Bicaval Cannulation Research Articles

Selective monitoring of superior and inferior vena cava drainage flows in bicaval cannulation: Potential clinical benefits of proximal junction placement on the CPB side.

Background: In cardiac surgery, precision and efficiency are crucial, especially in managing venous drainage flows during complex procedures. This practical technique evaluates the benefits of placing the proximal junction on the cardiopulmonary bypass (CPB) side rather than on the surgical table in bicaval cannulation. Bicaval cannulation, involving both the superior vena cava (SVC) and inferior vena cava (IVC), ensures efficient venous return.Practical technique: Placing the junction on the CPB side allows for accurate, real-time control of venous drainage, allowing for swift responses to fluctuations and maintaining stable hemodynamics.Perspectives: This approach could minimize the risk of congestion in the liver, splanchnic system, and cerebral venous return, thereby preventing related complications. Another important potential benefit of this approach could be the ability to closely monitor and manage metabolic demands and oxygen consumption for SVC and IVC. Additionally, EmTec flow technology can be integrated for more precise management.

AN UNCOMMON CASE OF SUPERIOR VENA CAVA SYNDROME FOLLOWING CARDIAC SURGERY

Abstract Superior vena cava (SVC) syndrome (SVCS) is due to the obstruction of the SVC leading to swelling of the upper body and to low cardiac output. Non tumoral causes, mainly thrombosis of endovascular devices, account for 30% of cases. We report a case of acute iatrogenic SVCS. A 7 years old 16 kg boy underwent mitral valve surgery in severe rheumatic mitral regurgitation. After induction a 15 cm 5.5 Fr 3 lumens central venous catheter (CVC) was inserted in the right internal jugular vein (IJV) under ultrasound guidance without issues. After achieving proper anticoagulation ascending aorta (18 Fr) and bicaval cannulation were performed (20 Fr single stage cannula with right–angled metal tip in the SVC and 26 Fr single stage cannula in the inferior vena cava). Cardiopulmonary bypass (CPB) was performed with pediatric circuit and the mitral valve was repaired. Despite apparently good result of the repair and uneventful weaning from CPB a more accurate transesophageal echo (TEE) showed moderate iatrogenic mitral stenosis. Cannulation was re–performed with same size cannulas and mitral valve replacement (St.Jude 25 mm) was provided. After weaning from CPB with mild cardiovascular support (adrenaline 0.03 mcg/kg/min and noradrenaline 0.05 mcg/kg/min) the TEE showed no abnormalities and the patient was transferred to the ICU in stable conditions. The central venous pressure (CVP) never raised over 10 mmHg. In the ICU the patient developed sinus tachicardia and hypotension, unresponsive to fluids and vasopressors, and swelling of the face with no increase in CVP. The chest Xray showed enlargement of the right upper mediastinum with TEE evidence of accellerated flow in the SVC around the CVC (fig.1). The patient was taken to the operating room and a too tigh pursue string suture was found on the SVC. After optimization of the suture the flow through the SVC was restored with immediate clinical improvement and de–escalation of the cardiovascular support. The face oedema quickly decreased allowing extubation on the day after surgery. The following course was uneventful. SVCS is a life threatening complication of cardiac surgery. A too tight pledgetted pursue–string suture is an uncommon cause compared to clot compression. The CVP measured by a IJV CVC is generally elevated in SVCS, but in our case the tip of the CVC was downstream to the stenosis so showing normal values. Multimodal monitoring is mandatory to lead to emergency surgical treatment in case of need.

