Cases Of 30-day Mortality Research Articles

Effectiveness and Safety of Endoanchors in Abdominal and Thoracic Endovascular Aneurysm Repair: A Systematic Review and Meta-analysis

Purpose: This systematic review aimed to summarize the effectiveness and safety of endoanchor, a stabilizing device for the proximal endograft designed to prevent endoleak and stent migration in endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR). Materials and methods: A systematic review and meta-analysis was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. Literature up to May 31, 2023 was searched and independently screened from 4 databases. Data were pooled for meta-analysis. Primary outcomes included intraoperative and follow-up endoleak, stent migration, and reintervention rates; sac regression; and 30-day all-cause mortality. Results: Sixteen EVAR (n=1145) and 6 TEVAR studies (n=163) using the Heli-Fx EndoAnchor system were included from 2225 retrieved records. For EVAR patients (mean follow-up=11.9 months), the endoleak, graft migration, and reintervention rates were 3.97% (95% confidence interval [CI]=0.36%-1.99%), 0.004% (95% CI=0.00%-0.76%), and 5.43% (95% CI=0.86%-12.54%), respectively. The endoleak rates for primary and revision EVAR were 0.16% (95% CI=0.00%-1.65%) and 3.60% (95% CI=0.14%-9.72%), respectively. Only 4 cases of 30-day mortality (n=4) were reported in the literature. For TEVAR patients, the endoleak, stent migration, and reintervention rates were 7.4% (95% CI=0.03%-0.13%), 0.2% (95% CI=0.00%-0.06%), and 17.1% (95% CI=0.01%-0.45%), respectively. The 30-day mortality was 0.9% (95% CI=0%-0.12%). Conclusions: Endoanchor fixation in EVAR and TEVAR is effective and safe in preventing and treating endoleak and stent migration. The mortality is minimal in EVAR but higher in TEVAR. Clinical Impact Endoleak, graft migration, and reintervention in EVAR and TEVAR with endoanchor use were rare. Mortality in EVAR was low. The adjunctive deployment of endoanchors is an effective and safe means to prevent and treat endoleak and stent migration in EVAR and TEVAR. Yet, long-term efficacy and safety data and randomized controlled trials would be required to definitively recommend endoanchor use in routine clinical practice.

Outcomes of fenestrated endovascular abdominal aortic repair in distal entry tears of chronic debakey IIIb aortic dissection.

Currently, there have been very few reports within the literature which specifically address using fenestrated and branched stent grafts to completely isolate and repair distal entry tears of chronic DeBakey IIIb aortic dissection. This study aimed to evaluate the clinical outcomes of a 3-dimensional (3D) printed aortic model-guided fenestrated stent in the treatment of distal tears of chronic DeBakey IIIb aortic dissection after thoracic endovascular aortic repair (TEVAR). The study was a one-center retrospective study comprising 36 patients who underwent TEVAR and fenestrated endovascular abdominal aortic repair (F-EVAR) between April 2014 and December 2022. Patient data was compiled and analysed for preoperative, intraoperative, and perioperative characteristics. In total, 36 patients (12 females and 24 males) were incorporated into this study. All of the patients included in this study had hypertension, and among them, the leading cause for undergoing II-stage F-EVAR was the progression of a false lumen, accounting for 24 cases (66.7% of the total). The technical success rate was 97.2% and there were no cases of 30-day mortality, myocardial infarction, permanent paraparesis, or organ failure. One year post-F-EVAR treatment, surviving patients showed significant false and true lumen remodelling with 100% complete false-lumen thrombosis. A total of five patients died during the follow-up, two patients died related to aorta complications and three patients died of heart failure, multiple organ failure, or septic shock. II-stage F-EVAR was safe and feasible operation to repair all distal tears of chronic DeBakey IIIb aortic dissection.

Impact of Serum Albumin Levels and Body Mass Index on Outcomes of Open Abdominal Aortic Aneurysm Repair in Korean Population

