Cardiopulmonary Bypass Support Research Articles

Shortening cardioplegic arrest time in patients undergoing combined coronary and valve surgery: results from a multicentre randomized controlled trial: the SCAT trial.

OBJECTIVES: Combined coronary artery bypass grafting and valve surgery requires a prolonged period of cardioplegic arrest (CA) predisposing to myocardial injury and postoperative cardiac-specific complications. The aim of this trial was to reduce the CA time in patients undergoing combined coronary artery bypass grafting and valve surgery and assess if this was associated with less myocardial injury and related complications. METHODS: Participants were randomized to (i) coronary artery bypass grafting performed on the beating heart with cardiopulmonary bypass support followed by CA for the valve procedure (hybrid) or (ii) both procedures under CA (conventional). To assess complications related to myocardial injury, we used the composite of death, myocardial infarction, arrhythmia, need for pacing or inotropes for >12 h. To assess myocardial injury, we used serial plasma troponin T and markers of metabolic stress in myocardial biopsies. RESULTS: Hundred and sixty patients (80 hybrid and 80 conventional) were randomized. Mean age was 66.5 years and 74% were male. Valve procedures included aortic (61.8%) and mitral (33.1%) alone or in combination (5.1%). CA time was 16% lower in the hybrid group [median 98 vs 89 min, geometric mean ratio (GMR) 0.84, 95% confidence interval (CI) 0.77–0.93, P = 0.0004]. Complications related to myocardial injury occurred in 131/160 patients (64/80 conventional, 67/80 hybrid), odds ratio 1.24, 95% CI 0.54–2.86, P = 0.61. Release of troponin T was similar between groups (GMR 1.04, 95% CI 0.87–1.24, P = 0.68). Adenosine monophosphate was 28% lower in the hybrid group (GMR 0.72, 95% CI 0.51–1.02, P = 0.056). CONCLUSIONS: The hybrid procedure reduced the CA time but myocardial injury outcomes were not superior to conventional approach. TRIAL REGISTRATION: ISRCTN65770930.

Resection of Stage IV Cavoatrial Tumor Extension Using Cardiopulmonary Bypass or Extracorporeal Life Support: Comparison of Long-Term Outcomes

Resection of Stage IV Cavoatrial Tumor Extension Using Cardiopulmonary Bypass or Extracorporeal Life Support: Comparison of Long-Term Outcomes

Extraction of Atrial and Pulmonary Thrombi Using Angiovac Aspiration System with Transesophageal Echocardiography and Fluoroscopic Guidance

Surgical embolectomy is widely used to treat massive or submassive pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. [1]-[3] However, recently a new minimally invasive transvenous approach to clot evacuation using the AngioVac aspiration system (Vortex Medical, Norwell, Massachusetts) such as AngioVac aspiration system has been successfully used for retrieval of right atrial clot [4]-[6]. This is the first case report describing evacuation of trans-septal thrombus using an AngioVac aspiration system utilizing transesophageal echocardiograph (TEE) and fluoroscopic guidance. This case report also highlights the potential complications involved in AngioVac system which were readily diagnosed using TEE. We present a 66-year-old Caucasian female with a right atrial thrombus extending into left atrium through a patent for ovale (PFO) defect and a pulmonary artery thrombus. She underwent suction evacuation with an AngioVac aspiration system under TEE and fluoroscopic guidance. The right atrial thrombus extending into left atrium through a PFO was successfully evacuated through the PFO. However, the evacuation of the clot in the pulmonary artery was complicated by a rupture of the right ventricle requiring emergent sternotomy, cardiopulmonary bypass (CPB) and transient extracorporeal mechanical oxygenation (ECMO) support. The patient rapidly improved post-operatively and was discharged from hospital. Echocardiographic documentation of right heart thrombus and pulmonary emboli has poor prognostic implications. This report delineates the utility of TEE for visualization of cannula placement and real time aspiration of clots through the cannula. Potential complications associated with this technique are mechanical dislodge of thrombus from its attachment with subsequent embolization and rupture of cardiac chambers. Accessing the thrombus in the PA can be challenging and actual visualization of the cannula in the PA is often difficult and available only through TEE. This report highlights the utility of TEE for demonstrating trans-septal clot and the importance of precise positioning of cannula in avoiding complications. In spite of complications, AngioVac aspiration system under TEE and fluoroscopic guidance may become a safe alternative for surgical removal of intracardiac thrombi.