Use of bi-caval cannulae for veno-venous ECMO in neonates and children

PurposeVeno-arterial ECMO remains the most common mode of extracorporeal support in infants and children, and despite increases in overall ECMO numbers the utilisation of veno-venous ECMO in neonates appears to be decreasing. We report here outcomes of neonatal and paediatric patients managed with veno-venous ECMO via bi-caval cannulae over a 10-year period in a tertiary referral ICU.MethodsRetrospective single-centre case series of veno-venous ECMO cases using dual lumen cannulae over a 10-year period at a tertiary referral paediatric hospital with a low volume ECMO program.ResultsIn the 10-year period 2013–2022, 33 patients required ECMO with 23 receiving veno-arterial ECMO and 10 managed with veno-venous cannulation - 8 with bi-caval cannulae and 2 with multi-site cannulation. Overall survival was 23/33 (69.6%) and in the veno-venous group survival was 7/10 (70%). Median oxygenation index prior to veno-venous cannulation in the 8 patients undergoing bi-caval cannulation was 48 (range 34–54) and median PaO2 was 42 mmHg (range 34–59 mmHg). Duration of ECMO ranged from 7 to 14 days (median 9 days). Complications included migration of the cannula into the hepatic vein, minor and major bleeding, and compromised blood flow secondary to pneumomediastinum.ConclusionsVeno-venous ECMO can be reliably established via a single bi-caval cannula in the majority of patients. Outcomes in this small series from a low volume centre are broadly comparable to those reported from the ELSO database.

Totally thoracoscopic surgical resection of left ventricular benign tumor.

The study objective was to explore the feasibility and safety of totally endoscopic resection of a left ventricular tumor through small chest incisions without robotic assistance. Four patients with a left ventricular tumor (1 papillary fibroelastoma, 1 lipoma, and 2 myxomas) underwent surgery with peripheral cardiopulmonary bypass. The mean age of patients was 58±15years. There were 3 female patients and 1 male patient. Through 3-port incisions in the right chest, pericardiotomy, bicaval cannulation, cardiac arrest, and atriotomy, left ventricular tumor resection was performed under thoracoscopy. All patients had successful resections. The cardiopulmonary bypass and aortic crossclamp times were 110 ± 14 minutes and 58 ± 19minutes, respectively. The length of stay in the intensive care unit was 38 ± 27 hours. There were no mortalities or complications in this cohort. Patients were discharged 7 days after the operation. Transthoracic echocardiography showed that the cardiac tumor was completely removed without any residue 3 months after surgery. Totally endoscopic left ventricular tumor resection without a robotically assisted surgical system is feasible and reproducible. This technique could minimize surgical trauma and achieves complete tumor resection.

Discontinuation of the OriGen® Dual-Lumen Right Atrial Cannula Decreased Venovenous ECMO Usage in Neonates and Older Children: A Survey of the American Pediatric Surgical Association

IntroductionDual-lumen cannulas for venovenous (VV)-ECMO are widely used in pediatric patients. The popular OriGen® dual-lumen right atrial cannula was discontinued in 2019 without a comparable replacement. MethodsA survey covering VV-ECMO practice and opinions was distributed to attending members of the American Pediatric Surgical Association. Results137 pediatric surgeons responded (14%). Prior to discontinuation of the OriGen®, 82.5% offered VV-ECMO to neonates, and 79.6% cannulated with the OriGen®. Following its discontinuation, those that offered only venoarterial (VA)-ECMO to neonates increased to 37.6% from 17.5% (p = 0.0002). An additional 33.8% changed their practice to sometimes use VA-ECMO when VV-ECMO was indicated. Reasons for not incorporating dual-lumen bi-caval cannulation into practice included risk of cardiac injury (51.7%), inexperience with bi-caval cannulation in neonates (36.8%), difficulty with placement (31.0%), and recirculation and/or positioning problems (27.6%). For the pediatric/adolescent population, 95.5% of surgeons offered VV-ECMO prior to OriGen® discontinuation. Few switched to exclusive VA-ECMO (1.9%) when the OriGen® was discontinued, but 17.8% of surgeons began to incorporate selective use of VA-ECMO. ConclusionDiscontinuation of the OriGen® cannula drove pediatric surgeons to alter their cannulation practices, dramatically increasing VA-ECMO use for neonatal and pediatric respiratory failure. These data may suggest a need for targeted education accompanying major technological shifts. Level of evidenceLevel IV.

