is a commonly performed procedure for a variety of cyanotic congenital heart diseases that lead eventually to a single ventricle repair (2).It is an important intermediate palliation in patients with a structurally or functionally univentricular heart who are ultimately destined to have a Fontan-type operation (3). Avoidance of cardiopulmonary bypass (CPB) has the advantage of early extubation, less blood products, reduced requirement and duration of inotropic support (4).The end-to-side anastomosis of the superior vena cava (SVC) to the right or left pulmonary artery, which may be converted to a total cavopulmonary connection later, can effectively both increase arterial blood oxygen saturation of the patients and decrease volume overload of the ventricle (5)

Nephrectomy and thrombectomy in renal cell carcinoma patients with extensive tumor venous thrombosis: how to minimize surgical risks?

Objective: to evaluate the outcomes of thrombectomy performed using different surgical techniques in renal cell carcinoma (RCC) patients with extensive tumor venous thrombosis.Materials and methods. This study included 345 RCC patients with extensive tumor venous thrombosis who underwent surgical treatment.The median age was 57 years (range: 16—79 years); the male-to-female ratio was 1:1.9. Two hundred and sixty patients (75.4 %) had their tumor thrombus originating from the right renal vein, 85 patients (24.6 %) — from the left renal vein. In 169 patients (49.0 %), the thrombus spread to the retrohepatic inferior vena cava (IVC), while in 176 patients (51.0 %), it spread above the diaphragm (to the intrapericardial IVC in 59 patients (17.1 %) and to the right heart cameras in 117 patients (33.9 %)). Regional metastases were found in 90 individuals (26.1 %), while distant metastases were observed in 124 patients (35.9 %). All patients underwent surgical treatment (radical in 251 patients (72.8 %) and cytoreductive — in 94patients (27.2 %)); the technique of vascular control and circulatory support was chosen individually. In 97 patients (28.1 %), the control over the cranial thrombus boarder did not require opening of the chest cavity; eleven patients (3.2 %) were operated on with cardiopulmonary bypass.Results. The median surgery time was 215 minutes; the median blood loss was 4500 mL. Intraoperative complications were registered in 209 patients (60.6 %) and postoperative complications were observed in 118 patients (35.1 %) (including those of grade I—II in 43 individuals (12.8 %) and grade III—V in 75 individual (22.3 %)). The in-hospital mortality rate was 10.7 % (37/345). At a median follow-up of 32.3 months, overall and diseasespecific survival rates among all patients were 51.9 % and 68.3 %, respectively; relapse-free survival rate in 226patients who have undergone radical surgeries and discharged from the hospital was 61.5 %; progression-free survival rate in 82 patients who have undergone cytoreductive surgery was 33.0 %. The method ofIVC control and circulatory support had no effect on both short-term and long-term treatment outcomes (p >0.05 for both).Conclusion. The use of minimally invasive techniques of vascular control and avoidance of cardiopulmonary bypass in carefully selected RCC patients with extensive tumor venous thrombosis do not worsen the outcomes of nephrectomy and thrombectomy.

Personalized External Aortic Root Support (PEARS) for Aortic Root Aneurysm

The Personalized External Aortic Root Support (PEARS) procedure offers a novel alternative to traditional surgical options for aortic root aneurysms in patients with connective tissue disorders and neo-aortic root dilatation following the arterial switch or Ross procedures. It has a lower biological insult than conventional surgical management with shorter operating times and avoidance of cardiopulmonary bypass and cardioplegic arrest in most cases. The patient's own valve, root architecture, and blood to vessel wall interface are maintained. Avoidance of mechanical valve replacement negates the requirement for anticoagulation which is especially beneficial in young patients. This article aims to describe the key principles and operative steps for implanting the PEARS device. We describe the technical steps applicable to all PEARS implants and have included our tips and tricks at each stage. We consider PEARS to be a valid alternative therapeutic option for surgical teams managing patients with aortopathies.

Long-term outcomes after conventional surgical repair versus perventricular device occlusion for doubly committed subarterial ventricular septal defects: a propensity score matched study.