Effects of Perioperative Fluid Replacement Therapy in Lung Transplant Patients.

Approximately 10 to 25 lung transplant procedures are performed annually in Finland, and 1-year survival has been 95% over the last 10 years. Our aim was to find associations between perioperative fluid replacement therapies and postoperative patient outcomes, with special emphasis on the use of colloids and blood products. We retrospectively evaluated data from 100 patients who underwent lung transplant with cardiopulmonary bypass support in Finland from 2007 to 2013. Outcomes of interest were length of intensive care unit and hospital stays, time in ventilator, use of extracorporeal membrane oxygenation postoperatively, postoperative renal replacement therapy, postoperative graft failure, and 1-year mortality. Of 100 patients, 12 were on extracorporeal membrane oxygenation preoperatively. The 1-year mortality was 5/100 (5%), and the 3-year mortality was 7/100 (7%). Intraoperative fluid balance was positive (4762 a 3018 mL) but fell significantly postoperatively (below +1000 mL on postoperative day 1). During postoperative days 2 to 7, net fluid balance continued decreasing and stayed negative. Intraoperative use of hydroxyethyl starch and fresh frozen plasma were significantly higher in patients who died during follow-up versus those who survived (P < .05). Intraoperative use of fresh frozen plasma, but not red blood cells or platelets, correlated with graft failure (P = .012). Postoperative use of colloids or blood products did not correlate with mortality or graft failure. Patients who were on extracorporeal membrane oxygenation preoperatively stayed longer on ventilators and had longer intensive care unit and hospital stays (P < .001). Eight patients needed postoperative renal replacement therapy. Intraoperative use of fresh frozen plasma and hydroxyethyl starch is associated with increased mortality and graft failure. Postoperative use of colloids and red blood cells did not correlate with patient outcome. Use of extracorporeal membrane oxygenation preoperatively resulted in prolonged length of hospital stay.

Selective cerebral perfusion prevents abnormalities in glutamate cycling and neuronal apoptosis in a model of infant deep hypothermic circulatory arrest and reperfusion

Deep hypothermic circulatory arrest is often required for the repair of complex congenital cardiac defects in infants. However, deep hypothermic circulatory arrest induces neuroapoptosis associated with later development of neurocognitive abnormalities. Selective cerebral perfusion theoretically provides superior neural protection possibly through modifications in cerebral substrate oxidation and closely integrated glutamate cycling. We tested the hypothesis that selective cerebral perfusion modulates glucose utilization, and ameliorates abnormalities in glutamate flux, which occur in association with neuroapoptosis during deep hypothermic circulatory arrest. Eighteen infant male Yorkshire piglets were assigned randomly to two groups of seven (deep hypothermic circulatory arrest or deep hypothermic circulatory arrest with selective cerebral perfusion for 60 minutes at 18℃) and four control pigs without cardiopulmonary bypass support. Carbon-13-labeled glucose as a metabolic tracer was infused, and gas chromatography–mass spectrometry and nuclear magnetic resonance were used for metabolic analysis in the frontal cortex. Following 2.5 h of cerebral reperfusion, we observed similar cerebral adenosine triphosphate levels, absolute levels of lactate and citric acid cycle intermediates, and carbon-13 enrichment among three groups. However, deep hypothermic circulatory arrest induced significant abnormalities in glutamate cycling resulting in reduced glutamate/glutamine and elevated γ-aminobutyric acid/glutamate along with neuroapoptosis, which were all prevented by selective cerebral perfusion. The data suggest that selective cerebral perfusion prevents these modifications in glutamate/glutamine/γ-aminobutyric acid cycling and protects the cerebral cortex from apoptosis.