Although obese patients seem to be susceptible to chronic diseases, obesity paradox has been observed in the field of vascular surgery, in which many previous studies have reported that overweight patients have good postoperative outcomes and underweight patients have poor postoperative outcomes. The purpose of our study is to evaluate the impact of body mass index (BMI) and serum albumin levels, which are evaluated as indicators of nutritional status, on outcomes of open abdominal aortic aneurysm (AAA) repair. We reviewed the vascular surgery database of a single tertiary referral center for all patients who underwent open AAA repair due to degenerative etiology from 1996 to 2021. To analyze the effect of BMI, patients were classified into 4 groups according to the Asian-Pacific classification of BMI: underweight (UW) (<18.5kg/m2), normal weight (NW) (18.5-22.9kg/m2), overweight (OW) (23-24.9kg/m2), and obese (OB) (≥25kg/m2). The χ2, Fisher's exact, and Kruskal-Wallis tests were used to compare demographics, comorbidities, radiologic findings, surgical details, and 1-year mortality rates between the 4 groups. We also compared the preoperative serum albumin levels of each group to assess nutritional status indirectly. Cox's proportional hazards model was performed to determine factors associated with mortality. A Kaplan-Meier survival analysis was performed, and the differences were analyzed by a log-rank test. We did not perform an analysis for 30-day mortality because cases of 30-day mortality in UW patients were rare due to the unbalanced distribution of the number of patients in the 4 groups. Among a total of 678 patients, 22 were classified as UW (3.2%), 200 as NW (29.5%), 183 as OW (27.1%), and 273 as OB (40.1%). The median age was 70 (64-75) years and 577 of 678 (85.1%) patients were male gender. Higher serum albumin level was associated with decreased 1-year mortality (hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.15-0.63; P=0.001). UW patients had a higher 1-year mortality rate than NW patients (HR, 3.67; 95% CI, 1.02-13.18; P=0.046). OB patients had a lower overall mortality rate than NW patients (HR, 0.73; 95% CI, 0.53-1; P=0.05). Low BMI (<18.5kg/m2) and low serum albumin level were associated with poor 1-year survival after elective open AAA repair. These patients also need more careful preoperative intervention, like weight gain or nutritional support, for better outcomes. The obesity paradox existed in our study; high BMI (≥25kg/m2) was associated with better overall survival after elective open AAA repair.

The Efficacy of Second-Stage Endovascular Repair Strategy for Acute Type A Aortic Dissection.

To evaluate the usefulness of a hybrid treatment strategy for acute type A aortic dissection (AAAD). We retrospectively evaluated the outcomes of 39 partial arch replacements (PAR; 26 male/13 female, mean age=67.9 years) in 62 patients with AAAD operated at our hospital from January 2019 to January 2023. The technique included PAR with graft-designed landing length and translocated the brachiocephalic artery inflow site during the initial surgery to minimize the invasiveness of the surgery. Thereafter, second-stage thoracic endovascular aortic repair (second TEVAR) for distal aortic events in the chronic phase was performed. There was 1 case of 30-day mortality (2.6%) and 2 cases of postprocedural cerebral infarction (5.1%). The cumulative survival rates were 97.4%/1 year and 97.4%/3 years. The cumulative freedom from aorta-related second-stage procedure for the distal aortic event after initial PAR, which was performed in 13 patients (33.3%), was 63.9%/1 year and 59.7%/3 years. All patients requiring re-intervention after initial PAR underwent a second TEVAR with a 100% success rate and no postoperative complications. Initial PAR for AAAD in anticipation of the second TEVAR is a valuable strategy for enabling minimally invasive additional treatment of aorta-related re-intervention for distal aortic events in the chronic phase. This study provides detailed information on the hybrid aortic repair strategy of the initial open partial arch repair and second staged endovascular repair for the acute type A aortic dissection. Based on this study, distal aortic re-intervention after initial open partial arch repair was necessary only in about 30% of cases, and no cases of SCI were observed in the initial treatment or in the second-stage endovascular repair and no cases of distal SINE were observed after the second staged endovascular repair. Overall, the results suggest that limiting the initial open partial arch repair can achieve good perioperative and early outcomes of initial surgery, and that second staged endovascular re-intervention for distal aortic events can be performed reliably, safely, and with minimal invasiveness.

30-day mortality in patients treated for brain metastases: extracranial causes dominate

BackgroundEstablished prognostic models, such as the diagnosis-specific graded prognostic assessment, were not designed to specifically address very short survival. Therefore, a brain metastases-specific 30-day mortality model may be relevant. We hypothesized that in-depth evaluation of a carefully defined cohort with short survival, arbitrarily defined as a maximum of 3 months, may provide signals and insights, which facilitate the development of a 30-day mortality model.MethodsRetrospective analysis (2011–2021) of patients treated for brain metastases with different approaches. Risk factors for 30-day mortality from radiosurgery or other primary treatment were evaluated.ResultsThe cause of death was unrelated to brain metastases in 61%. Treatment-related death (grade 5 toxicity) did not occur. Completely unexpected death was not observed, e.g. accident, suicide or sudden cardiac death. Logistic regression analysis showed 9 factors associated with 30-day mortality (each assigned 3–6 points) and a point sum was calculated for each patient. The point sum ranged from 0 (no risk factors for death within 30 days present) to 30. The results can be grouped into 3 or 4 risk categories. Eighty-three percent of patients in the highest risk group (> 16 points) died within 30 days, and none survived for more than 2 months. However, many cases of 30-day mortality (more than half) occurred in intermediate risk categories.ConclusionExtracranial tumor progression was the prevailing cause of 30-day mortality and few, if any deaths could be considered relatively unexpected when looking at the complete oncological picture. We were able to develop a multifactorial prediction model. However, the model’s performance was not fully satisfactory and it is not routinely applicable at this point in time, because external validation is needed to confirm our hypothesis-generating findings.