This study aimed to investigate the long-term outcomes of perventricular device occlusion and surgical repair for doubly committed subarterial ventricular septal defect using propensity score matched analysis because previous comparative studies were limited by differences in the baseline characteristics. We reviewed inpatients with isolated doubly committed subarterial ventricular septal defect aged <18 years who underwent surgical repair or device occlusion between January 2011 and December 2017. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics. A total of 336 patients underwent surgical repair; 99 underwent device occlusion. After matching, the repair group included 164 patients, whereas the device group had 91 patients. There were no significant differences in the baseline characteristics. The median follow-up periods were 46 and 58 months for the device and repair groups, respectively. No significant difference was noted in the rates of cumulative adverse events in the 2 groups (7.9% vs 5.5%; P = 0.61). The repair group required longer periods of hospitalization (P = 0.002) and mechanical ventilation (P = 0.016). No grade 3 or higher valvular regurgitation or high-degree atrioventricular block events were observed. All patients were in sinus rhythm at the last follow-up examination. In selected patients with doubly committed subarterial ventricular septal defect, compared with conventional repair, perventricular device occlusion has comparable efficacy and safety, less invasiveness in terms of time in the hospital and on mechanical ventilation and avoidance of cardiopulmonary bypass.

Level of Cardiac Biomarkers in Immediate Post-Operative Period after Off-Pump CABG and Its Comparison with On-Pump CABG: A Prospective Analytical Study

Background: Coronary artery bypass grafting (CABG) is an important modality of treatment for ischemic heart disease. Both off-pump and on-pump CABG have direct effect on the level cardiac biomarkers in the perioperative period. The use of cardiopulmonary bypass (CPB) and aortic cross-clamping may cause additive myocardial damage leading to further elevation of blood markers. The present study is aimed at measuring and comparing the cardiac biomarker levels in immediate post-operative period after on-pump CABG (ONCAB) and off-pump CABG (OPCAB). Methods: All the patients who underwent CABG from January 2015 to June 2016 on elective or emergency basis at Nilratan Sircar Medical College & Hospital have been included in the study. Total 106 patients were operated for CABG of which 75 patients were operated for OPCAB and 31 patients were operated for ONCAB. For the comparison of data the blood markers Troponin-T (Trop-T) and Creatine Kinase-MB (CK-MB) are measured during anesthesia before surgery, post-operatively after 1 hour, post-operatively after 4 hours and post-operatively after 20 hours. All recorded data are analyzed using standard statistical methods. Results: We found the markers are elevated immediately after surgery and gradually come down within 24 hours after surgery in both OPCAB and ONCAB groups. The elevation is more after ONCAB than OPCAB group in immediate post-operative period but the difference is not significant after 20 hours of surgery. Conclusion: Elevated levels of cardiac biomarkers in the immediate post-operative period indicate myocardial damage during surgery, especially after ONCAB in comparison to OPCAB. This may attribute to the better hemodynamic stability in the immediate post-operative period after OPCAB than ONCAB assuming comparable and adequate revascularization in patients of both groups. The avoidance of CPB and cross-clamp may explain better myocardial functioning immediately after OPCAB. But after 20 hours, the level of cardiac markers is comparable in both groups indicating little difference in post-operative recovery and long-term prognosis.

