Cardiopulmonary Bypass Time Research Articles

Early outcomes of total arch replacement in the treatment of aortic dissection

Abstract: Overview: Aortic dissection are severe pathologies with high mortality and complication rates post-surgery despite significant advancements in both diagnosis and surgical treatment. Aortic arch replacement surgery is a classic and highly effective treatment method at Cho Ray Hospital. Objectives: Describe clinical, paraclinical characteristics, postoperative results, general complications and early hospital mortality. Methods: Descriptive cross sectional study. Results: 102 patients underwent aortic arch replacement surgery due to aortic dissection. Males predominated at 72.5%. The male:female ratio was 2.5:1. The average age was 56.45 ± 11.79 years. A history of hypertension was present in 81.4% of cases. Most patients with aortic dissection were admitted in an acute condition, accounting for 95%. Patients with type A aortic dissection accounted for 87.3%, with the entry tear in the ascending aorta at 27.5%. Isolated aortic arch replacement was performed in 46.1% of patients, while 53.9% underwent aortic arch replacement with frozen elephant trunk technique. 7 patients required aortic root replacement, 7 needed aortic valve surgery, and 10 required CABG. Most patients were cooled to 25 degrees C with cerebral perfusion to three branches. Ascending aorta cannulation was established in 45.2% of cases. The average cardiopulmonary bypass time was 257.7 minutes, with selective cerebral perfusion time at 115.9 minutes and lower body circulatory arrest time averaging 57.2 minutes. Postoperative neurological complications occurred in 10.8%, and the rate of renal failure requiring dialysis was 17.8%. The mortality rate was 9.6%. Longer cardiopulmonary bypass times and body temperatures above 25 degrees significantly increased the rate of postoperative renal failure requiring dialysis. Patients with postoperative renal failure requiring dialysis had a statistically significant increase in postoperative mortality rates. Aortic root intervention surgery combined with arch replacement did not affect the rate of postoperative complications. Aortic arch replacement with frozen elephant trunk technique did not affect cardiopulmonary bypass time, clamping time, or the rate of postoperative complications. Conclusions: Total arch replacement at Cho Ray Hospital initially showed a safe and effective with acceptable mortality rate.

Evaluate the results of anesthesia and resuscitation of minimally invasive surgery for pediatric patients with ventricular septal defect at Cardiovascular Center, E hospital in 2022

Objective: Minimally invasive surgery has recently been implemented safely and effectively on children. The study aimed to evaluate the results of anesthesia and resuscitation in pediatric patients with ventricular septal defects (VSD) undergoing minimally invasive surgery. Methods: A cross-sectional study from January 1, 2021 to June 30, 2022 on 65 patients underwent minimally invasive surgery to repair ventricular septal defect, at Cardiovascular Center, E Hospital. Result: A toltal of 65 children aged from 1 month to 34 months, mean weight of 9.0 ± 6.3kg, mean height of 73.6 ± 22.1cm, with main clinical symptoms of slow weight gain (62.5%) and grade I heart failure (87.7%). The most common VSD location was perimembranous VSD (67.7%) with an mean size of 5.7±2.6 mm. The mean surgical time was 175 minutes with cardiopulmonary bypass time and aortic cross-clamp time of 77.5 and 53.0 minutes, respectively. Postoperative hemodynamic parameters changed statistically significantly compared to pre-operation: blood pressure decreased, heart rate increased, lactate level increased, P/F ratio decreased, blood potassium level decreased. The patient mainly needed to use 1 vasopressor, 1 type of sedative analgesic, continuous diuresis, and prophylactic antibiotics with a vasopressor withdrawal time of 34.2 hours, a sedation withdrawal time of 13.35 hours, and a sedative withdrawal time of 13.35 hours. Intubation time of 20.8 hours (minimum 2 hours) and length of stay ICU was 3.8 days. Postoperative complications were low, mainly pneumonia (9.2%) and residual shunt (9.2%), and no death was observed. Conclusion: Minimally invasive ventricular septal defect surgery showed that the anesthesia and surgical process did not change much, with relatively fast post-operative recovery results, short medication time, quick recovery, and no recording severe complications.

