Cardiac Surgical Practice Research Articles

Surgical explantation of transcatheter heart valves: A single institution experience

ObjectiveOver the past decade, there has been a dramatic growth in the utilization and diversity of available transcatheter devices for the replacement and repair of all heart valves. The aim of this study is to examine temporal trends, failure profiles, and clinical outcomes involved in the surgical explantation of transcatheter valve prostheses. MethodsAdult patients undergoing surgical explantation of transcatheter valve prostheses between 2014 and 2022 at a single institution were identified. Retrospective cohort review and survival analysis were performed to assess patient characteristics, indications for explant, and operative outcomes. ResultsFrom 2014 to 2022, 8 surgeons at a single institution performed explantation of transcatheter valve prostheses in 44 patients. Among explanted devices, 50% were removed within 1 year of transcatheter implantation. Surgical explantation was performed on an urgent or emergent basis in 57% of patients. Indications for explantation included valve prosthesis failure (57%), iatrogenic injury (16%), and endocarditis (11%). Operative mortality was 11%, with a mean Society of Thoracic Surgeons mortality risk of 12%. Patients undergoing elective explantation had improved survival compared with those undergoing urgent or emergent explantation (P = .03). Overall survival was 77% at 3 years following transcatheter valve explantation. ConclusionsThere is a rising annual incidence of transcatheter valve explantation in all valve positions. Surgical explantation performed on both elective and non-elective bases is increasingly common in adult cardiac surgical practice. The clinical impact of transcatheter valve explantation is significant and should be strongly considered by multidisciplinary heart teams in the lifetime management strategy of cardiac valvular disease.

The emerging role of minimally invasive extracorporeal circulation in totally endoscopic and robotic-assisted cardiac surgery procedures.

Background: This review explores the potential benefits of combining totally endoscopic and robotic-assisted cardiac surgery with minimally invasive extracorporeal circulation (MiECC). Robotic techniques herald a new era of surgical precision, leveraging advanced instrumentation and enhanced visualization to navigate cardiac anatomy with unprecedented accuracy. Purpose: Concurrently, MiECC systems provide tailored physiological support during cardiopulmonary bypass, meticulously managing perfusion parameters to safeguard vital organs' function. Results: The convergence of these cutting-edge technologies marks a paradigmatic shift in cardiac surgical practice, with potential mitigation of invasiveness, attenuation of perioperative complications, and expedite postoperative recovery. Conclusions: This review also addresses prevailing challenges and limitations, including technological complexities and procedural intricacies, while elucidating the strategic imperatives for optimizing their collaborative utilization.

Early Saphenous Vein Graft Aneurysm Rupture: A Not So-Late Complication. Case Report and Comprehensive Literature Review.

Saphenous vein graft (SVG) is a cardiac surgical practice used to create a cardiac bypass in cases of coronary artery obstruction. It consists of a surgical procedure that involves the creation of an aorto-coronary communication by a venous conduit (saphenous vein) to bypass coronary stenosis and allow cardiac revascularization. This practice can be affected by early and late complications. The most feared complication is graft aneurysm or pseudoaneurysm degeneration and rupture which are considered late complications. This paper presents a rare case of SVG aneurysmal rupture that occurred 24 h after surgery and a review of the literature to provide a general look at the state of knowledge. The systematic review was carried out using the guidelines according to the PRISMA method. Cases of aneurysmal rupture have never been described prior to one month after surgery. The male sex and subjects under 45 are the most affected by this complication. Death occurs in less than half of the cases, being more frequent in young people. Performing a CT or angio-CT examination led to the diagnosis. It is impossible to estimate the implanted vessel's quality, so postoperative follow-up is fundamental. Transesophageal ultrasound can be useful, and hematochemical tests are valuable early diagnostic tools, whrease CT and angio-CT can be useful even months after surgery. Forensic analysis should always perform an autopsy and graft histological examination.