Cavoatrial hypernephroma resection on cardiopulmonary bypass: Mild/normo-versus moderate hypothermia.

Renal cell carcinoma (RCC) is one of the most prevalent malignant tumors. It extends up into the systemic veins and right atrium. Surgical extraction of such extensions is usually carried out using cardiopulmonary bypass (CPB) with moderate hypothermic (MH) being frequently applied in order to obtain a clear surgical field. However, due to obvious disadvantages of hypothermia, approaches with mild/normothermia (NT) during CPB have also been established. The current study aims to compare the outcomes of patients undergoing RCC tumor and extensions resection using MH versus NT. This is a retrospective, non-randomized study. All patients who underwent RCC tumor and extensions resection for stage III or IV (Staehler) RCC in a single center between 2006 and 2020 were included. During surgery, MH or NT were applied. CPB was realized using aortic and bicaval cannulation. We compared the procedural times, transfusion requirements and postoperative outcomes, respectively between the MH and NT groups. A total of 24 consecutive patients (n(NT) = 12, n(MH) = 12) were included in the study (median age NT 68.5 and MH 66.5). The study only showed a significant difference in heart-lung machine times (median CPB time NT 45.5 min and MH 110.0 min, p = 0.004). All other results, loss of drainage, administration of blood products, as well as the postoperative course and mortality were comparable in both groups. The results showed a high perioperative and long-term mortality. The perioperative course was similar after surgery with NT or MH. Therefore, NT which minimizes potential complications of MH should be preferred.

Technical tips in non-robotic endoscopic mitral valve surgery: How to approach and expose the mitral valve.

The non-robotic endoscopic mitral valve surgery is performed via a right mini-thoracotomy without the use of rib spreader or robotic assistance. Although it has several advantages over the direct vision minimally invasive and robotic approaches, operating in very limited working space without robotic assistance is technically demanding. In the first place, it is impossible to perform non-robotic endoscopic mitral valve surgery safely and efficiently without knowing how to approach and expose the mitral valve in very limited working space without robotic assistance. This manuscript introduces detailed technical tips for efficient approach and uncompromised exposure of the mitral valve in non-robotic endoscopic mitral valve surgery, including separate bicaval cannulation, decentralized positioning of the instruments, controlling the direction of traction sutures and appropriate use of retractors.

Thoracoabdominal Normothermic Regional Perfusion for Cardiac Procurement.

In donation after circulatory death donors, warm ischemia time is a significant threat to successful cardiac transplantation. The ability to perfuse these organs during the minutes after death, until cardiac evaluation is completed to satisfaction, is crucial in limiting total warm ischemic time. Thoracoabdominal normothermic regional perfusion (TANRP) has emerged as a promising strategy for recovering and monitoring these hearts. We propose a series of clinical practice pearls that we follow for all donation after circulatory death procurements to streamline the process of setting up a TANRP circuit and ensuring all team members present at time procurement are familiar with the procedure. Bicaval cannulation is achieved via the abdomen for aortic cannulation, and via the chest for right atrial cannulation, avoiding deairing maneuvers and providing the shortest possible duration from incision to initiation of cardiopulmonary bypass. Here, we describe a series of practice techniques which we have utilized in our early experience with TANRP.

Atrial Embolization after a Transcatheter Mitral Valve Replacement

Atrial Embolization after a Transcatheter Mitral Valve Replacement

Successful use of veno-venous extracorporeal membrane oxygenation for acute chest syndrome in a child with sickle cell disease and SARS-CoV-2.