Early outcomes of minimal invasive surgery via the axillary approach for complex congenital heart disease at the Cardiovascular Center - E hospital

Objective: This study aims to outline the initial outcomes of implementing minimally invasive surgery via the right axillary approach to completely repair complex congenital heart diseases. Summary: Minimally invasive surgical techniques have gained widespread adoption in managing simple congenital heart diseases such as atrial septal defect, ventricular septal defect, partial atrioventricular septal defect, cor triatriatum, and partial anomalous pulmonary venous return. Postoperative results have demonstrated equivalence, if not superiority, to traditional sternotomy procedures while offering enhanced cosmetic benefits. However, for more intricate congenital heart conditions such as tetralogy of Fallot (TOF), complete atrioventricular septal defect (CAVSD), and Ebstein syndrome, this study evaluates the early outcomes of employing minimally invasive surgery via the right axillary approach, a technique that remains relatively uncommon globally. Our study seeks to assess the initial outcomes of this approach in managing complex congenital heart diseases. Subjects and methods: descriptive method based on a series of cases. From April 2023 to December 2023, 45 patients diagnosed with complex congenital heart disease underwent minimally invasive surgery utilizing the axillary approach. This cohort comprised 40 patients with tetralogy of Fallot, 3 patients with complete atrioventricular septal defect, and 2 patients with Ebstein syndrome. Results: All procedures were technically successful, without requiring sternotomy. The cardiopulmonary bypass times for the TOF, complete AVSD, and Ebstein syndrome groups were 81 minutes, 91 minutes, 96 minutes, respectively. Corresponding aortic cross - clamp times were 70 minutes, 72 minutes, and 74 minutes. There were no postoperative fatalities or significant complications. Postoperative echocardiographic evaluations demonstrated favorable outcomes. Conclusion: Minimally invasive surgery via the axillary approach for managing complex congenital heart diseases yields promising early results and offers notable cosmetic advantages.

Acute Kidney Injury Requiring Dialysis After Pediatric Heart Transplant.

Acute kidney injury (AKI) is a common complication of pediatric heart transplant, with a subset of patients developing severe AKI requiring dialysis (AKI-D). We aimed to identify the epidemiology, risk factors, and outcomes of postoperative AKI-D in pediatric heart transplant recipients. We retrospectively identified all pediatric first-time, single-organ heart transplants at our institution from 2014 to 2022. Postoperative AKI was defined as AKI within 2 weeks of transplant. Unadjusted and adjusted logistic regression were used to identify characteristics associated with AKI-D, and unadjusted time-to-event analyses were used to determine the association between AKI-D and survival free of kidney failure. Among 177 patients included, 116 (66%) developed postoperative AKI of any stage, including 13 (7%) who developed AKI-D with median time from transplant to dialysis initiation of 6 days (IQR 3-13). In adjusted models, increased cardiopulmonary bypass time (OR 1.19, 95% CI 1.04-1.37, per 15 min increase in bypass time) and higher weight at transplant were associated with higher odds of AKI-D, whereas patient demographics and pretransplant kidney function were not associated with AKI-D. AKI-D was associated with greater mortality during initial hospitalization (46% vs. 1%, p < 0.001) and a lower rate of survival free of kidney failure. The incidence of AKI-D after pediatric heart transplant was 7%, with extended cardiopulmonary bypass time associated with postoperative AKI-D even in adjusted models. Further research is needed to improve the prediction and management of AKI-D in this population.

Minimally Invasive Surgery through Right Mini-Thoracotomy for Mitral Valve Infective Endocarditis: Contraindicated or Safely Possible?