Impact of surgical technique on the development of post-operative vasoplegia

Introduction Vasoplegia after cardiothoracic surgery is associated with severe post-operative complications and worse outcomes. Despite recent innovations, lung transplantation (LTx) remains one of the highest risk surgeries. We hypothesise that the avoidance of cardiopulmonary bypass (CPB) and the use of lesser invasive surgical approaches, namely the “minimally invasive” thoracotomy approach (MI) compared to the traditional Clam shell technique (CS), may reduce the incidence of vasoplegia post-operatively. Furthermore, we explore the association of vasoplegia and endothelial dysfunction by analysing the plasma release of endocan. Methods 90 patients received a LTx between October 2013 and June 2015 at Harefield Hospital. 40 were recruited in our prospective study. Clinical data, including surgical approach, use of CPB and OCS were recorded. Vasoplegia in the first 48 hours was defined according to Tsiouris et al (1). Plasma levels of endocan were then measured by ELISA at baseline and at 0, 6, 12, 24, 48 after Ltx. Data were analysed and reported as appropriate. Results 7 patients (44%) in the CPB group developed vasoplegia vs. 6 (46%) in the off-group (p 0.305), 3 after unexpected conversion to CPB (30% of the unexpected CPB group, p 0.302). Within the surgical approach groups, 8 patients (32%) of the CS group developed vasoplegia compared to 5 patients (33%) of the MILT-group (p 1.000). Patients in the vasoplegic group showed a tendency for longer CPB time (146 [81, 230] min vs. 110 [44, 184] min, p 0.470) and surgery duration (335 [290, 425] min vs. 310 [270, 435] min, p 0.690). Only 1 patient developed vasoplegia after OCS-LTx (20%, p 1.000). 2 patients in the vasoplegia group (15%) required re-exploration for bleeding vs. 2 (7%) in the no-vasoplegia group (7%, p 0.584). One patient required ECMO during the ITU stay and he was vasoplegic. Endocan levels were similar during the first 48 hours after LTx and between groups. Discussion Here, we demonstrate a high incidence of vasoplegia after LTx. The development of vasoplegia was not affected by either the surgical approach or the use of CPB. In addition, we found no evidence for association between vasoplegia and endothelial dysfunction. However, vasoplegia may be related to longer duration of CPB and surgery. Further studies are needed to identify mechanisms of vasoplegia following LTx.

Transverse Sternal Split: a Safe Mini-invasive Approach for Perventricular Device Closure of Ventricular Septal Defect.

ObjectivePerventricular device closure of ventricular septal defect through midline sternotomy avoids the cardiopulmonary bypass, however, lacks the cosmetic advantage. Perventricular device closure of ventricular septal defect with transverse split sternotomy was performed to add the cosmetic advantage of mini-invasive technique.MethodsThirty-six pediatric patients with mean age 7.14±3.24 months and weight 5.00±0.88 kg were operated for perventricular device closure of ventricular septal defect through transverse split sternotomy in 4th intercostal space under transesophageal echocardiography guidance. In case of failure or complication, surgical closure of ventricular septal defect was performed through the same incision with cervical cannulation of common carotid artery and internal jugular vein for commencement of cardiopulmonary bypass. All the patients were postoperatively followed, and then discharged from hospital due to their surgical outcome, morbidity and mortality.ResultsProcedure was successful in 35 patients. Two patients developed transient heart block. Surgical closure of ventricular septal defect was required in one patient. Mean duration of ventilation was 11.83±3.63 hours. Mean intensive care unit and hospital stay were 1.88±0.74 days and 6.58±1.38 days, respectively. There was no in-hospital mortality. A patient died one day after hospital discharge due to arrhythmia. No patients developed wound related, vascular or neurological complication. In a mean follow-up period of 23.3±18.45 months, all 35 patients were doing well without residual defect with regression of pulmonary artery hypertension as seen on transthoracic echocardiography.ConclusionTransverse split sternotomy incision is a safe and effective alternative to a median sternotomy for perventricular device closure of ventricular septal defect with combined advantage of better cosmetic outcomes and avoidance of cardiopulmonary bypass.

Invited Commentary

Invited Commentary

Combined Procedure for Coronary Artery Bypass Grafting and Pulmonary Hydatid Disease

In this study we reported one case of combined procedure for coronary artery bypass grafting and excision of right pulmonary hydatid cyst. Concerns of possible hydatid systemic dissemination as a result of direct vascular breaches are raised. We suggest that avoidance of cardiopulmonary bypass (CPB) if that possible is beneficial for the treatment. If not possible then the excision and clearance of the hydatid cyst should be done in the first place before going on bypass.

Minimally invasive left ventricular assist device placement.