Children with sickle cell disease (SCD) are at increased risk for severe illness due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We describe the successful native lung recovery of a child with SCD referred for lung transplant (LTx) evaluation who was on prolonged veno-venous extracorporeal membrane oxygenation (VV-ECMO). He initially presented with acute chest syndrome complicated by SARS-CoV-2 infection that ultimately required dual-lumen, single bicaval VV-ECMO cannulation for respiratory support. Despite the increased risk of hemolysis and thrombosis from SCD and SARS-CoV-2 infection, he was successfully supported on VV-ECMO for 71 days without complications leading to native lung recovery with meticulous management of his SCD therapy. This report provides new insight on our approach to VV-ECMO support in a child with SCD and SARS-CoV-2 infection. With a successful outcome, the patient has returned home but still on mechanical ventilation with LTx still an option if he is not eventually liberated from invasive respiratory support.

Enbloc Heart and Lung Transplantation – A Case Report

Enbloc heart and lung transplantation is the recommended ultimate option of surgery for candidates suffering from irreversible end stage heart and lung disease. This major surgery requires a cohesive multidisciplinary teamwork approach to yield a favourable outcome. The role of perfusionist is vital in this complex operation who is an active participant in the preoperative period intra-op and post-operative period. Our Enbloc heart and lung experience - case report highlights the key elements of this surgery from the perfusionist perspective. A 68 year old male patient was suffering from end stage heart and lung disease refractory to medical therapy due to worsened interstitial lung disease and coronary artery disease. His life style was restricted and required heart and lung transplantation at the earliest. He got a suitable donor and successfully underwent Enbloc heart and lung transplantation. The donor was a 24 year old male who was in comatose state due to traumatic brain injury. The donor specific antibody test was performed and the report was negative. Cold custodial and Perfadex Plus was administered to the donor heart and lungs and were harvested. The gold standard approach for Enbloc heart and lung transplantation is the median sternotomy. Standard bicaval and aortic cannulation was done and cardiopulmonary bypass was instituted. The total Cardio Pulmonary Bypass time was 250 minutes. Cold cycle was 144 minutes and warm cycle was 75 minutes. Continuous zero balanced ultrafiltration was done to eliminate the inflammatory mediators and to keep the serum lactate within the normal limits. The various perfusion strategies involved in Enbloc heart and lung transplantation and the involvement of perfusionists in the management of these patients is discussed in the article. Enbloc heart and lung transplantation is the treatment of choice for end-stage heart and lung disease. This type of surgery demands a holistic teamwork approach involving a multidisciplinary team and this helped in the speedy recovery of the patient in the case presented.

Right Vertical Infra-Axillary Thoracotomy Approach in Simple Congenital Heart Diseases

Right thoracotomy approach has been gaining popularity in the repair of simple congenital heart diseases; especially, right vertical infra-axillary thoracotomy (RVIAT) provides a cosmetic benefit that is concealed and less evident but often requires peripheral cannulation. The surgical technique for RVIAT involved a 6-cm vertical incision in the right axillary fold, and cardiopulmonary bypass was established with ascending aorta and bicaval cannulations directly through the same surgical field. Intercostal block was routinely performed intra- and postoperatively to facilitate fast-track postoperative recovery. There is still a large potential to expand the selection criteria of RVIAT approach for further complicated diseases as a promising alternative to standard median sternotomy. Right thoracotomy approach has been gaining popularity in the repair of simple congenital heart diseases; especially, right vertical infra-axillary thoracotomy (RVIAT) provides a cosmetic benefit that is concealed and less evident but often requires peripheral cannulation. The surgical technique for RVIAT involved a 6-cm vertical incision in the right axillary fold, and cardiopulmonary bypass was established with ascending aorta and bicaval cannulations directly through the same surgical field. Intercostal block was routinely performed intra- and postoperatively to facilitate fast-track postoperative recovery. There is still a large potential to expand the selection criteria of RVIAT approach for further complicated diseases as a promising alternative to standard median sternotomy.