Značaj nivoa serumske mokraćne kiseline i sintaks skora u dugoročnom preživljavanju kardiohirurških bolesnika - mokraćna kiselina kod kardiohirurških bolesnika

Introduction: The connection between serum uric acid (SUA) and the occurrence of cardiovascular diseases has long been known. Despite the SYNTAX score emerging as useful for risk identification and stratification in the clinical practice of interventional cardiology, it has not been proven useful in cardiac surgical clinical practice. The aim of the paper is to examine the significance of SUA levels, the significance of the SYNTAX score and the Clinical SYNTAX score in predicting the long-term survival of cardiac surgery patients. Methods: A retrospective analysis of 160 cardiac surgery patients operated on between 2013 and 2014 was conducted. SUA, SYNTAX and clinical SYNTAX score was measured. In the follow-up period of 3 years, clinical outcomes of patients were tracked. Results: The average SYNTAX score was 25.2 ± 11.4, the average Clinical SYNTAX score was 26.9 ± 8.3. The average preoperative SUA level was 361 ± 94.1 mg/ dL. No statistically significant difference was found in the values of the ejection fraction, end-diastolic and end-systolic dimensions of the left ventricle in relation to the treatment outcome in the long-term follow-up (p > 0.05). Preoperative left atrial diameter was significantly higher in deceased patients (p = 0.013). No statistically significant difference was found in the average values of the syntax score in relation to the treatment outcome in the long-term follow-up (p = 0.388), while a statistically significant difference was found in the values of the clinical SYNTAX score (p = 0.029). A statistically significant difference was found in the preoperative values of SUA in relation to the postoperative occurrence of adverse cardiovascular events (p = 0.035). Conclusion: Significant predictors of mortality in the long-term follow-up of cardiac surgery patients were left atrial diameter and clinical SYNTAX score. Predictors of adverse cardiovascular outcomes were left atrial diameter, clinical SYNTAX score and preoperative serum uric acid level.

Evolution of surgery of ventricular septal defect closure

A ventricular septal defect is one of the foremost prevalent congenital heart defects, accounting for around 20% of all congenital heart malformations.<br /> Nowadays, there are three surgical methods for ventricular septal defect: surgical treatment of ventricular septal defect with a heart-lung machine, interventional closure of ventricular septal defect by percutaneous puncture, and hybrid operation (with no heart-lung machine).<br /> Hybrid operation – there is some of the latest evolutions introduced in cardiac surgical treatment practice. This technique is mild, to reduce surgical trauma, and perform not connecting the patient to the heart-lung machine, without X-ray exposure, and there are additional indications than the interventional procedure.<br /> The article reviewed literature sources on the surgical treatments of the ventricular septal defect and the results of the above methods, and also considers more detail especially hybrid operation (without a heart-lung machine).

Replacement of aortic valve flaps with an autopericardium using the S. Ozaki technique

Classical aortic valve replacement is often fraught with negative outcomes for patients. When replacing the aortic valve with a mechanical valve prosthesis, the patient is associated for life with the use of indirect anticoagulants, which often leads to hemorrhagic and thrombotic complications. In the case of replacement of the aortic valve with a biological prosthesis, a fairly frequent complication is early calcification and, consequently, a high frequency of dysfunctions of the biological prosthesis. In addition, mechanical and biological prosthetics of heart valves are quite expensive, which creates a serious economic load on the healthcare institution. But in the last decade, the technique of neocuspidization of the aortic valve with autopericardial flaps has been introduced into wide cardiac surgical practice, which is a clear alternative to prosthetics of heart valves.