The use of left ventricular assist device (LVAD) as bridge-to-transplant and destination therapy has increased significantly in the recent years along with the rapidly increasing heart failure patient population worldwide. It is crucial to be familiar with the standard surgical technique of LVAD implantation, but also to further advance the technique to optimize patient outcomes. Numerous studies have shown minimally invasive cardiac surgeries, including cardiac valves procedures can improve patient outcomes with decrease post-operative bleeding, reduced blood transfusion requirement, shorter hospital stay, faster recovery rate and lower hospital cost. With the advancement of mechanical circulatory support, the smaller and current generation of centrifugal continuous-flow LVADs has made minimally invasive LVAD implantation feasible. In this review, we described our surgical technique of minimally invasive LVAD placement. In addition to the standard pre-LVAD implantation evaluation, multiple studies, including chest radiography, chest computed tomography and echocardiography are further examined for patient selection and planning of the operation. Instead of a full standard sternotomy, a lateral mini-thoracotomy and hemi-sternotomy or second intercostal space anterior mini-thoracotomy are utilized. Special techniques are also applied to allow easy access for future re-entry, e.g., heart transplantation and to improve post-operative outcomes. Off-pump approach is our prefer approach for the minimally invasive procedure. With minimally invasive approach, avoiding a full sternotomy, can reduce surgical trauma and post-operative bleeding, and can make subsequent LVAD explantation and heart transplantation less technically challenging and will allow patients to have a faster post-operative recovery rate. With the intact pericardium, the right ventricle can be protected from acute unrestricted dilation and further right heart failure after LVAD placement. The use of off-pump approach allows the avoidance of cardiopulmonary bypass and will decrease the incidence of post-operative vasoplegia and coagulopathy. With the current generation of LVADs, minimally invasive surgical approach is very feasible and may improve patient outcomes. Further large prospective randomized studies will help to further demonstrate the potential advantages and disadvantage of minimally invasive LVAD placement. The upcoming generations of LVADs and minimally invasive instrumentations are currently being evaluate and will further advance the success of LVAD therapy.

Minimally invasive atrial septal defect closure: what is that?

In this issue, Nezafati et al. [1] present their centre’s experience on off-pump atrial septal defect closure. Interestingly, they opted for caval inflow occlusion. Technological advances enable treatment for a wide range of congenital defects with often excellent results. As a result, both children and adults with congenital heart defects can now expect better outcomes. In recent years, however, surgical techniques have also centred around reduction of trauma and postoperative recovery time and also improvement of cosmetic results. However, these techniques have had selective application in congenital cardiac surgery when compared with adults. Open heart procedures for congenital lesions have been largely confined to operations where an intracardiac repair is carried out through the right atrium. A conventional full sternotomy approach for treatment of ‘simple’ lesions can now largely be avoided; instead, approaches vary from an anterior thoracotomy, inframammary thoracotomy and posterior thoracotomy to a limited inferior sternotomy. Nowadays, Atrial septal communications can usually be closed by an interventional cardiologist, unless morphological features are unfavourable. I would call this a true minimally invasive method. Any other attempt is rather ‘minimal access’ surgery. For the latter, a range of approaches are currently used: cardiopulmonary bypass (CPB)-assisted operations with minimal thoracotomies or ‘hybrid procedures’. The term ‘hybrid procedures’ refers to the combined use of direct surgical access to cardiac structures and catheterbased techniques to treat cardiac defects [2]. Nezafati et al. [1] describe a technique that lies somewhat in between. Even though any percutaneous programme is costly and requires a specific setup, Butera et al. [3] showed in a summary of data from studies comparing surgical versus percutaneous closure of atrial septal defects that treatment by a percutaneous approach has a significantly lower rate of either total or major early post-procedural complications compared with surgery. Economical issues are, however, a concern in many countries. In part, this seemed to have led the colleagues to aim for avoidance of CPB. Even though they report on a low overall complication rate, I would personally not advocate the use of this approach unless patients are carefully informed and selected, and all team members are acquainted in detail with all procedural steps. It is of note, however, that, for instance, mitral valve surgery is occasionally done on the beating heart too [4]. Personally, potential neurological sequelae and assurance of 100% closure of any interatrial connection would be my major concern. The described technique must be carried out within a limited time, both for visualizing the atrial septal defect margins and subsequent closure. It is of note that none of the defects could be closed with a patch. With regard to the surgical approach, I am in favour of staying well away from future breast tissue in prepubescent patients, especially in female patients. We have highlighted this issue and have since only opted for a midaxillary incision in young patients [5]. Beyond puberty, we cannulate the jugular vein and the femoral vessels, and perform only a very limited anterolateral thoracotomy. It will be interesting to see whether the described contribution triggers further applications. If cardiologists fail to close an atrial septal defect, a surgeon ought to offer the patient a safe and reliable treatment, keeping cosmetic aspects in mind.