Background: Mitral valve infective endocarditis (IE) still has a high mortality. Minimally invasive mitral valve surgery (MIMVS) is technically more challenging, especially in patients with endocarditis. Here, we compare the early postoperative outcome of patients with endocarditis and other indications for MIMVS. Methods: Two groups were formed, one consisting of patients who underwent surgery because of mitral valve endocarditis (IE group: n = 75) and the other group consisting of patients who had another indication for MIMVS (non-IE group: n = 862). Patients were observed for 30 postoperative days. Data were retrospectively reviewed and collected from January 2011 to September 2023. Results: Patients from the IE group were younger (60 vs. 68 years; p < 0.001) and had a higher preoperative history of stroke (26% vs. 6%; p < 0.001) with neurological symptoms (26% vs. 9%; p < 0.001). No difference was seen in overall surgery time (211 vs. 206 min; p = 0.71), time on cardiopulmonary bypass (137 vs. 137 min; p = 0.42) and aortic clamping time (76 vs. 78 min; p = 0.42). Concerning postoperative data, the IE group had a higher requirement of erythrocyte transfusion (2 vs. 0; p = 0.041). But no difference was seen in the need for a mitral valve redo procedure, bleeding, postoperative stroke, cerebral bleeding, new-onset dialysis, overall intubation time, sepsis, pacemaker implantation, wound healing disorders and 30-day mortality. Conclusions: Minimally invasive mitral valve surgery in patients with mitral valve endocarditis is feasible and safe. Infective endocarditis should not be considered as a contraindication for MIMVS.

Standard versus High Cardiopulmonary Bypass Flow Rate: A Randomized Controlled Subtrial Comparing Brain Injury Biomarker Release

To compare brain injury biomarker release levels between two different cardiopulmonary bypass (CPB) flow rates in elective cardiac surgery and to explore differences in postoperative delirium between groups and associations between age, sex, CPB time, oxygen levels, and near-infrared spectroscopy, and biomarker levels. A randomized controlled substudy trial SETTING: Sahlgrenska University Hospital, Sweden PARTICIPANTS: Forty patients undergoing elective cardiac surgery with CPB INTERVENTION: Patients were assigned at random to either a standard (2.4 L/min/m2) or a high (2.9 L/min/m2) CPB flow rate. Glial fibrillary acidic protein, neurofilament light chain, total-tau, and phosphorylated-tau217 were sampled in plasma before anesthesia induction, after 60 minutes on CPB, and at 30 minutes, 24 hours, and 72 hours post-CPB. Mixed models for repeated measures were used to analyze differences in biomarker levels between groups and to assess relationships, which showed no differences between the 2 flow rate groups. There also was no difference in the occurrence of delirium between the 2 groups. Associations were found between age and increased neurofilament light chain levels. Female sex, oxygen delivery >330 mL/min/m2, and near-infrared spectroscopy level >60% were associated with lower biomarker levels. An increased flow rate did not have any significant effects on biomarker levels compared to a standard flow rate. Several associations were identified between treatment characteristics and biomarker levels. No difference in delirium was seen.

Left anterior mini-thoracotomy: an alternative approach for pulmonary valve replacement after surgically corrected tetralogy of fallot

IntroductionPulmonary regurgitation (PR) remains a common sequela in patients following surgically corrected TOF, and may lead to progressive right ventricle dilatation and dysfunction. The conventional approach of redo-sternotomy for pulmonary valve replacement (PVR) is associated with increased operative time as well as risks of bleeding and injury to the heart and great vessels. Thus, left anterior mini-thoracotomy has become an alternative approach in eliminating the risks of redo-sternotomy in these patients. This series aimed to determine the outcomes of minimally invasive pulmonary valve replacement after surgical TOF correction.MethodsA retrospective analysis was conducted on 24 patients with severe PR post-surgical TOF correction who underwent left anterior mini-thoracotomy PVR in Penang General Hospital from January 2021 to January 2023.ResultsThe median age was 23.5 years (I.Q.range 17.6-36.3), with a male:female ratio of 1:4. Majority of patients had mild to moderate symptoms prior to surgery and 19 patients (79.1%) were on regular diuretics medication. All patients had severe free-flow PR with evidence of right ventricular dilatation and dysfunction. Magnetic Resonance Imaging and computed tomography of pulmonary artery were performed prior to surgery. Minimally invasive PVR was performed on all patients via left upper anterior mini-thoracotomy and femoral-femoral bypass without cardioplegic arrest. The operative time and cardiopulmonary bypass time were 208 (I.Q.range 172-324) and 98.6 minutes(I.Q.range 87.4-152.4) respectively. The time to wean off inotropes postoperatively was 6.2 hours (I.Q.range1.4-14.8), and no postoperative arrhythmia and chest re-exploration were reported. Most patients stayed in Intensive Care Unit (ICU) for 10.8 hours (I.Q.range 8.4-36.5), and the total hospital stay was 4.2 days (I.Q.range 3.4-7.6). 2 patients (11.1%) required blood transfusion postoperative. There was no paravalvular leak and no mortality during the follow-up period of up to 28 months.ConclusionMinimally invasive PVR after surgical correction of TOF is a safe alternative to the conventional redo-sternotomy approach in patients with favorable anatomy. This approach is able to reduce the risks associated with redo-sternotomy, particularly bleeding and injury to mediastinal structures, with the additional benefit of expedited recovery and hospital discharge. Our series has shown a safe and efficient approach in these patients with favorable outcomes.