ICU Readmission in Cardiac Surgical Subset: A Problem Worth Pondering

AbstractOver the past decades, there have been noteworthy advancements in the cardiac surgical practice that have assisted fast-tracking and enhanced recovery after cardiac surgery (ERACS). With that said, intensive care unit (ICU) readmission in this high-risk patient cohort entails a significant morbidity–mortality burden. As an extension of the same, there has been a heightened emphasis on a comprehensive evaluation of the predisposition to readmission following a primary ICU discharge. However, the variability of the institutional perioperative practices and the research complexities compound our understanding of this heterogeneous outcome of readmission, which is intricately linked to both patient and organizational factors. Moreover, a discussion on ICU readmission in the recent times can only be rendered comprehensive when staged in close conjunction to the fast-tracking practices in cardiac surgery. From a more positive probing of the matter, a preventative outlook can likely mitigate a part of the larger problem of ICU readmission. Herein, focused cardiac prehabilitation programs can play a potential role given the emerging literature on the positive impact of the former on the most relevant readmission causes. Therefore, the index review article aims to address the subject of cardiac surgical ICU readmission, highlighting the magnitude and burden, the causes and risk-factors, and the research complexities alongside deliberating the topic in the present-day context of ERACS and cardiac prehabilitation.

FLEXIBLE IMPLANTABLE PEDIATRIC TOTAL ARTIFICIAL HEARTS: THE FUTURE IS HERE

In pediatric patients with congenital heart diseases need for ventricular assist devices adds on to risk score, especially in single ventricle situations. If technology provides with devices that could t into the available pericardial space without venous compression, total articial hearts would be the acceptable rst option in pediatric patients with indications for the same, the repertoire of which is continuously expanding with availability of smaller devices and emerging horizon of drive less articial hearts. Borderline situations can be very correctly evaluated using virtual t technologies. Of around 1000 TAH implants worldwide, less than 5% are pediatric, the volume of which would increase exponentially if exible implantable pumps with adequate hemodynamics emerge in the eld. Though initial applications centre on bridge to transplant, emerging technologies would make it feasible as destination therapy. Syncardia 50cc and evolving versions of Saispandan, based on hybrid bearing less switched reluctance motors which are ultra miniaturized are exciting prospects. But the future belongs to exible articial organs which would include implantable micro pumps that are centrifugally levitated with specialized impeller coating and CET charging methods. Total articial hearts would be the gold standard management in horizon for pediatric biventricular failure. Use of soft materials and exible electronics with tissue compatible materials are emerging fast to revolutionize the domain of cardiac surgical practice. Future is for exible articial organs – pediatric total articial hearts, microuidac lungs to begin with.

Effects of the COVID-19 Pandemic on Cardiac Surgery Practice and Outcomes.

BackgroundWhile the coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of health care, its impact on cardiac surgical practice and outcomes is yet to be determined. We compared the outcomes of our cardiac surgical practice from the past year during the pandemic to those in a similar pre-pandemic period.MethodsRetrospective data were collected from 307 patients who were involved in all adult cardiac surgical procedures performed between March 2020 and February 2021, which was considered the pandemic period, at Amrita Institute of Medical Sciences, India. These were compared with data from the 1-year period between March 2019 and February 2020. During that earlier period, 491 patients underwent surgery, and the surgical outcomes were assessed. Outpatient visit data were also collected to evaluate the effect of COVID-19 on outpatient follow-up visits.ResultsA 37% decrease in surgical case volume was observed during the study period. No difference was found in operative mortality between the 2 time periods (3.3% vs. 2.6%, p=0.383). Overall postoperative complications were less frequent during this period, at 23% compared to 38% the previous year (p<0.001).ConclusionThe COVID-19 pandemic caused a dramatic decrease in surgical volume and outpatient medical follow-up. However, the pandemic and its attendant social restrictions did not yield a significant change in the surgical outcomes of our patients. Hence, it is reasonable to continue cardiac surgical care during global health crises, and this can be done with good results.

Ukraine, war and cardiac surgical practice: correspondence.

Ukraine, war and cardiac surgical practice: correspondence.