Outcomes of the extracardiac fontan procedure using cardıopulmonary bypass: early results.

Although the avoidance of cardiopulmonary bypass during the Fontan procedure has potential advantages, using cardiopulmonary bypass during this procedure has no adverse effects in terms of morbidity and mortality rates. In this study, we assessed the postoperative outcomes of our first 9 patients who have undergone extracardiac Fontan operation by the same surgeon using cardiopulmonary bypass. Between September 2011 and April 2013, 9 consecutive patients (3 males and 6 females) underwent extracardiac Fontan operation. All operations were performed under cardiopulmonary bypass at normothermia by the same surgeon. The age of patients ranged between 4 and 17 (9.8 ± 4.2) years. Previous operations performed on these patients were modified Blalock-Taussig shunt procedure in 2 patients, bidirectional cavopulmonary shunt operation in 6 patients, and pulmonary arterial banding in 1 patient. Except 2 patients who required intracardiac intervention, cross-clamping was not applied. In all patients, the extracardiac Fontan procedure was carried out by interposing an appropriately sized tube graft between the inferior vena cava and right pulmonary artery. The mean intraoperative Fontan pressure and transpulmonary gradient were 12.3 ± 2.5 and 6.9 ± 2.2 mm Hg, respectively. Intraoperative fenestration was not required. There was no mortality and 7 patients were discharged without complications. Complications included persistent pleural effusion in 1 patient and a transient neurological event in 1 patient. All patients were weaned off mechanical ventilation within 24 hours. The mean arterial oxygen saturation increased from 76.1% ± 5.3% to 93.5% ± 2.2%. All patients were in sinus rhythm postoperatively. Five patients required blood and blood-product transfusions. The mean intensive care unit and hospital stay periods were 2.9 ± 1.7 and 8.2 ± 1.9 days, respectively. The extracardiac Fontan operation performed using cardiopulmonary bypass provides satisfactory results in short-term follow-up and is associated with favorable postoperative hemodynamics and morbidity rates.

Organ Dysfunction in Patients with Left Ventricular Impairment: What is the Effect of Cardiopulmonary Bypass?

We have previously demonstrated that avoidance of cardiopulmonary bypass may reduce early mortality and cardiac related complications in patients with left ventricular dysfunction. This study examines the impact of cardiopulmonary bypass in the same subgroup in terms of organ dysfunction and non-cardiac related complications A systematic literature review identified 24 studies including 7,976 patients. Data was extracted for the following outcomes of interest: stroke, renal failure, ventilation time, pulmonary complications and sternal wound infection. Random effects meta-analysis was used to aggregate the data. Sensitivity and heterogeneity were assessed. Meta-analysis through subgroup analysis of the highest quality studies revealed that the off-pump technique is associated with significantly lower incidence of stroke, renal failure, ventilation time and sternal wound infection. These results highlight an important link between cardiopulmonary bypass and the incidence of multi-organ dysfunction in patients with left ventricular dysfunction. The results add to the growing body of evidence that off-pump surgery is more beneficial in high-risk patients. Even in the light of mixed reports on graft patency and completeness of revascularisation, the technique may be justified in selected patients in attempt to reduce organ dysfunction.