Early Outcomes of Robotic Versus Video-Assisted Thoracoscopic Anatomical Resection for Lung Cancer.

BackgroundWe compared the safety and effectiveness of robotic anatomical resection and video-assisted thoracoscopic surgery (VATS).MethodsA retrospective analysis was conducted of the records of 4,283 patients, in whom an attempt was made to perform minimally invasive anatomical resection for lung cancer at Seoul National University Hospital from January 2011 to July 2020. Of these patients, 138 underwent robotic surgery and 4,145 underwent VATS. Perioperative outcomes were compared after propensity score matching including age, sex, height, weight, pulmonary function, smoking status, performance status, comorbidities, type of resection, combined bronchoplasty/angioplasty, tumor size, clinical T/N category, histology, and neoadjuvant treatment.ResultsIn total, 137 well-balanced pairs were obtained. There were no cases of 30-day mortality in the entire cohort. Conversion to thoracotomy was required more frequently in the VATS group (VATS 6.6% vs. robotic 0.7%, p=0.008). The complete resection rate (VATS 97.8% vs. robotic 98.5%, p=1.000) and postoperative complication rate (VATS 17.5% vs. robotic 19.0%, p=0.874) were not significantly different between the 2 groups. The robotic group showed a slightly shorter hospital stay (VATS 5.8±3.9 days vs. robotic 5.0±3.6 days, p=0.052). N2 nodal upstaging (cN0/pN2) was more common in the robotic group than the VATS group, but without statistical significance (VATS 4% vs. robotic 12%, p=0.077).ConclusionRobotic anatomical resection in lung cancer showed comparable early outcomes when compared to VATS. In particular, robotic resection presented a lower conversion-to-thoracotomy rate. Furthermore, a robotic approach might improve lymph node harvesting in the N2 station.

Robot-Assisted Pancreatic Surgery—the Russian Experience.

Surgical procedures that involve working in small anatomical spaces can be successfully performed using robot-assisted surgery. We did a retrospective study of the results of 86 robot-assisted pancreatic operations performed in the Abdominal Department No.1 of the A.V. Vishnevsky Institute of Surgery, Moscow. Seventy (81.4%) patients were female, and 16 (18.6%) were male; the average age was 49 (37; 59). The following robot-assisted surgeries were performed: 17 pancreaticoduodenectomies, 45 distal pancreatectomies, 16 tumor enucleations, 6 median resections, and 2 total duodenopancreatectomies. The duration of robot-assisted surgical operations varied depending on the extent of the surgery: for a pancreaticoduodenectomy (PD), it was 400 (360–550) min; for a distal pancreatectomy, it was 210 (180–250) min. Estimated blood loss in a PD was 200 (150–500) ml; in a distal pancreatectomy, it was 100 (50–300) ml. Conversions happened in 6 cases: 2 of them in PD and 4 in distal pancreatectomies. The postoperative length of stay was 15 ± 9 days and depended on the extent of the surgery. The maximum length (16 days) was after robot-assisted pancreaticoduodenectomies (14–25), the minimum (12 days) after organ-preservation surgery (8; 15). Pancreatic fistula А and В occurred in 35 (40.7%) patients and hemorrhages in 6 (7.0%) cases; there were 2 cases of 30-day mortality (2.3%). Robotic assistance can be successfully used in pancreatic surgery. Robot-assisted procedures ensure the precision of lymphadenectomy and anastomoses formation, and the postoperative lengths of stay are more comfortable for patients due to minimal tissue injury. The use of the robot-assisted approach in pancreatic surgery does not guarantee that specific postoperative complications will not occur.

Fenestrated endografting is the preferred option for juxta-renal aortic aneurysm reconstruction.