Cardiac Surgery and Covid-19 Insight into Peri-Operative Management

Background: Health care is seriously affected by the corona virus disease 2019 (COVID-19) pandemic with alarming effects upon conduct of cardiac surgery. The initial resource conservation strategy has to modify for handling the surging case load due to deference of routine care in the face of pandemic. Methods: The cardiac surgical practice during the lockdown period (from 25th March till 30TH November 2020) at a tertiary care centre was observed. The cardiac diagnosis of the ones operated, conduct algorithm, and working policy were analyzed. Descriptive statistics was applied to calculate the percentages of different case subsets in both adult and pediatrics groups. Results: Total of 333 emergency cases were operated on during the time frame from 25thMarch 2020 to 30thNovember 2020. Cases were divided into adult and pediatric cases. Total adult cases were 160 (48%) in number. Adult cases were further classified into aortic cases, coronary artery disease, valvular pathologies and miscellaneous ones. Total 11 aortic cases (6.8%), 43 CABG cases (26.8%), 42 valvular cases (26.2%) and 83 miscellaneous cases (51.8%) were operated. In the pediatric population, a total of 173 cases (52%) were operated, with 42 cases (24.2%) being arterial switch operations, one case of ALCAPA repair (0.5%), 25 cases (14.4%) of TAPVC repair and others (60.6%). All cases were preoperatively COVID-19 negative. However postoperatively 10 patients (3%) showed symptoms of COVID-19 and on testing turned out to be COVID-19 positive. 8 patients (80%) were transferred to dedicated COVID-19 facility for management and later 6 (60%) were discharged after successful management. There was no COVID-19-related mortality and none of the health-care workers developed COVID-19 in the entire study period. Conclusion: The initial phase of resource conservation has undermined the routine cardiac surgical practice. The study showed that strict adherence to management algorithm is necessary for persisting smooth continuation of cardiac surgical practice with provision of optimum critical care. The strategic comeback against COVID-19 would urge institutional development of protocols to aid the post-surge period.

Effects of COVID-19 pandemic on cardiac surgery and practice. Did we hit the mark: strategy or casuality?

BackgroundCOVID-19 pandemic is having a collateral health effect on delivery of surgical therapies and reports from management and maintaining surgical care are little.PurposeInvestigate the impact of COVID-19 in our cardiac surgical ward and practice by scoping review of the last two years of activity, between 1st March 2019 and 28th February 2021.MethodsOur Hospital is a private institution accredited with the National Health Service with a global volume load of 750 cardiac cases per year.We analized the pre-pandemic and the ongoing pandemic period on volume activity, the capacity of satisfying the needs of cardiosurgical patient and the mortality rate.ResultsWe observed a minimal cardiac surgery caseload decline of 14.8%, probably due to environmental factor, the absence of E.D. in our institute, the rapid re-organization pathways, the hospital surveillance, the supply of personal protective equipment, the informative measures to improve patient and personnel welfare.In order to enhance the pshycological impact of this devastating event, we invited all the health workers to fill a questionnaire regarding concerns and worries about the risk of transmitting the infection to their families or to aquire it themselves.ConclusionDuring this devastating pandemic the rapid response in re-organization pathways and hospital surveillance allowed us to preserve the cardiac surgery volume of life-saving and non deferrable cases.Funding AcknowledgementType of funding sources: None.

Derailed Cardiac Surgical Practice during COVID-19 Pandemic: Concerns and Proposed Solution Strategy

AbstractThe current ongoing novel corona virus disease 2019 (COVID 19) pandemic has led to reallocation of substantial hospital resources and workforce depriving the institution’s ability to handle the routine caseload. The sustenance of health care would require a comprehensive management plan and focused strategy. The cardiac surgical department would consume majority of critical care resources, hence, a balance should be sought between the resumption of routine surgeries and the emergency unavoidable ones. We have proposed an alternative plan to guide the formulation of a strategic comeback.