Abstract PR063

Background & Objectives: Inferior vena caval (IVC) tumor thrombus with cardiac extension is a very rare phenomenon, which proliferates fast and could be very challenging to the surgery. This research was designed to investigate the influence of Transesophageal Echocardiography (TEE) on the surgical resection of IVC tumor extending into right cardiac cavities. Materials & Methods: Six cases from our medical institute, preoperatively diagnosed as IVC tumor with cardiac extension and scheduled for the surgical resection, were retrospectively analyzed. In addition to real-time and dynamic monitoring, comprehensive TEE exams were performed for all the patients respectively after anesthesia induction, namely before tumor resection and after tumor resection. Cardiac extension was defined by the preoperative finding of cardiac mass originated from IVC tumor by Transthoracic Echocardiography (TTE), computerized tomography (CT) or CT angiography (CTA). Results: In all the cases, intraoperative TEE provided an accurate and excellent view of the IVC tumor. For case three, the IVC tumor was found at the IVC entrance to right atrium without further cardiac extension; for case five, the IVC tumor proliferated into right atrium but the extended cardiac mass was very slim and flexible and the tricuspid valve was untouched; for case four, the IVC tumor extended into right atrium and even cross the tricuspid valve but the extended cardiac mass was also very slim and flexible. Based on the TEE-provided information, the originally scheduled surgical decision was modified and the surgical resection was performed without cardiopulmonary bypass (CPB). For other three cases, the intraoperative TEE showed similar results to preoperative findings. The huge IVC tumor extended into the right heart, presented almost no flexibility and dramatically compromised the intracardiac blood flow. For the three cases, CPB support was indispensible for the tumor resection. The full TEE exam after tumor resection in all the six patients displayed clear surgical resection without tumor residuals, but in those three patients suffered with severely compromised cardiac extension, severe tricuspid regurgitation was noticed. All the six patients were closely monitored until discharged, and no TEE related complications were observed. Conclusion: Our research is the first report about TEE’s utilization in a series of consecutive patients undergoing surgical resection of IVC tumor with cardiac extension. In addition to its safety and effectiveness, TEE can provide valuable information for surgical decision making, results assessment of the surgical intervention and anesthesia management strategies. Disclosure of Interest: None declared

Cardiopulmonary Bypass and Mechanical Support

Cardiopulmonary Bypass and Mechanical Support

Clinical equivalency of cardiopulmonary bypass and extracorporeal membrane oxygenation support for pediatric tracheal reconstruction.

Pediatric surgery for congenital tracheal stenosis continues to be a therapeutic challenge, and it often requires cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) for intra-operative extracorporeal cardiorespiratory support. The purpose of this study was to compare the peri-operative outcomes of CPB with ECMO in pediatric tracheal reconstruction. Forty-three consecutive patients who underwent tracheal reconstruction without intra-cardiac repair for congenital tracheal stenosis at Kobe Children's Hospital between January 2000 and August 2012 were enrolled in this retrospective study. They were divided into two groups according to intra-operative extracorporeal cardiopulmonary support [CPB (n=17) or ECMO (n=26)]. Peri-operative variables were compared between the two groups. The CPB and ECMO groups had similar patient and operative characteristics. However, the CPB group required larger priming volume and higher doses of total heparin injection. Although the ECMO group exhibited less peri-operative bleeding and lower red blood cell requirement, there were no statistically significant differences between the two groups. Compared to the ECMO group, patients in the CPB group had significantly less positive fluid balance during surgery and in the first 24h after surgery, and exhibited a trend towards higher ratios of PO2 to the fraction of inspired oxygen and lower PCO2 at the time of ICU admission and on post-operative day 1. Pediatric tracheal reconstruction should be performed with intra-operative CPB or ECMO, after considering the advantages of utilizing each extracorporeal cardiorespiratory support type according to the patient's specific condition and situation.