The absolute lactate levels versus clearance for prognostication of post-cardiotomy patients on veno-arterial ECMO.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving procedure for supporting patients with cardiogenic shock after cardiac surgery. This work aimed to analyse the impact of changes in blood lactate levels on the survival of patients on post-cardiotomy ECMO (PC-ECMO) and whether lactate clearance (LC) performs better than absolute lactate levels. We retrospectively analysed the data of adult patients who received PC-ECMO at our centre between 2016 and 2022. The primary outcome was the in-hospital mortality rate. Arterial lactate levels were measured at ECMO initiation, peak and 12 and 24h after VA-ECMO support. LC was calculated at 12 and 24h. Out of 2368 patients who received cardiac surgeries, 152 (median age, 48years; 57.9% of them were men) received PC-ECMO. Of them, 48 (31.6%) survived and were discharged, while 104 (68.4%) died during the index hospitalization. Non-survivors had higher frequencies of atrial fibrillation (41.35% vs. 12.5%, P<0.001), chronic kidney disease (26.9% vs. 6.3%, P=0.004), prolonged cardiopulmonary bypass (237 vs. 192min, P=0.016) and aortic cross-clamping times (160 vs. 124min, P=0.04) than survivors. Non-survivors had a significantly higher median Sequential Organ Failure Assessment (SOFA) score at ECMO initiation (13.5 vs. 9, P<0.001) and a lower median Survival After Veno-arterial ECMO (SAVE) score (-3 vs. 3, P<0.001) with higher SAVE classes (P<0.001) than survivors. After 12h of VA-ECMO support, the blood lactate level was negatively correlated with LC in survivors (r=-0.755, P<0.001) and non-survivors (r=-0.601, P<0.001). After 24h, the same negative correlation was identified between survivors (r=-0.764, P<0.001) and non-survivors (r=-0.847, P<0.001). Blood lactate levels measured at 12h to determine hospital mortality [>8.2mmol/L, area under the receiver operating characteristic curve (AUROC): 0.868] and 24h (>2.6mmol/L, AUROC: 0.896) had the best performance, followed by LC-T12 (<21.94%, AUROC: 0.807), LC-T24 (<40.3%, AUROC: 0.839) and peak blood lactate (>14.35mmol/L, AUROC: 0.828). The initial pre-ECMO blood lactate (>6.25mmol/L, AUROC: 0.731) had an acceptable ability to discriminate mortality but was less than the following measurements and clearance. Kaplan-Meier curves demonstrated that LC of <21.94% at T12h and <40.3% at T24h was associated with decreased survival (log-rank P<0.001). Cox proportional hazards regression analysis for mortality revealed that LC of <21.94% at T12h had an adjusted hazard ratio (HR) of 2.73 [95% confidence interval (CI): 1.64-5.762, P<0.001] and LC of <40.3% at T24h had an adjusted HR of 1.98 (95% CI: 1.46-4.173, P<0.001). The predictors of hospital mortality after PC-ECMO were the lactate level at 12h [odds ratio (OR): 1.67, 95% CI: 1.121-2.181, P=0.001], initial SOFA score (OR: 1.593, 95% CI: 1.15-2.73, P<0.001), initial blood lactate (OR: 1.21, 95% CI: 1.016-1.721, P=0.032) and atrial fibrillation (OR: 6.17, 95% CI: 2.37-57.214, P=0.003). Bivariate models using lactate levels and clearance at the same points revealed that blood lactate levels performed better than the clearance percentage. Serial measurements of arterial blood lactate and LC help in obtaining early prognostic guidance in adult patients supported by VA-ECMO after cardiac surgery. Absolute lactate levels, compared with LC at the same time points, demonstrated better performance in differentiating mortality.