Method of optimal hydraulic dilatation of venous conduits for coronary artery bypass grafting

Hydraulic dilatation is used in everyday cardiac surgical practice for assessment of leak-proofness and prevention of spasm of autovenous shunts. The classical technique envisages manual high-pressure solution injection, which exerts a negative effect on venous conduits and is one of the causes of incompetence of shunts in the postoperative period. Limiting pressure during hydraulic dilatation is necessary to minimize morphological changes and preserve functional viability of venous conduits. The purpose of the present study was to develop and assess efficacy of a standardized methodology of controlled hydraulic dilatation of venous conduits. We worked out an original technique of controlled hydraulic dilatation of venous conduits under perfusion pressure of artificial circulation. This was followed by assessing morphological changes and functional viability of venous segments after controlled hydraulic dilatation as compared with veins after conventional uncontrolled hydraulic dilatation and the control intact veins. Uncontrolled hydraulic dilatation was accompanied by endothelial damage (p<0.05), multiple conduit wall tears (p<0.05) according to the findings of light microscopy, leading to a significant decrease in the functional vitality of the venous conduit (a decreased reaction to hyperpotassium solution, phenylephrine, acetylcholine and sodium nitroprusside (p<0.05) according to the findings of biophysical examination. Our original technique of controlled hydraulic dilatation of venous conduits under perfusion pressure of artificial circulation made it possible not only to evaluate leak-proofness of the vessel but also to achieve comparable to the control segments parameters of structural integrity of the venous wall and functional viability of the conduit. Thus, using the developed method of controlled hydraulic dilatation makes it possible to minimize morphofunctional alterations in venous conduits, influencing the function of autovenous shunts.

To Retrograde Autologous Prime or Not?

To Retrograde Autologous Prime or Not?

Perioperative care in cardiac surgery.

As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.

Using near-infrared spectroscopy myocardial oximetry to monitor myocardial oxygen balance in a swine model of cardiac surgery: a descriptive study.

Monitoring of the adequacy of myocardial protection with cardioplegia is nearly non-existent in clinical cardiac surgical practice and instead relies on well-defined protocols for delivery of cardioplegia often resulting in inadequate protection. We hypothesized that Near Infrared Spectroscopy technology could be useful in the monitoring of the myocardial oxygen state by attaching the monitors to the epicardium in a porcine model of cardiac surgery. The experiments were conducted with 3 different protocols of 2 pigs each for a total of 6 pigs. The objective was to induce episodic, oxygen supply-demand mismatch. Methods for decreased supply included decreasing coronary blood flow, coronary blood hypoxemia, coronary occlusion, hypovolemia, and hypotension. Methods for increase demand included rapid ventricular pacing and the administration of isoproterenol. Changes in myocardial tissue oximetry were measured and this measurement was then correlated with blood hemoglobin saturations of oxygen from coronary sinus blood samples. We found that decreases in myocardial oxygen supply or increases in demand due to any of the various experimental conditions led to decreases in both myocardial tissue oximetry and hemoglobin oxygen saturation of coronary sinus blood with recovery when the conditions were returned to baseline. Correlation between myocardial tissue oximetry and hemoglobin oxygen saturation of coronary sinus blood was moderate to strong under all tested conditions. This may have translational applications as a monitor of adequacy of myocardial protection and the detection of coronary occlusion.

Cardiac Surgery Conduct during COVID-19 Pandemic

Abstract Background Health care is seriously affected by the coronavirus disease 2019 (COVID-19) pandemic with alarming effects upon conduct of cardiac surgery. The initial resource conservation strategy has to modify for handling the surging case load due to deference of routine care in the face of pandemic. Methods The cardiac surgical practice during the lockdown period (from 25th march till 25th June) at a tertiary care centre was observed. The cardiac diagnosis of the ones operated, conduct algorithm, and working policy were analyzed. Descriptive statistics was applied to calculate the percentages of different case subsets in both adult and pediatric groups. Results A total of 93 cardiac patients were consecutively operated during the 3 months’ period in two cardiac theatres of a total eight dedicated and were rotated cyclically. A total of 37 (39.78%) adult cardiac surgeries were performed out of 93 cases, with coronary artery bypass grafting (11.83%: 11/93) and valvular heart diseases (11.83%: 11/93) constituting the majority. Pediatric cardiac surgeries constituted 56 cases (60.21%) which comprised of arterial switch operation (19.35%), total anomalous pulmonary venous connection (8.60%), and Blalock Taussig shunts (7.53%) predominantly. There was no COVID-19-related mortality and none of the health-care workers developed COVID-19 in the entire study period. Conclusions The initial phase of resource conservation has undermined the routine cardiac surgical practice. The study showed that strict adherence to management algorithm is necessary for persisting smooth continuation of cardiac surgical practice with provision of optimum critical care. The strategic comeback against COVID-19 would urge institutional development of protocols to aid the post-surge period.