Cardiopulmonary Bypass and Extracorporeal Life Support in Non-cardiac Surgery

Cardiopulmonary Bypass and Extracorporeal Life Support in Non-cardiac Surgery

A rare case of right ventricular myxoma causing recurrent stroke

We present a 62-year-old lady admitted in our hospital with two episodes of acute ischemic stroke about 2 weeks apart. She was evaluated for acute ischemic stroke and was thrombolysed for recent stroke in right MCA territory first time. On further evaluation, she was found to have a RVOT mass. A transthoracic and transesophageal echocardiogram revealed a PFO and a large, 5.1cm×2.3cm, ovoid, well circumscribed, echogenic mass in the right ventricle outflow tract attached by small pedicle to the ventricular side of anterior tricuspid leaflet, partly obstructing the right ventricular outflow tract and protruding through the pulmonic valve during systole. She was scheduled for surgery (right ventricular mass excision and PFO closure) after 3 weeks due to the risk of secondary hemorrhage in the infarcted area following thrombolysis and anticoagulation and so was discharged with medications after full neurologic recovery after about a week of hospital stay.She was readmitted 7 days after discharge, before the scheduled date of surgery with history of weakness of right upper limb, slurred speech and mild breathing difficulty lasting for about 20min following which she improved slowly (transient ischemic attack). The tumor was completely removed with the stalk using cardiopulmonary bypass support. The histopathological findings confirmed the diagnosis of myxoma.

Histological examination of the right atrial appendage after failed catheter ablation for focal atrial tachycardia complicated by cardiogenic shock in a post-partum patient

A 26-year-old woman in her first pregnancy presented with persistent atrial tachycardia (AT). AT was resistant to medications, cardioversions, and the first attempt of catheter ablation. Two months after delivery she developed severe systolic dysfunction and circulatory collapse. Emergent catheter ablation was performed with the support of percutaneous cardiopulmonary bypass and intraaortic balloon pump. The AT originated in the apex of the right atrial appendage (RAA). Repeated attempts at ablation were unsuccessful, prompting surgical RAA resection, which terminated the tachycardia and improved the cardiac function. Histological examination of resected RAA provided insights into mechanism of resistance to catheter ablation.

Monitoring the correlation between passive leg-raising maneuver and fluid challenge in pediatric cardiac surgery patients using impedance cardiography

Aim The aim of the study was to highlight the effectiveness of passive leg-raising maneuver as a predictor of fluid responsiveness in pediatric patients following cardiac surgery and to determine the parameter that we can depend on to assess its responsiveness. Patients and methods This prospective randomized study was performed in the ICU. Forty pediatric patients aged 2-7 years with a noncyanotic cardiac defect scheduled for elective corrective cardiac surgery under cardiopulmonary bypass (CPB) support were included if they needed fluid challenge (FC) in the early postoperative period (10 ml/kg normal saline infusion). Hemodynamic parameters [heart rate, mean blood pressure, stroke volume (SV), and cardiac index (CI)] were assessed at baseline, after passive leg raising (PLR), at baseline again, and after FC. Statistical analysis A comparison of pre-PLR and post-PLR hemodynamic parameters and those before and after FC was made using the paired Student's t-test, whereas a comparison after passive leg raising (PLR) and FC was made using the unpaired Student's t-test. The hemodynamic parameters after PLR and its relation to the responses to fluid administration were analyzed using diagnostic validity tests and the χ2 -test. Results The increase in SV and CI with PLR is significantly correlated with the response to fluid administration. An increase in CI by 10% or more due to PLR predicted preload-dependent status with a sensitivity of 65% and a specificity of 75%, whereas an increase in SV by more than 10% due to PLR predicted preload-dependent status with a sensitivity of 42.1% and a specificity of 85.7%. Conclusion The PLR maneuver is a reliable noninvasive method that can predict volume responsiveness in post-cardiac-surgery pediatric patients. Both SV and CI can be used as predictors of fluid responsiveness, although CI is a more accurate.

Mechanical Circulatory Support Following Norwood Palliation

Historically, mechanical circulatory support for the newborn, particularly those with a single-ventricle physiology, such as hypoplastic left heart syndrome, has been limited to extracorporeal membrane oxygenation. The results using extracorporeal membrane oxygenation have been less than optimal, and the application of the Berlin Heart, the only pediatric ventricular assist device the Food and Drug Administration has approved to date, has also been unsuccessful. We present a compilation of techniques that can be applied to these infants. The key principle revolves around the cannulation technique (and cannula used), which involves the placement of an aortic cannula flush with the surface of the common atrium (avoiding any extracorporeal surface exposure within the heart chambers). Further, the application of a centrifugal pump allows for a quite effective decompression of the heart in this setting. Lastly, the described approach allows the provision of support in a rather simple fashion without the use of cardiopulmonary bypass support and without the need for a ventriculotomy.