PERCUTANEOUS RETRIEVAL OF THE SUTURE-ENTRAPPED SWAN-GANZ CATHETER

TOPIC: Cardiothoracic Surgery TYPE: Fellow Case Reports INTRODUCTION: Pulmonary artery catheters (PAC) are used in cardiac surgery to provide critical clinical data. While safe, they are not harmless with multiple associated risks, including surgical entrapment. Causes of include suture snaring and PAC knotting. We present the case of a surgically entrapped PAC that was successfully removed in a percutaneous fashion. CASE PRESENTATION: A 61-year-old man with MV regurgitation presented for surgical repair. A PA catheter was placed through an 8-FR sheath in the RIJ vein. Sternotomy was performed and the patient was placed on central cardiopulmonary bypass with bicaval venous cannulation. The LA was entered through the inter-atrial groove, and MV repair performed. Following both atriotomy closure and venous decannulation, the anesthesia team reported seamless PAC mobility and the chest was closed. On POD1, removal of the PAC was met with resistance. Imaging confirmed normal PAC position without obvious entrapment. The patient was taken to the IR suite where fluoroscopy revealed tethering of the PAC at the inferior third of the SVC. The proximal aspect of the PAC was then cut and the indwelling sheath was replaced with a 9-FR braided sheath over the PAC, which served as 'guide-wire'. A point of obstruction was detected by tactile sensation. The sheath was then upsized to a 10-FR braided vascular sheath. With gentle, simultaneous, back-and-forth maneuvering of the catheter and sheath, the PAC was liberated and removed. Superior venacavogram revealed brisk flow of contrast through the SVC, RA and pulmonary outflow tract with no evidence of injury. Mediastinal tubes were removed on POD2 and the patient was discharged on POD5. DISCUSSION: PACs provide critical data to help guide therapy. In a review of over 15,000 patients, Kaplan et al reported a low risk associated with their use with entrapment constituting only 0.065%-0.1% of cases. The most common reported sites of entrapment are around the atrio-caval and atriotomy closure site. While a re-do sternotomy has been the traditional approach for retrieval, it carries inherent associated risks. Percutaneous options can be considered if the offending suture is sufficiently loose and has not perforated the PAC. This must be performed in a controlled environment with the appropriate resources available for a re-do sternotomy. Clinical surveillance with a repeat TTE in 24-HR are critical. Ultimately prevention is the best therapy with heightened vigilance during surgery to avoid PAC suture entrapment. CONCLUSIONS: A heightened sense of vigilance and recognition are key to the prevention and management of PAC entrapment. Sensible planning, cautious catheter instrumentation and attentive post-procedure assessment are all key to a successful outcome. In the unfortunate situation that this surgical complication does occur, a percutaneous approach for recovery is a viable and safe option to consider as discussed in our report. REFERENCE #1: A heightened sense of vigilance and recognition are key to the prevention and management of PAC entrapment. Sensible planning, cautious catheter instrumentation and attentive post-procedure assessment are all key to a successful outcome. In the unfortunate situation that this complication does occur, a percutaneous approach for recovery is a viable and safe option to consider. REFERENCE #2: Pfeiffer K, Widmann M, Deusch H, Guggenberger H, Duda S, Seboldt H. Inadvertant suture fixation of a Swan-Ganz catheter to the pulmonary artery following heart surgery. Anaesthetist. 1995;44:782–4 REFERENCE #3: Kaplan M, Demirtas M, Cimen S, et al. Swan-Ganz Catheter Entrapment in Open Heart Surgery. J Cardiothorac Surg. 2000;15:313-315. DISCLOSURES: No relevant relationships by Roger Goldman, source=Web Response Consultant relationship with Medtronic Please note: 5 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Johnson and Johnson Please note: 3 Years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Boston Scientific Please note: 4 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Edwards Life Sciences Please note: 3 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with Abbott Please note: 6 months Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria No relevant relationships by David Li, source=Web Response No relevant relationships by AMIR SARKESHIK, source=Web Response

Optimising risk factors for atrial fibrillation post-cardiac surgery.

Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%-60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery.

Venous drainage for minithoracotomy approach in an adult with interrupted inferior vena cava.