Elevated preoperative C reactive protein level as an independent risk factor for mortality after coronary bypass graft surgery

Introduction Perioperative risk estimation score systems used in cardiac surgical daily practice contains variables about preoperative laboratory parameters. C reactive protein was studied as a potential risk factor in cardiovascular/coronary artery diseases (CAD). We aimed to identify the relationship between the preoperative C reactive protein level and surgical patients postoperative mortality. Methods Current study was performed in a cardiac surgery center at Semmelweis University, Budapest, Hungary. During a retrospective analysis patients who underwent coronary artery bypass graft surgery were examined between 2009 and 2019. Routine preoperative patient and laboratory parameters, basic surgical variables were collected. The effect of preoperative C reactive protein and overall mortality was observed as primary outcome. After descriptive statistics clustering was performed. Low CRP level was coded below 1,99, normal between 2 and 4,99, elevated between 5 and 9,99 and high above 10mg/L. Survival analysis (Kaplan-Meier method) and Cox-regression were performed using clusters. Results Totally 1010 patients were enrolled, 75.2% were male. Median age was 66 years (IQR: 61-72ys), the median follow-up time was 899 days (IQR: 482-1473 days). During follow-up 144 patients (14.26%) has died. Elective surgery was 26.34%, urgent 57.03% and acute/rescue 16.63% of the cases. According to CRP level: 43.66% was low, 29.90% normal, 13.37% elevated and 13.03% high. In the aspect of survival there was a significant difference between normal and elevated (p=0.002) and normal and high (p Discussion Even the mildly elevated preoperative C reactive protein level could be an independent risk factor in patients undergoing coronary artery bypass grafting. Consideration of the preoperative CRP level could be a useful supplement to general risk estimation score systems.

A rare chest X-ray sign in the diagnosis of an intracardiac bullet: case report

BackgroundGunshot injuries to the heart are often seen in cardiac surgical practice. Victims are usually investigated with various types of imaging modalities, including simple chest X-ray (CXR) which is a primary imaging modality that can easily locate a bullet and is useful in monitoring before surgical intervention as bullets may migrate.Case presentationA 32-year-old man was admitted as an emergency in a primary hospital after being injured by a gunshot to the chest. The bullet entry was over the back of the left shoulder with no exit point seen. The chest X-ray showed left pleural effusion and a retained intrathoracic bullet. A chest drain was inserted and drained 2200 ml of blood. Computed tomography (CT) scan showed an intracardiac bullet associated with left lower lobe contusion and left-sided hemothorax. He was urgently transferred to theater for exploration via left thoracotomy. The bullet could not be found so the inlet point in the left ventricle was sutured. After stabilizing the patient, he was referred to a specialized cardiac center for further management.The patient arrived at our center 2 days after the injury, fully conscious and hemodynamically stable. On arrival, chest X-rays were obtained to rule out possible migration of the bullet and revealed that the retained bullet was still within the cardiac silhouette. The X-ray appearance of the bullet showed a characteristically double contour, strongly suggesting that the bullet had lodged in the heart muscle and was moving with each heartbeat.The patient was transferred to the theater for median sternotomy. The aorta, superior vena cava, and inferior vena cava were cannulated, and cardiopulmonary bypass was initiated. The aorta was cross-clamped and the cardioplegia was given. Palpation of the still heart readily identified the bullet within the interventricular septum. The left ventricle was opened 1 cm from the left anterior descending artery just on top of the bullet. The bullet was successfully retrieved. The bullet was transfixing the septum causing a small ventricular septal defect which was closed using a Teflon patch and the ventricle was repaired.ConclusionThe double contour appearance of the bullet indicates that the bullet is moving and strongly suggests an intramyocardial position.