Transfemoral transcatheter aortic valve insertion-related intraoperative morbidity: Implications of the minimalist approach

ObjectivesTransfemoral transcatheter aortic valve insertion may be performed in a catheterization laboratory (ie, the minimalist approach). It seems reasonable when considering this approach to avoid it in patients at risk for intraoperative morbidity that would require surgical intervention. We hypothesized that it would be possible to associate baseline characteristics with such morbidity, which would help heart teams select patients for the minimalist approach. MethodsWe reviewed the records of 215 consecutive patients who underwent transfemoral transcatheter aortic valve insertion with a current commercially available device from November 2008 through July 2015. Demographic characteristics of the patients included a mean age of 78.9 ± 10.6 years, female sex in 73 patients (34.0%), and a mean Society of Thoracic Surgeons predicted risk of mortality of 8.7% ± 5.4%. Valve prostheses were balloon-expandable in 126 patients (58.6%) and self-expanding in 89 patients (41.4%). ResultsSignificant intraoperative morbidity occurred in 22 patients (10.2%) and included major vascular injury in 12 patients (5.6%), hemodynamic compromise requiring cardiopulmonary bypass support in 4 patients (1.9%), cardiac tamponade requiring intervention in 3 patients (1.4%), ventricular valve embolization in 2 patients (0.9%), and inability to obtain percutaneous access requiring open vascular access in 1 patient (0.5%). Intraoperative morbidity was similarly distributed across all valve types (P = .556) and sheath sizes (P = .369). There were no baseline patient characteristics predictive of intraoperative morbidity. ConclusionsPatient and valve characteristics are not predictive of significant intraoperative morbidity during transfemoral transcatheter aortic valve insertion. The finding has implications for patient selection for the minimalist approach.

Abstract 10894: Cerebral Energy Metabolism and Pools of Neurotransmitters Related to the Use of Deep Hypothermic Circulatory Arrest in Infant Piglets

Introduction: Complex congenital cardiac defect repair in infants often requires deep hypothermic circulatory arrest (DHCA). As immediate or late neurological complications still occur, adjunctive selective cerebral perfusion (SCP) theoretically provides superior neural protection by supplying oxygen and substrate and maintaining energy metabolism. Hypothesis: SCP preserves glucose utilization, energy metabolism, and glutamate cycling in comparison to DHCA alone. Methods: Fourteen male Yorkshire piglets (age 34-44 days) were assigned randomly to 2 groups (DHCA or SCP for 60 minutes at 18°C). Cerebral perfusion through 1st branch of aorta was maintained at 40 ml/kg/min during SCP. After the completion of rewarming, 13-Carbon-labeled glucose ( 13 C-glucose) was infused through common carotid artery for 1 hour under continuous cardiopulmonary bypass support and then cerebral tissue was extracted. Gas chromatography-mass spectrometry and nuclear magnetic resonance were used for cerebral metabolic analysis in the frontal cortex of brain. Results: There were no operative or technical complications in any groups. Cerebral rSO 2 in simple DHCA dropped substantially to ~ 25% during DHCA, but maintained over 80% in SCP. Apoptosis by TUNEL assay was significantly less in SCP at 2.5 hours after DHCA. ATP levels in the extracted cerebral tissue were similar between 2 groups but glycogen store were higher in SCP. Absolute levels of lactate and citric acid cycle intermediates and their 13 C-enrichment were similar in the cerebral tissue between the 2 groups. However, SCP increased absolute and 13 C-enrichment for glutamate and compared to DHCA, while gamma aminobutyric acid (GABA) increased in DHCA. Conclusions: SCP added to DHCA does not provide additional ATP preservation or modify glucose oxidation. However, SCP does alter glucose cycling into alternate pathways, leading to preservation of glycogen, and shifts flux away from GABA, a major inhibitory neurotransmitter, and towards glutamate. These flux changes suggest that SCP decreases synaptic inhibition, which may relate to the reduced neural apoptosis.

Radical surgical resection of advanced thymoma and thymic carcinoma infiltrating the heart or great vessels with cardiopulmonary bypass support.