Clinical Outcomes, Predictors, and Surgical Management of Infracardiac Total Anomalous Pulmonary Venous Connection.

This study sought to find the risk factors of postoperative pulmonary venous obstruction (PVO), PVO-related reintervention, and postoperative mortality, determine the relationship between pulmonary venous confluence (PVC) morphology and the clinical outcomes, and provide the basis for the selection of the optimal surgical strategy for infracardiac total anomalous pulmonary venous connection (TAPVC). From December 2009 to December 2023, 101 patients with infracardiac TAPVC undergoing surgical repair in our institution were included [Conventional surgery (CS) group, n = 73; Sutureless technique (ST) group, n = 28]. The Kaplan-Meier curve was used to demonstrate the survival estimates. The Cox proportional hazard model was used to identify risk factors for primary endpoints. There were 8 in-hospital deaths and 4 late deaths. The survival rates at 1, 5, and 10years were 88.8%, 87.6%, and 87.6%, respectively, in the whole cohort. Multivariable analysis showed that prolonged cardiopulmonary bypass (CBP) time was associated with overall mortality and Y-shaped PVC has a trend for a higher mortality rate. Postoperative PVO occurred in 27 patients. Freedom from postoperative PVO at 1, 5, and 10years were 81.8%, 69.9%, and 69.9%, respectively. Y-shaped PVC and preoperative PVO were incremental risk factors for PVO, but ST repair was a protective factor. Sixteen patients underwent PVO-related reintervention. Y-shaped PVC was the only independent risk factors for PVO-related reintervention while ST repair was a protective factor. Sutureless technique can achieve satisfactory outcomes for infracardiac TAPVC repair. Compared with CS repair, ST repair is significantly associated with decreased postoperative PVO and PVO-related reintervention. Y-shaped PVC is associated with a higher risk of PVO, PVO-related reintervention, and mortality, respectively. Patients with preoperative PVO are more likely to develop postoperative PVO.

The use of minimally invasive surgical techniques ın pediatric patients with partial anomalous pulmonary venous return

Aim The use of minimally invasive procedures in low-risk congenital heart surgeries has been increasing recently. Compared to traditional median sternotomy, minimally invasive techniques offer better cosmetic results and provide more satisfaction to both the patient and their parents. Partial anomalous pulmonary venous return (PAPVR) can be safely repaired using these techniques. Material and Metods The perioperative data of right- sided PAPVR patients who were operated on using minimally invasive approaches in our clinic between March 2019 and January 2023 were reviewed retrospectively. The perioperative data of the patients' including , type of surgery , cardiopulmonary bypass time, cross-clamp time, postoperative cardiac rhythm, total operation time, total drainage, total intensive care unit time, and total hospital stay time were obtained. The results were compared with the data in the current literature. Results During the study period, 14 patients underwent surgical repair. Five (36%) of them were female and nine (64%) were male. Patients undergoing right infraaxillary vertical thoracotomy (RIAVT) and right anterolateral thoracotomy (RALT) had mean ages of 48±26.6 and 42±18.2 month, respectively. High venosum type atrial septal defect (ASD) was detected in 12 (85.7%) of the patients. The most frequently used surgical treatment was the double patch technique which was used in 12 patients (85.7%). This was followed by single patch repair with one patient (7.1 %). The Warden procedure was used in one patient (7.1%) who was operated on with the RIAVT technique. Patients’ cross-clamp, cardiopulmonary bypass (CPB), and total operation times were comparable to those reported in the medical literature. Conclusion RIAVT and RALT are two of the oftenly used minimally invasive surgical techniques in congenital heart surgery. After gaining sufficient experience, both of these methods can be safely applied to PAPVR repair.