The aim of this study was to report early/mid-term-up outcomes of fenestrated endografting (FEVAR) for juxta-renal aneurysms (j-AAAs). Between 2008 and 2019, all consecutive j-AAAs treated by FEVAR were prospectively collected and retrospectively analyzed. Early endpoints were technical success, renal function worsening and 30-day mortality. Follow-up endpoints were survival, freedom from re-interventions (FFRs) and target visceral vessels (TVVs) patency. Among 240 cases of FB-EVAR, 98(41%) were j-AAAs. Endografts with 1,2,3,4 and 5 fenestrations were planned in 3(3%), 25(26%), 35(36%), 33(34%) and 2(1%) cases, respectively. Overall, 360 TVVs were treated by fenestrations and scallops. Technical success was achieved in 97(99%) cases. The only failure was 1 type III endoleak requiring renal artery relining. No TVVs were lost. Renal function worsening was reported in 22(22%) and 12(12%) cases at 24-hour and 30-day, respectively. One patient required hemodialysis and died within 30-day (1%). This was the only case of 30-day mortality. The mean follow-up was 36±32months. Aneurysm sac shrinkage or stability was observed in 55(56%) and 41(42%) cases, respectively. Two (2%) patients with persistent type II endoleak had sac enlargement and required re-interventions. Freedom from reinterventions at 5-year was 86%. An asymptomatic celiac trunk occlusion (accommodated by a scallop) occurred at 24-month in a case with a severe preoperative stenosis. No late renal arteries occlusions or type I-III endoleaks occurred. TVVs-patency was 96% at 5-year. Renal function worsening was reported in 10(10%) patients during follow-up. Survival at 5-year was 73%, with no j-AAA related mortality. Chronic obstructive pulmonary disease (COPD) (P=0.007; OR:4.8; 95% CI: 1.5-15.3) and postoperative renal function worsening (P=0.028; OR:1,1; 95% CI: 1.1-1.2) were independent predictor for mortality at the multivariate analysis. FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with these results, it could be proposed as the first line treatment in high risk patients if anatomically fit. Long term survival is reduced in the presence of preoperative COPD and postoperative renal function worsening.

Early and Long-term Efficacy of Fenestrated Endografting in the Treatment of Juxta-renal Aortic Aneurysms

Introduction - Juxta-renal aneurysms (j-AAAs) are increasingly repaired by endovascular means with fenestrated endografts (FEVAR) worldwide, however long-term data are presently lacking. Aim of our study was therefore to evaluate late outcome of FEVAR in j-AAAs Methods - Between 2008 and 2017, all consecutive patients undergoing endovascular repair for j-AAAs (neck length ≤5mm) by FEVAR (Cook-Zenith platform) were prospectively collected. Preoperative clinical and morphological features, together with procedural and postoperative data were analyzed. Early endpoints were: technical success (TS: patency of target visceral vessels; TVVs, absence of type I-III endoleak; iliac leg stenosis/occlusion and 24-hour survival), renal function worsening (reduction of baseline GFR ≥30%) and 30-day mortality. Late endpoints were: survival, freedom from re-intervention (FFR), TVV-patency, j-AAA shrinkage (> 5mm) and renal function worsening. Results - During the study period, overall 181 cases underwent FB-EVAR repair. Sixty-six patients with j-AAA (M: 94%; age: 72±6years; ASA 3/4: 79/21%) were enrolled. The mean j-AAA diameter was 58±6mm. Endograft with 1, 2, 3 and 4 fenestrations were planned in 2 (3%), 22 (33%), 27 (41%) and 15 (23%) cases, respectively. Overall, 236 TVVs were treated by fenestrations and scallops (3.6±1 TVV/patient). Technical success was achieved in 65 cases (99%). The only failure occurred for a type III endoleak requiring renal artery relining on postoperative day 32. No TVVs were lost. Cardio and pulmonary morbidities were 5% and 6%, respectively. There were no cases of acute splanchnic ischemia. Renal function worsening occurred in 7 cases (10%): 4 returned to baseline within 30-day; 1 required hemodialysis and died within 30-day (1.5%). This was the only case of 30-day mortality. The mean follow-up was 46±32 months. Aneurysm sac shrinkage or stability was observed in 42 (64%) and 22 (33%) cases, respectively. Two patients (3%) with persistent type II endoleak had sac enlargement and required re-interventions (sac embolization by trans-limb approach). Freedom from re-interventions at 1, 3 and 5 years was 97%, 93% and 88%, respectively. An asymptomatic celiac trunk occlusion occurred at 36-month in a case with asevere pre-operative stenosis - accommodated by a scallop. No late renal arteries occlusions or type I-III endoleaks occurred. Overall, renal function worsening was reported in 5 patients (8%) during follow-up (2 persisted from post-operative period and 3 with new onset). Survival at 1, 3 and 5 years was 92%, 86% and 67%, respectively, with no j-AAA related mortality. At the univariate analysis, COPD (p:.006), BMI >31 (p:.048), preoperative chronic renal failure (p:0.44) and late renal function worsening (p:.050) were risk factors for mortality. COPD was the only independent predictor for mortality at the multivariate analysis (p:.021; OR:5.3; 95%CI, 1.3-21.9) Conclusion - FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with the results of this series, FEVAR could be proposed as the first line treatment for j-AAAs in anatomically fit cases if performed in high volume centers. Long term survival is reduced in the presence of pre-operative COPD. The results of the present series should be taken in consideration when considering alternative open surgery technique in the treatment of J-AAAs