For atrial septal defect closure via right minithoracotomy in an adult patient with infra-hepatic interruption of the inferior vena cava with azygos connection, an alternative venous cannulation strategy was applied. In addition to bicaval cannulations to the femoral vein and the internal jugular vein, a 20 Fr straight cannula draining the hepatic vein was added to the proximal IVC through the right atrium wall via a working port. A bloodless operative field in the right atrium was afforded with bicaval encircling. Preoperative imaging test of the continuity of the IVC was important planning cardiac surgery with peripheral cannulations.

Anesthetic management of pulmonary artery replacement for idiopathic dilatation of the pulmonary artery with a Kommerell\u2019s diverticulum: a case report

BackgroundIdiopathic dilatation of the pulmonary artery (IDPA) is a rare condition in which the pulmonary artery dilates without an obvious cause. Pulmonary artery replacement is indicated in severe cases to prevent serious complications.Case presentationA 59-year-old man was diagnosed with an IDPA of 64 mm and Kommerell’s diverticulum (aortic aneurysm located at the aberrant left subclavian artery). A computed tomography scan revealed slight compression of the aneurysm to the trachea, although not interfering with airway management. The surgical approach was a median sternotomy, and cardiopulmonary bypass was established through aortic and bicaval cannulations. The perioperative course was uneventful.ConclusionsTo prevent injury to the dilated pulmonary artery, a strategy for cardiopulmonary bypass and a surgical approach should be discussed beforehand. As dilatation of the pulmonary artery is often complicated by anatomic abnormalities, preoperative evaluation should be aimed at appropriate assessments using imaging modalities.

Extremely rapid growth of a left atrial myxoma

A 56-year-old lady presented to the Accident and Emergency department with worsening shortness of breath, decreased exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, and recurrent dizzy spells. Symptoms had been persistent in the last one month but worsened over the last two weeks prior to presentation. She is a professional horse rider/trainer and has had multiple trauma to her hip following falls over the past 17 years. Her medical history includes previous small left cerebellar infarct 10 years ago, asthma, previous multiple trauma to the hip with open reduction and internal fixation (ORIF) to the pelvis and right hip replacement, awaiting left total hip replacement, spondylolisthesis L5/S1, previous pulmonary embolism two years prior, previous fall from a horse resulting in fractured clavicle (ORIF right clavicle) and ribs two years prior, lifetime non-smoker. She has had multiple computed tomography (CT) scans for these reasons which were available for comparison (Video1). At presentation, she was dyspneic at rest (NYHA IV) and tachycardic, bilateral crepitations with a soft mid diastolic murmur at the cardiac apex. D-dimer was 1407 ng/mL, with a mild Troponin T rise of 17 ng/L. Emergency department suspected pulmonary embolism and an urgent computed tomography pulmonary angiogram (CTPA) revealed a large filling defect in the left atrium (LA) measuring 6.2 cm by 4.2 cm (Figure 1). She was reviewed by the cardiologist and trans-thoracic echocardiogram confirmed a large mobile mass in the LA measuring 7.67 cm by 3.46 cm. The mass was attached to the left superior pulmonary vein area, plunged into the left ventricle obstructing the mitral orifice in diastole. Right ventricle was dilated with preserved function (Figure 2) (Video2). Her brain natriuretic peptide (BNP) was 4269 pg/mL. She was managed for decompensated heart failure due to obstructive atrial myxoma, commenced on diuretics, anticoagulation, and urgent referral made to the on-call cardiac surgeon. Based on the acute clinical condition and symptoms (frequent dizzy episodes) she was prioritized for out of hours emergency surgery. On induction, she became bradycardic and hypotensive (peri-arrest) but recovered after placing in a Trendelenburg position with right lateral rotation. The rest of the surgery was uneventful. Median sternotomy, bi-caval cannulation, and cardioplegic arrest was performed. Trans-septal approach was used; a large mass was noted, attached by a 2 cm wide base to the back of the LA between the left pulmonary veins; the mass was excised (Figure 3). No patch was required. The mitral valve was normal. The procedure was completed as per routine. Her post-operative course was uneventful. Histology confirmed a left atrial myxoma. At eight weeks follow-up her breathing had improved and she was back to her normal baseline with excellent exercise tolerance.