Association of Hyperoxia During Cardiopulmonary Bypass and Postoperative Delirium in the Pediatric Cardiac ICU.

ICU delirium commonly complicates critical illness associated with factors such as cardiopulmonary bypass (CPB) time and the requirement of mechanical ventilation (MV). Recent reports associate hyperoxia with poorer outcomes in critically ill children. This study sought to determine whether hyperoxia on CPB in pediatric patients was associated with a higher prevalence of postoperative delirium. Secondary analysis of data obtained from a prospective cohort study. Twenty-two-bed pediatric cardiac ICU in a tertiary children's hospital. All patients (18 yr old or older) admitted post-CPB, with documented delirium assessment scores using the Preschool/Pediatric Confusion Assessment Method for the ICU and who were enrolled in the Precision Medicine in Pediatric Cardiology Cohort from February 2021 to November 2021. None. Of 148 patients, who underwent cardiac surgery, 35 had delirium within the first 72 hours (24%). There was no association between hyperoxia on CPB and postoperative delirium for all definitions of hyperoxia, including hyperoxic area under the curve above 5 predetermined Pao2 levels: 150 mm Hg (odds ratio [95% CI]: 1.176 [0.605-2.286], p = 0.633); 175 mm Hg (OR 1.177 [95% CI, 0.668-2.075], p = 0.572); 200 mm Hg (OR 1.235 [95% CI, 0.752-2.026], p = 0.405); 250 mm Hg (OR 1.204 [95% CI, 0.859-1.688], p = 0.281), 300 mm Hg (OR 1.178 [95% CI, 0.918-1.511], p = 0.199). In an additional exploratory analysis, comparing patients with delirium within 72 hours versus those without, only the z score for weight differed (mean [sd]: 0.09 [1.41] vs. -0.48 [1.82], p < 0.05). When comparing patients who developed delirium at any point during their ICU stay (n = 45, 30%), MV days, severity of illness (Pediatric Index of Mortality 3 Score) score, CPB time, and z score for weight were associated with delirium (p < 0.05). Postoperative delirium (72 hr from CPB) occurred in 24% of pediatric patients. Hyperoxia, defined in multiple ways, was not associated with delirium. On exploratory analysis, nutritional status (z score for weight) may be a significant factor in delirium risk. Further delineation of risk factors for postoperative delirium versus ICU delirium warrants additional study.

789 Alternative Operative Procedures in Repeat Mitral Valve Surgery: A Systematic Review and Meta-Analysis

Abstract Aim Median sternotomy remains the gold standard redo mitral valve surgery. However, this can be physically demanding for patients and affect mortality and morbidity. Alternative procedures such as the right anterolateral mini thoracotomy have been explored to mitigate the risks of a re-sternotomy. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini thoracotomy (MT) in mitral valve surgery. Method A systematic, electronic search was performed according to PRISMA guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via an MS approach. Results Twelve studies were identified, enrolling 4,514 patients. Length of hospital stay (MD= -3.71, 95% CI[-4.92, -2.49]), 30-day mortality(OR = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure(OR=0.38, 95% CI [0.22, 0.65]) were statistically significant in favour of the MT approach. Infection rates(OR=0.56, 95% CI[0.25, 1.21]) and length of ICU stay (MD= -0.55, 95% CI[-1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time(MD=-2.33, 95% CI [-8.15, 3.50]), aortic cross-clamp time MD= -1.67, 95% CI[-17.07, 13.76]), and rates of stroke(OR=1.03, 95% CI[0.55, 1.92]). Conclusions Right MT offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis and hence, can be considered a safe alternative. This review calls for robust trials in the field to further strengthen the evidence.