Off-Pump Versus On-Pump Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) remains the preferred treatment in patients with complex coronary artery disease. However, whether the procedure should be performed with or without the use of cardiopulmonary bypass, referred to as off-pump and on-pump CABG, is still up for debate. Intuitively, avoidance of cardiopulmonary bypass seems beneficial as the systemic inflammatory response from extracorporeal circulation is omitted, but no single randomized trial has been able to prove off-pump CABG superior to on-pump CABG as regards the hard outcomes death, stroke or myocardial infarction. In contrast, off-pump CABG is technically more challenging and may be associated with increased risk of incomplete revascularization. The purpose of the review is to summarize the current literature comparing outcomes of off-pump versus on-pump coronary artery bypass surgery.

Off-pump surgery: is it beneficial in patients with left ventricular dysfunction?

On-pump coronary artery bypass surgery remains the gold standard for complex multivessel disease. Off-pump revascularization has matured as a technique over the last twenty years, but is used in less than 20% of cases worldwide. The poor uptake has been attributed to the significant learning curve in learning the procedure and conflicting evidence reports, together with concerns over mortality related conversion, graft patency and completeness of revascularization. Given these concerns, patient selection continues to be paramount and the subgroups that benefit most are hotly debated. Patients with left ventricular dysfunction constitute a high-risk subgroup which is enlarging in size. There is some evidence to suggest that avoidance of cardiopulmonary bypass in this group may lead to superior results in terms of early mortality, non-cardiac complications and organ dysfunction. Even with the theoretical risk of incomplete revascularization, the technique may be an attractive option in managing high-risk patients.

Invited Commentary

Off-pump coronary artery bypass graft (OPCABG) surgery has been a controversial topic for many years, with a growing number of randomized controlled trials demonstrating that early and 1-year survival are no different whether the heart-lung machine is used or not. Two observational studies [1Bakaeen F.G. Chu D. Kelly R.F. et al.Performing coronary artery bypass grafting off-pump may compromise long-term survival in a veteran population.Ann Thorac Surg. 2013; 95: 1952-1958Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 2Filardo G. Grayburn P.A. Hamilton C. Hebeler R.F. Cooksey W.B. Hamman B. Comparing long-term survival between patients undergoing off-pump and on-pump coronary artery bypass graft operations.Ann Thorac Surg. 2011; 92: 571-577Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar] have recently suggested that long-term survival could actually be worse after OPCABG than after conventional coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass. Greater technical difficulty, fewer number of grafts with possible incomplete revascularization, and lower quality of the anastomoses in OPCABG surgery have been hypothesized as possible causes of such reduced survival. The study by Dalén and colleagues [3Dalén M. Ivert T. Holzmann M.J. Sartipy U. Long-term survival after off-pump coronary artery bypass surgery: a Swedish nationwide cohort study.Ann Thorac Surg. 2013; 96: 2054-2060Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] demonstrates once again that performing CABG off-pump does not improve early operative survival in a large population of unselected coronary patients, but distinguishing this study is the length of follow-up—a mean of 7.1 years with survival assessment at 10 years. Remarkably, in this extensive and meticulous retrospective observational study, on more than 50,000 consecutive patients, late survival was not at all diminished in off-pump patients, even though the percentage of OPCABG was very low and became lower as time went on (16% in the year 2000, progressing to 1% in 2008, with a variance of 3% to 11% of all isolated coronary operations in the different participating centers). Actually, both curves describing survival and freedom from major events seem to begin to diverge in favor of OPCABG after 9 to 10 years [3Dalén M. Ivert T. Holzmann M.J. Sartipy U. Long-term survival after off-pump coronary artery bypass surgery: a Swedish nationwide cohort study.Ann Thorac Surg. 2013; 96: 2054-2060Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. There are probably several different reasons, besides avoidance of cardiopulmonary bypass, for such an excellent outcome of OPCABG in this study: one reason may be the more extensive use of arterial grafts, with the radial artery utilized twice as frequently in off-pump patients. Possibly, a liberal use of intraoperative graft validation with transit-time flow measurement, very popular in Scandinavia in the past decade, might also have played a role in improving the outcome of OPCABG patients, (Unfortunately, though, we do not know the transit-time flow measurement utilization in the study group.) Incongruous in this study is the higher incidence of perioperative complications such as stroke, reexploration for sternal wound problems, reoperation for bleeding (each occurring twice as frequently after OPCABG), and acute renal failure recorded in the off-pump group. In fact, while some aspects of off-pump coronary surgery are still debated, randomized controlled trials have shown that OPCABG reduces bleeding, stroke, and acute kidney injury, especially in high-risk patients. This noteworthy study on a remarkably large series of patients, in a “real-world” setting, shows that OPCABG can be performed with excellent results despite infrequent performance. Further investigation of survival and freedom from major adverse events at a longer follow-up on the same series of patients would be particularly appealing. Long-Term Survival After Off-Pump Coronary Artery Bypass Surgery: A Swedish Nationwide Cohort StudyThe Annals of Thoracic SurgeryVol. 96Issue 6PreviewThe aim of this study was to analyze long-term survival after primary isolated off-pump coronary artery bypass grafting (CABG) compared with on-pump CABG in a nationwide patient cohort. Full-Text PDF