Early and Mid-term Efficacy of Fenestrated Endograft in the Treatment of Juxta-Renal Aortic Aneurysms

The aim of this study was to report early and mid-term outcomes of fenestrated endografting (FEVAR) for juxtarenal aneurysm (J-AAAs). Between 2008 and 2017, all consecutive J-AAAs treated by FEVAR were prospectively collected. Early endpoints were technical success, renal function worsening, and 30-day mortality. Follow-up endpoints were survival, freedom from reinterventions (FFRs), target visceral vessels (TVVs) patency, J-AAAs shrinkage, and renal function worsening. Among 181 cases who underwent FB-EVAR, 66 (36%) were J-AAAs. Endograft with 1, 2, 3, and 4 fenestrations were planned in 2 (3%), 22 (33%), 27 (41%) and 15 (23%) cases, respectively. Overall, 236 TVVs were treated by fenestrations and scallops. Technical success was achieved in 65 (99%) cases. The only failure occurred for a type III endoleak requiring renal artery relining. No TVVs were lost. Renal function worsening occurred in 7 (10%) cases: 4 returned to baseline within 30-day, 1 required hemodialysis and died within 30 days (1.5%). This was the only case of 30-day mortality. The mean follow-up was 46±32months. Aneurysm sac shrinkage or stability was observed in 42 (64%) and 22 (33%) cases, respectively. Two patients (3%) with persistent type II endoleak had sac enlargement and required reinterventions. Freedom from reinterventions at 5 years was 88%. An asymptomatic celiac trunk occlusion (accommodated by a scallop) occurred at 24 months in a case with a severe preoperative stenosis. No late renal arteries occlusions or type I-III endoleaks occurred. Overall, renal function worsening was reported in 5 (8%) patients during follow-up. Survival at 5 years was 67%, with no j-AAA-related mortality. COPD was the only independent predictor for mortality at the multivariate analysis (P: 0.021; OR: 5.3; 95% CI, 1.3-21.9). FEVAR for J-AAAs is safe and effective at early and mid-term follow-up. According to these results, it could be proposed as the first-line treatment in high-risk patients if anatomically fit. Long-term survival is reduced in the presence of preoperative COPD.

Long-Term Outcomes of the FORMA Transcatheter Tricuspid Valve Repair System for the Treatment of Severe Tricuspid Regurgitation: Insights From the First-in-Human Experience

ObjectivesTo evaluate the long-term (≥2 years) outcomes following transcatheter tricuspid valve repair (TTVr) with the FORMA Transcatheter Tricuspid Valve Repair System (Edwards Lifesciences, Irvine, California). BackgroundScarce data exist on long-term outcomes following TTVr. MethodsThis multicenter experience included patients with severe tricuspid regurgitation (TR) who underwent TTVr with the FORMA system at 4 centers under a compassionate clinical use program. Data were collected at baseline, 30 days, and 1 year, and yearly thereafter. ResultsNineteen patients (76 ± 9 years of age, 74% women, mean EuroSCORE II [European System for Cardiac Operative Risk Evaluation] 9.2 ± 5.6%) with functional TR were included. Procedural success was achieved in 17 (89%) patients and there were no cases of 30-day mortality. At a median follow-up of 32 (interquartile range: 24 to 36) months, 4 (24%) patients had died (3 from terminal heart failure, 1 from sepsis) and 3 (18%) patients required rehospitalization for heart failure. There was 1 device-related thrombosis and 1 pulmonary embolism, both in the setting of subtherapeutic oral anticoagulation. Less than severe TR was observed at echocardiography in 67% of patients at the 2- to 3-year follow-up. Among 15 successfully implanted patients with at least 24-month follow-up, significant improvements in New York Heart Association functional class (p < 0.001), 6-min walk test (+54 m; p = 0.016) and Kansas City Cardiomyopathy Questionnaire score (+16 points; p = 0.016) were observed, compared with baseline. ConclusionsTTVr using the FORMA system showed favorable long-term safety profile in high-surgical-risk patients, with sustained functional improvement and acceptable TR reduction up to 3 years.

Mitral valve repair versus replacement with preservation of the entire subvalvular apparatus.