Echocardiographic guided, transatrial closure of a patent foramen ovale

BackgroundThe management of an incidental patent foramen ovale found during planned cardiac surgery remains a challenge, and current guidelines are not helpful. Although evidence is accumulating, that closure of an incidental found patent foramen ovale might be beneficial, especially in planned off-pump procedures, the diagnosis of a formerly unknown patent foramen ovale with the patient on the operation table has vast consequences by making it necessary to switch to on pump, bi-caval cannulation for patent foramen ovale closure. We therefore developed a technique for transatrial closure of a patent foramen ovale, guided by transesophageal echocardiography.ResultsWe have performed this surgery in 9 patients. None of them had a previously diagnosed patent foramen ovale. Mean age was 74 (±5) years, Operation time was 175 min (± 34 min), Clamp time 35 min (± 16 min) and Cardiopulmonary bypass time 80 (±17 min). Mortality was 0%. Periprocedural transesophageal echocardiography revealed closure of the patent foramen ovale in all cases.ConclusionWe report a new surgical method for transoesophageal echocardiography controlled closure of a patent foramen ovale without the need for an atriotomy. This new technique is especially useful for the closure of patent foramen ovale in the setting of on-pump and off-pump coronary artery bypass graft surgeries alike.

The Da Silva cone operation after the Starnes procedure for Ebstein's anomaly: New surgical strategy and initial results.

The Da Silva cone operation after the Starnes procedure for Ebstein's anomaly: New surgical strategy and initial results.

Cardiac interventions in patients with achondroplasia: a systematic review.

Patients with achondroplasia and other causes of dwarfism suffer from increased rates of cardiovascular disease relative to the remainder of the population. Few studies have examined these patients when undergoing cardiac surgery or percutaneous intervention. This systematic review examines the literature to determine outcomes following cardiac intervention in this unique population. An electronic search was performed in the English literature to identify all reports of achondroplasia, dwarfism, and cardiac intervention. Of the 5,274 articles identified, 14 articles with 14 cases met inclusion criteria. Patient-level data was extracted and analyzed. Median patient age was 55.5 [interquartile ranges (IQR), 43.8, 59.8] years, median height 102.0 [98.8, 112.5] cm, median BMI 32.1 [27.0, 45.9], and 57.1% (8/14) were male. Of these 14 patients, nine had the following documented skeletal abnormalities: 66.7% (6/9) had scoliosis, 66.7% (6/9) had kyphosis, 11.1% (1/9) had lordosis, 11.1% (1/9) pectus carinatum and 11.1% (1/9) spinal stenosis. Coronary artery disease was present in 53.8% (7/13), and 30.8% (4/13) patients previously suffered a myocardial infarction. Of the eight patients who underwent cardiac surgery, 37.5% (3/8) underwent multivessel coronary artery bypass grafting, 37.5% (3/8) underwent aortic valve replacement, 25.0% (2/8) underwent type A aortic dissection repair, and the remaining 12.5% (1/8) underwent pulmonary thromboendarterectomy. Six patients underwent percutaneous intervention. Median cardiopulmonary bypass time was 136.5 [110.0, 178.8] minutes. Median arterial cannula size was 20.0 [20.0, 24.0] Fr. Bicaval cannulation was performed in all cases describing cannulation strategy (5/5). Median superior vena cava cannula size was 28.0 [28.0, 28.0] Fr, and inferior vena cava cannula size was 28.0 [28.0, 28.0] Fr. No mortality was reported with a median follow up time of 6.0 [6.0, 10.5] months. In conclusion, Common cardiac procedures can be performed with reasonable safety in this patient population. Operative adjustments may need to be made with respect to equipment to accommodate patient-specific needs.