BackgroundRadical surgical resection of advanced thymic tumors invading either the heart or great vessels facing towards the heart is uncommonly performed because of the potential morbidity and mortality. To achieve a complete tumor resection, the use of cardiolpulmonary bypass (CPB) support might be necessary.MethodsRetrospective analysis of the results in six patients, who underwent radical tumor resection with CBP support.ResultsMean age was 46 years (27 to 66 years) and five patients were male. Tumor infiltration of the heart or the great vessels was evident in all patients. Five patients underwent induction therapy. Two patients were operated in complete cardioplegic arrest (antegrade cerebral perfusion: n = 1). Arterial cannulation of the ascending aorta (n = 5) or the femoral artery (n = 1) and venous cannulation of the right atrium (n = 4) or the femoral vein (n = 2) were performed. Resection of the left brachiocephalic vein (n = 6), resection of the superior caval vein (n = 2), the ascending aorta (n = 1) and the complete aortic arch with outgoing branches (n = 1) were performed. A macroscopic complete resection (R0/R1) was achieved in five patients, whereas one patient was resected incompletely (R2). In-hospital mortality was 0 %. Three (50 %) patients needed operative revision (hematothorax: n = 2, chylothorax: n = 1). All patients had a complicated postoperative course and developed respiratory insufficiency.ConclusionsLocally advanced thymoma/thymic carcinoma invading the heart or great vessels can be treated with radical surgical resection alongside with increased perioperative morbidity. The usage of CBP improves the chance of complete tumor resection in selected patients and might lead to a prolonged survival.

Focus on the surgical approach to transcatheter aortic valve implantation: Complications, outcome, and preoperative risk adjustment

ObjectivePerioperative complications in patients undergoing transcatheter aortic valve implantation remain a major issue affecting outcome. Because preoperative risk adjustment remains challenging and a valid scoring system is missing, we sought to determine the incidence of peri- and postprocedural complications of transapical (TA) or transaortic (TAO) access to define the influence of specific complications on early safety, 30-day mortality, and 1-year survival. Furthermore, we aimed to develop a risk-stratification model to allow an estimation of the perioperative risk and the 1-year survival rate, based on the individual preoperative condition of each patient. MethodsWe performed an outcome analysis of 230 consecutive patients who underwent aortic valve implantation via transapical or transaortic access between 2008 and 2012, with regard to Valve Academic Research Consortium II criteria, including univariate and multivariable regression analysis, to develop a risk-stratification model. ResultsThirty-day mortality was 12.7%. Estimated 1-year survival was 0.69 (95% confidence interval [CI], 0.631-0.757), and 3-year survival was 0.554 (95% CI, 0.474-0.634). Univariate logistic regression analysis revealed a significant influence on 30-day mortality in case of life-threatening bleeding (16.1-fold), abdominal complications (8.5-fold), and acute kidney injury (3.2-fold). Pacemaker implantation (odds ratio, 1.55; 95% CI, 0.42-5.81; P = .512) was not a significant predictor. Concerning use of intraprocedural hemodynamic bridging therapy via cardiopulmonary bypass (CPB), Cox regression analysis revealed no significant survival difference after 1 year. A preoperative risk-stratification model for 1-year survival revealed that a logistic European System for Cardiac Operative Risk Evaluation score >20%, preoperative existing coronary artery disease, and prior myocardial infarction appeared to be significant predictors for diminished survival. ConclusionsConcerning intraprocedural complications, CPB support for hemodynamic stabilization is a safe treatment option. Therefore, the heart team approach with CPB standby represents a life-saving option. Attention should also be drawn to specialized and individual postoperative care, because nonprocedure-specific complications clearly affect postoperative short- and long-term outcome. In addition, the risk-stratification model might facilitate preoperative decision making.

Resection of thoracic malignancies infiltrating cardiac structures with use of cardiopulmonary bypass.

BackgroundOnly few reports exist on malignant thoracic neoplasms that require cardiopulmonary bypass during resection. We aimed to investigate the early and late clinical outcome of these patients.MethodsPatients with thoracic malignancies that underwent surgery between 2002 and 2014 were analyzed. All patients had cardiopulomonary bypass support during resection. Clinical and perioperative data was retrospectively reviewed for outcome and overall survival.ResultsFifteen patients (12 female, mean age of 55 ± 15 years, range 24 to 80 years) were identified. Eleven (8 female) were diagnosed with primary thoracic malignomas and four with metastases. Three patients died early postoperatively. Patients diagnosed with sarcoma had a significantly worse outcome than non-sarcoma patients (83.3 ± 15.2 % after 1 year, 31.3 ± 24.5 % after 5 years vs. 83.3 ± 15.2 % after 1 year, 0 ± 0 % after 5 years, p = 0.005).ConclusionsMalignancies with extension into cardiac structures or infiltration of great vessels can be resected with cardiopulmonary bypass support and tolerable risk. Carefully selected patients can undergo advanced operative procedures with an acceptable 1-year-survival, but only few patients achieved good long-term outcome.