This study aimed to evaluate the outcomes of mitral valve (MV) repair versus MV replacement with preservation of the entire subvalvular apparatus. We retrospectively searched our dedicated in-hospital database for patients who underwent MV surgery between 2012 and 2017. A total of 82 patients were divided into a group that underwent MV replacement (n = 35) and a group that underwent MV repair (n = 47). Patients undergoing MV replacement were significantly older (p < 0.01). Mortality at 30days was not significantly different [MV replacement: n = 1 (2.9%), MV repair: n = 0 (0%); p = 0.43]. The single case of 30-day mortality after MV replacement was due to acute aortic dissection. The total cohort did not show significant differences in long-term survival (p = 0.07). There were no cardiac-related deaths in this cohort. Postoperative left ventricular end-diastolic diameter (MV replacement: 45.4 ± 6.2mm, MV repair: 45.6 ± 5.8mm; p = 0.89), left ventricular end-systolic diameter (MV replacement: 29.6 ± 7.1mm, MV repair: 29.4 ± 5.2mm; p = 0.89), and ejection fraction (MV replacement: 59.2 ± 11.4%, MV repair: 62.0 ± 6.8%; p = 0.17) were not significantly different. This study found that MV replacement had operative mortality, long-term survival, and complication rates similar to those of MV repair. There were no cardiac-related deaths in this cohort. MV replacement with preservation of the entire subvalvular apparatus does not seem to be inferior to MV repair.

OC65 RIGHT MINI-THORACOTOMY APPROACH FOR ATRIAL SEPTAL DEFECT CLOSURE AND PARTIAL ANOMALOUS PULMONARY VENOUS RETURN CORRECTION

Objective: Over the last 20 years, right mini-thoracotomy cardiac surgery has confirmed its feasibility and effectiveness with remarkable early and long-terms outcomes. As a consequence of the excellent results reached, interest in minimal invasive cardiac surgery is rising also in the case of grown-up congenital heart disease patients. The rational is to minimize surgical trauma, accelerate recovery, reduce the rate of wound complications and hospital-related infections, and improve cosmetic outcomes. Aim of this study is to evaluate feasibility and effectiveness of the right mini-thoracotomy approach applied to patients with diagnosis of atrial septal defect (ASD) and partial anomalous pulmonary venous return (PAPVR). Methods: Patients with ASD and PAPVR undergoing right mini-thoracotomy cardiac surgery at our Department between November 2006 and January 2018 were retrospectively reviewed. Results: During the study period 17 patients underwent ASD closure with pericardial patch and PAPVR correction with anomalous vessels addressing into left atrium through right mini-thoracotomy and retrograde arterial perfusion (Table 1). Aortic clamping was achieved through endoaortic balloon in 13 out of 17 patients (76.5%) and through trans-thoracic clamp in 4 out of 17 patients (23.5%). No cases of conversion to full sternotomy, nor intra-operative vascular complications or re-exploration for bleeding were recorded. No cases of stroke nor cases of 30-day mortality were reported. Conclusions: Right mini-thoracotomy is nowdays the standard approach for ASD closure and PAPVR correction at our Department. Results of this case series show that it is an effective and reproducible alternative to median sternotomy.

A systematic review of isolated radial artery harvesting as a conduit for lower limb bypass grafting.

Whilst autologous vein conduits have been heralded as the first-line approach for patients undergoing lower limb bypass grafting procedures, patients with peripheral arterial occlusive disease may have exhausted venous options given prior use for cardiac surgery, varicose vein surgery, or lower limb revascularization. Hence, the use of a radial artery graft may serve as a viable alternative. The systematic review was performed in accordance to the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. An electronic search was performed on the following databases: Medline (via PubMed); EMBASE; Cochrane library to search for relevant publications. A narrative analysis was conducted. Four publications were included in this review including two retrospective cohort studies, one case series, and one case report, with a total of 43 patients. The most common indication for lower limb bypass grafting was critical limb ischemia, and the radial artery was chosen as graft conduit, most commonly due to the absence of suitable arm or leg vein. There was one case of 30-day mortality and 11 reinterventions. Despite the encouraging results, the paucity of high-quality studies prevents the establishment of any firm conclusion. This warrants the need for appropriately conducted randomized controlled trials to compare the radial artery graft to autologous vein grafts and prosthetic grafts for lower limb bypass grafting.

Neonatal Patent Ductus Arteriosus Ligation Operations Performed by Adult Cardiac Surgeons.