366 A Case Study: Application of Personalised External Aortic Root Support to Overcome a Failing Ross Procedure

Abstract Aortic root aneurysms are traditionally treated by aortic root replacement surgery alone or in combination with aortic valve replacement in a Modified Bentall procedure. We present a novel surgical approach using a Personalised External Aortic Root Support (PEARS) in the management of an aortic root aneurysm in a 24-year-old male, initially presenting in infancy with mixed aortic valve disease who underwent a free root Ross procedure in 2010 aged 11. Follow-up cardiac magnetic resonance imaging and transthoracic echocardiography showed mild aortic and pulmonary valve regurgitation with aortic root dilatation (51mm). In 2022, Computerised tomography (CT) exhibited dilation of the Sinus of Valsalva (43mm) and ascending aorta (56 mm). MDT review deemed redo valve-sparing root replacement appropriate as the ascending aorta was &amp;gt;55mm with an approximate 8mm increase over three years. As the young patient wished to avoid warfarinisation and the autograft valve maintained good function, a reduction PEARS was considered. In September 2023, a reduced aortic PEARS graft (80% reduction) was implemented along with a redo of the right ventricle to pulmonary artery conduit. Whilst applying the PEARS it was noted that there was a retroaortic circumflex artery, care was taken to mobilise this aberrant vessel to avoid compression by the graft. Cardiopulmonary bypass and cross-clamp times were 180 and 116 minutes respectively. Intraoperative transoesophageal echocardiography confirmed good bi-ventricular function with no pulmonary regurgitation additionally on postoperative CT the aortic diameter was 38mm. In conclusion, application of a reduction PEARS is a potential alternative to a valve-sparing aortic root replacement method in young patients.

The impact of onset-to-cut time in surgery for stable acute type A aortic dissection-a single-centre retrospective cohort study.

The goal of this study was to investigate the impact of onset-to-cut time on mortality in patients undergoing surgery for stable acute type A aortic dissection. Patients who underwent surgery for acute type A aortic dissection between January 2006 and December 2021 and available onset-to-cut times were included. Patients with unstable aortic dissection (preoperative shock, intubation, resuscitation, coma, pericardial tamponade and local/systemic malperfusion syndromes) were excluded. After descriptive analysis, a multivariable binary logistic regression for 30-day mortality was performed. A receiver operating characteristic curve for onset-to-cut time and 30-day mortality was calculated. Restricted cubic splines were designed to investigate the association between onset-to-cut time and survival. The final cohort comprised 362 patients. The median onset-to-cut time was 543 (376-1155) min. The 30-day mortality was 9%. Only previous myocardial infarction (P = 0.018) and prolonged cardiopulmonary bypass time (P < 0.001) were identified as independent risk factors for 30-day mortality. The corresponding area under the receiver operating characteristic curve showed a value of 0.49. Restricted cubic splines did not indicate an association between onset-to-cut time and survival (P = 0.316). Onset-to-cut time in the setting of stable acute type A aortic dissection does not seem to be a valid predictor of 30-day mortality in patients undergoing surgery and stayed stable during the preoperative course.

Platelet inhibitor withdrawal and outcomes after coronary artery surgery: an individual patient data meta-analysis.