Off-Pump Debranching and Thoracic Endovascular Aortic Repair for Aortic Arch Pathology.

This study aimed to simplify an until-now complex procedure for the treatment of proximal aortic arch pathology (zones 0 and 1), where a deep hypothermic circulatory arrest even with selective cerebral perfusion is still a high-risk procedure with accompanying splanchnic and spinal cord ischemia. From June 2012 until March 2013, 106 patients underwent aortic surgery in our institution, of whom, 20 patients underwent aortic arch surgery. Of the 20 patients, 7 with multiple comorbidities and a high operative risk and no other indication for a cardiopulmonary bypass were selected to undergo an off-pump aortic arch debranching and thoracic endovascular aortic repair: 4 patients had chronic dissections, and 3 patients had arch aneurysms. The procedure was performed through median sternotomy. The supraaortic branches were rerouted to the ascending aorta, and this process was followed by thoracic endovascular aortic repair of the aortic arch and proximal descending aorta. Transaortic antegrade stenting was performed in 5 cases. Cerebral protection and perfusion monitoring were achieved by biradial pressure monitoring, electroencephalogram, and online transcranial duplex sonography. The preoperative, operative, and postoperative data were collected and analyzed retrospectively. All procedures were successful. There were no conversions to cardiopulmonary bypass support. The mean operative time was 184 ± 24 minutes. Postoperatively, there was 1 rethoracotomy for bleeding and 1 cerebrovascular insult. The 30-day mortality was 1 patient. Off-pump aortic debranching with arch stenting is a reproducible procedure that could be favorable in certain situations, such as in patients with a higher operative risk profile, thereby reducing the risks associated with deep hypothermic circulatory arrest and also yielding favorable outcomes, even in an older patient cohort with more comorbidities.

Long-term outcome after bilateral lung transplantation – a retrospective study from a low-volume center experience

BackgroundThe aim of this study is to review the long-term outcomes of bilateral lung transplantation (BLTx) in our institution and examine the potential issues that may influence outcomes in a low-volume center.MethodsA retrospective review of BLTx performed in our institution between July 2006 and December 2012 was conducted. Standardized donor selection, procurement, and preservation protocols for brain-dead donors were applied. Measured outcomes were in-hospital mortality and actuarial survival using the Kaplan-Meier method.ResultsTwenty-five consecutive patients (13 male, 12 female) underwent BLTx with a mean age of 41.8 ± 13.5 years. Before LTx, the mean body mass index was 18.3 ± 3.1 kg/m2. Seven of these patients (28%) required oxygen supplementation at rest before LTx, while the remaining patients (72%) required noninvasive mechanical ventilation (n = 6, 24%), invasive mechanical ventilation (n = 9, 36%) or extracorporeal membrane oxygenation (ECMO) (n = 3, 12%). The lung grafts were procured from brain-dead donors with the mean age of 26.8 ± 11.4 year and the best PaO2 / FiO2 ratio of 513 ± 77 before procurement. All cross match results between same-race donors and recipients were negative. The percentage of same-sex matching and CMV mismatching were 64% and 4%, respectively. The mean time listed on the transplant list was 308 ± 261 days. The mean ischemic time for the first and second grafts were 222 ± 62 and 361 ± 67 minutes. During transplantation, 22 (88%) patients depended on ECMO and one (4%) on cardiopulmonary bypass support. All but two patients (82%) were discharged home in good condition; two (8%) patients died within 3 months after BLTx. The cumulative survival rates at 1-, 2-, 3-, and 5-years were 88%, 83%, 72%, and 72%, respectively.ConclusionsAlthough the comparatively few annual LTx performed is consistent with the low donation rate, our single-center growing experience demonstrates that good post-lung transplant outcomes can be achieved at a low-volume LTx center.