BackgroundPatent ductus arteriosus (PDA) ligation is usually performed by congenital cardiac surgeons. However, due to the uneven distribution of congenital cardiac surgeons in South Korea, many institutions depend solely on adult cardiac surgeons for congenital cardiac diseases. We report the outcomes of PDA ligations performed by adult cardiac surgeons at our institution.MethodsThe electronic medical records of 852 neonates at Chung-Ang University Hospital, Seoul, South Korea from November 2010 to May 2014 were reviewed to identify patients with PDA.ResultsOf the 111 neonates with a diagnosis of PDA, 26 (23%) underwent PDA ligation. PDAs were ligated within 28 days of birth (mean, 14.5±7.8 days), and the mean gestational age of these patients was 30.3±4.6 weeks (range, 26 to 40 weeks) with a mean birth weight of 1,292.5±703.5 g (range, 480 to 3,020 g). No residual shunts through the PDA were found on postoperative echocardiography. There was 1 case of 30-day mortality (3.8%) due to pneumonia, and 6 cases of in-hospital mortality (23.1%) after 30 days, which is comparable to results from other centers with congenital cardiac surgery programs.ConclusionAlthough our outcomes may not be generalizable to all hospital settings without a congenital cardiac surgery program, in select centers, PDA ligations can be performed safely by adult cardiac surgeons if no congenital cardiac surgery program is available.

Are Sutureless Aortic Valves Suitable for Severe High-Risk Patients Suffering from Active Infective Aortic Valve Endocarditis?

BackgroundSutureless aortic valves were introduced to facilitate minimally invasive aortic valve surgery. Since sutureless aortic valves are a feasible procedure, we evaluated if any benefits could be identified in severe high-risk patients with active infective endocarditis of the aortic valve.Material/MethodsBetween April 2014 and April 2015, a total of 42 patients received a sutureless Perceval® aortic valve (Sorin Biomedica Cardio Srl, Saluggia, Italy) for different indications. Nine of these patients (median age 71 years, range 47–83 years) suffered from active infective endocarditis, including four patients with prosthetic aortic valve endocarditis. Five patients underwent prior cardiac surgery, including transcatheter aortic valve implantation (TAVI). The median EuroSCORE II was 29.5% (range 16.8–87.7%). Post-operatively, data regarding mortality, operative results, and early operative morbidity were collected.ResultsThere were no cases of 30-day mortality. Four patients needed abscess closure with pericardium. Three patients underwent left atrial appendix closure: one left ventricular thrombectomy, one bypass grafting, and one arch replacement. Median aortic cross-clamp and cardiopulmonary bypass time was 35 minutes (range 26–88 minutes) and 52 minutes (range 40–133 minutes), respectively. The median intubation time was 14 hours (range 1–9 hours). In these high-risk patients, no postoperative morbidity was found except for one re-intubation due to extensive delirium and one re-exploration. No pacemaker implantation was needed. Echocardiographic evaluation showed no central or para-valvular regurgitation, and a median discharge mean gradient of 5.5 mm Hg (range 2.5–10.0 mm Hg).ConclusionsSutureless aortic valve replacement in very high-risk patients suffering from active infection endocarditis seems to be an option with limited morbidity and appropriate echocardiographic results, however, further studies are needed.

Safety of Live Case Demonstrations in Patients Undergoing Percutaneous Coronary Intervention for Chronic Total Occlusion

The data regarding the risk and benefits associated with live demonstrations at interventional cardiology congresses are scarce and controversial. We aimed to assess the clinical safety of chronic total occlusion percutaneous coronary intervention (CTO-PCI) procedures during live demonstrations. From January 2008 to December 2013, 739 consecutive patients underwent CTO-PCI at our center, and 199 patients were scheduled to undergo live CTO-PCI demonstrations at cardiology congresses that were globally transmitted to international meetings. The baseline characteristics, procedural complications, and clinical outcomes were compared between the live demonstration group and nonlive demonstration group. The procedural success rates were similar in the live demonstration group than in the nonlive demonstration group (91.5% vs 86.7%, p= 0.076), although the CTO lesions were longer and more tortuous in the live demonstration group (p= 0.029, p= 0.022, respectively). No cases of 30-day mortality were noted in the live demonstration group (0% vs 0.7%, p= 0.28), and no significant differences in procedural complications, such as coronary dissection, coronary perforation, and cardiac tamponade, were observed between the groups (p= 0.53, p= 0.12, and p= 0.40, respectively). The survival rates were similar in the 2 groups at a median follow-up duration of 51.2 ± 28.9months (log-rank test: p= 0.45). Compared with cases of unsuccessful CTO-PCI, the cases of successful CTO-PCI exhibited improved all-cause survival in both the live and nonlive demonstration groups (log-rank test: p= 0.045, p= 0.0056, respectively). In conclusion, we found that procedural and clinical outcomes of live demonstration CTO-PCI were not significantly different compared with cases undergoing routine CTO-PCI procedures.