Current Readings on Off-Pump Coronary Artery Bypass

Historically, the use of cardiopulmonary bypass (CPB) in performing coronary artery bypass grafting (CABG) has been the "gold standard" in coronary revascularization. However, with greater understanding of the inflammatory effects of CPB and the increased risks of strokes in atherosclerotic or calcified aortas, there has been a growing interest in less-invasive approaches to the standard conventional technique. One such approach is performing coronary revascularization without using CPB, also known as off-pump CABG (OPCAB). Several studies have reported that OPCAB is a safe and effective technique that avoids the significant morbidity associated with the use of CPB, whereas other studies report no overall advantage with the avoidance of CPB in coronary revascularization and a trend toward better outcomes in patients undergoing the conventional on-pump technique. The controversial topic of on-pump vs OPCAB has been the subject of ongoing debate for over a decade. This article reviews current literature and hopefully provides an unbiased guide for assessing the values, benefits, and risks of both the techniques.

Inferior vena cava thrombus

Summary Background: The inferior vena cava (IVC) thrombus is an entity with many different causes and clinical presentations. Methods: In the past five years, we treated 16 patients with IVC thrombus and a diagnosis of primary hepatic carcinoma in 6 (37.5%), metastatic hepatic carcinoma in 8 (50%), and Budd-Chiari syndrome in 2 patients (12.5%). Results: Conservative treatment with enhanced immunotherapy, chemotherapy, and transcatheter arterial chemoembolization for the hepatic malignancies led to an overall survial of 82.2% at 16-month follow-up. Discussion: The prognosis of IVC tumor thrombus is usually poor and the surgical techniques are quite challenging. Surgical re-section combined with chemotherapy for advanced hepatocellular carcinoma with tumor thrombus has led to promising results. Aggressive radical nephrectomy with IVC thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. With the development of minimally invasive surgical techniques and the avoidance of cardiopulmonary bypass, less trauma and prolonged survival can be expected for IVC thrombus of malignant etiology.

Transcatheter aortic valve implantation via transaortic access: a bail-out strategy in unexpectedly inoperable patients

Transcatheter aortic valve implantation is a procedure reserved for patients with severe aortic stenosis and high operative risk. Minimization of surgical trauma and avoidance of cardiopulmonary bypass makes this procedure interesting for bail-out situations of unexpectedly inoperable patients. We describe two cases of transcatheter aortic valve implantation via transaortic access in patients with intraoperatively diagnosed contraindications to conventional aortic valve replacement. In the first case, the procedure was performed via median sternotomy in order to allow central cannulation for extracorporeal circulation in a patient without access vessels for peripheral cannulation. In the second patient, the procedure was performed in a minimally invasive fashion via upper partial sternotomy. Both procedures were performed using a transapical sheath and an upside down mounted transcatheter aortic valve prosthesis. Transaortic valve implantation can be successfully used for unexpectedly inoperable patients even without previous evaluation for transcatheter valve implantation.