Technical Feasibility and Short-Term Outcome of Intracorporeal Hand-Sewn Esophagojejunostomy After Laparoscopic Total Gastrectomy: Our Experience.

The purpose of this study was to demonstrate the safety and technical feasibility of intracorporeal hand-sewn esophagojejunostomy after laparoscopic total gastrectomy. Laparoscopic total gastrectomy (LTG) is a technically challenging procedure, especially for esophagojejunal anastomosis (EJA). Various techniques have been described to overcome these difficulties using staplers with variable results. We report successfully performed complete intracorporeal hand-sewn EJA after LTG. The perioperative clinical data and short-term outcomes for 30 patients who underwent LTG using hand-sewn EJA for gastric cancer between 2013 and 2015 have been retrospectively reviewed. The mean age was 49.9years; 64% of patients were male and 36% were female. The mean body mass index (kg/m2) was 22.4, and the mean American Society of Anesthesiologists (ASA) score was 1.4. Eleven patients had co-morbidities, and six patients had previous abdominal operations. The mean operative time, time for EJA, and blood loss was 136.9min, 13.25min, and 166ml, respectively. The conversion rate was nil. The mean time for the first oral feeding and mean hospital stay was 8.3 and 9.8days respectively. The postoperative complications were found in 16% of patients with one case of 30-day mortality because of lobar pneumonia. There were three cases of anastomotic stenosis; however, no leakage was identified both clinically and radiologically. Complete intracorporeal hand-sewn EJA is a safe and feasible technique in the hands of experienced surgeons that can be considered as an alternative cost-effective method when performing LTG.

CHOICE OF THE IMPLANTABLE SUPPORT RINGS IN CONNECTIVE TISSUE DYSPLASIA AND SEVERE MITRAL REGURGITATION

Aim. To analyze the results of valve-securing surgery on mitral valve in connective tissue dysplasia. Material and methods . From 2011 to 2014 y., totally 171 patient included, with isolated mitral regurgitation. Patients were randomized to 2 groups. Mean age in the Group D — ring, and Group C — flex, was 57 [42;65] and 54 [41;63] year old, respectively (p=0,092). Part of males was 69 and 67% in the groups, respectively. Results. There were no cases of 30-day mortality. During 24 months of follow-up, in D ring and C flex groups, survival was 96,0±2,3% (95% CI 88,6-98,7%) and 94,3±2,8% (95% CI 85,5- 97,9%), resp. (р=0,899); no re-operation — 97,0±2,1% (95% CI 88,4-99,3%) and 100%, resp. (р=0,044); no return of significant mitral regurgitation 80,8±6,5% (95% CI 64,0-90,3%) and 92,8±3,1% (95% CI 83,4-97,0%), resp. (р=0,002). Conclusion. Application of flexible C flex rings in valve-securing operations makes it to achieve better results in middle-long-term post-operation period comparing to the usage of semi-hard support rings in patients with connective tissue dysplasia and severe mitral regurgitation.

Outcome of total arch replacement with coronary artery bypass grafting

There are few reports on the outcome of total arch replacement (TAR) with concomitant coronary artery bypass grafting (CABG); the present study was aimed at analysing outcomes after TAR with CABG at our institute. Between January 2002 and December 2012, 123 consecutive patients underwent elective TAR with or without CABG. The patients were divided into two groups: 46 who had concomitant CABG (Group T/C) and the rest, who had TAR only (Group T). TAR was performed under mild hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP) using a four-branched arch graft. The number with a low ejection fraction (<50%) was higher in Group T/C, in which the additive and the logistic EuroSCORE were also higher. The mean number of coronary anastomoses was 1.6 ± 0.8 in Group T/C. The mean durations of surgery (P < 0.01), cardiopulmonary bypass (P < 0.01), cardiac ischaemia (P < 0.01) and SACP (P < 0.01) were significantly longer in Group T/C. The early graft patency of bypass grafts was 96.7%. Between Group T and Group T/C, there were no significant differences in the incidence of stroke (3.9 and 10.9%, P = 0.13), perioperative myocardial infarction (0 and 2.2%, P = 0.37) and in-hospital mortality (2.6 and 8.7%, P = 0.14). There was one case of 30-day mortality in each group. Preoperative haemodialysis, NYHA III/IV and operation time were multivariate predictors (P < 0.05) of in-hospital mortality. Although concomitant CABG in TAR patients had higher operative risk, it can be safely performed with favourable outcomes.