To evaluate the association between guideline-conforming as compared to shorter than recommended withdrawal period of P2Y12 receptor inhibitors prior to isolated on-pump coronary artery bypass grafting (CABG) and the incidence of severe bleeding and ischaemic events. Randomized controlled trials are lacking in this field. We searched PUBMED, Embase and other suitable databases for studies including patients on P2Y12 receptor inhibitors undergoing isolated CABG and reporting bleeding and postoperative ischaemic events from 2013 to March 2024. The primary outcome was incidence of Bleeding Academic Research Consortium type 4 (BARC-4) bleeding defined as any of the following: perioperative intracranial bleeding, reoperation for bleeding, transfusion of ≥5 units of red blood cells, chest tube output of ≥2 l. The secondary outcome was postoperative ischaemic events according to the Academic Research Consortium 2 Consensus Document. Patient-level data provided by each observational trial were synthesized into a single dataset and analysed using a 2-stage IPD-MA. Individual data of 4837 patients from 7 observational studies were synthesized. BARC-4 bleeding, 30-day mortality and postoperative ischaemic events occurred in 20%, 2.6% and 5.2% of patients. After adjusting for EuroSCORE II and cardiopulmonary bypass time, guideline-conforming withdrawal was associated with decreased BARC-4 bleeding risk in patients on clopidogrel [adjusted odds ratio (OR) 0.48; 95% confidence intervals (CI) 0.28-0.81; P = 0.006] and a trend towards decreased risk in patients on ticagrelor (adjusted OR 0.48; 95% CI 0.22-1.05; P = 0.067). Guideline-conforming withdrawal was not significantly associated with 30-day mortality risk (clopidogrel: adjusted OR 0.70; 95% CI 0.30-1.61; ticagrelor: adjusted OR 0.89; 95% CI 0.37-2.18) but with decreased risk of postoperative ischaemic events in patients on clopidogrel (clopidogrel: adjusted OR 0.50; 95% CI 0.30-0.82; ticagrelor: adjusted OR 0.78; 95% CI 0.45-1.37). BARC-4 bleeding was associated with 30-day mortality risk (adjusted OR 4.76; 95% CI 2.67-8.47; P < 0.001). Guideline-conforming preoperative withdrawal of ticagrelor and clopidogrel was associated with a 50% reduced BARC-4 bleeding risk when corrected for EuroSCORE II and cardiopulmonary bypass time but was not associated with increased risk of 30-day mortality or postoperative ischaemic events.

Reoperative aortic root surgery: single-center long-term outcomes and literature review.

Reoperative aortic root surgery has become more and more common over the years and is considered high-risk, with significantly worse outcomes compared to first-procedure root surgery. At our institution, this kind of surgery is frequently performed. The aim of the present review is to describe currently available literature on reoperative surgery on the aortic root in terms of patients' population, indications for surgery and outcomes and to present our center's experience on the matter. A literature review was performed in order to identify pertinent studies. They were then compared and described. We also described preoperative characteristics, operative strategies and outcomes of all the patients who underwent redo aortic root surgery from January 1986 to December 2022 at our center. Our literature review identified 12 pertinent studies, with a total of 16,627 considered patients. The most frequent indications for redo surgery were endocarditis (35.5%), aneurysm, dissection and pseudoaneurysm. Mean cardiopulmonary bypass (CPB) and cross-clamp times were 218 and 152 minutes, respectively. In-hospital mortality was 12%. When analyzing our center's data, 344 procedures were identified. Aortic root dilation was the most frequent indication (36.9%). Mean CPB and cross-clamp times were 218.0±78.8 and 158.2±49.7 minutes, respectively. In-hospital mortality was 9.6%. Survival at 5 and 15 years was 76.1% and 51.4% respectively. Freedom from further aortic reintervention was 88.1% after 5 years and 64.9% after 15 years. Reoperative aortic root surgery is a difficult cardiac procedure which is linked to significantly higher mortality than first-time root replacement. If it is performed by experienced surgeons with a careful preoperative planning its result can still be satisfactory. Our results showed acceptable rates of mortality and reinterventions at follow-up. Endocarditis, however, was linked to worse outcomes.

Stroke outcomes following cardiac and aortic surgery are improved by the involvement of a stroke team

AbstractObjectivesPost‐cardiac and aortic surgery stroke is often underreported. We detail our single‐centre experience the following introduction of comprehensive consultant‐led daily stroke service, to demonstrate the efficacy of a stroke team in recovery from stroke following cardiac and aortic surgeries.MethodsThis retrospective, single‐centre observational cohort study analysed consecutive patients undergoing cardiac and aortic surgery at our institution from August 2014 to December 2020. Main outcomes included stroke rate, predictors of stroke, and neurological deficit resolution or persistence at discharge and clinic follow‐up.ResultsA total of 12,135 procedures were carried out in the reference period. Among these, 436 (3.6%) suffered a stroke. Overall survival to discharge and follow‐up were 86.0% and 84.0% respectively. Independent risk factors for post‐operative stroke included advanced age (OR 1.033, 95% CI [1.023, 1.044], p &lt; .001), female sex (OR 1.491, 95% [1.212, 1.827], p &lt; .001), history of previous cardiac surgeries (OR 1.670, 95% CI [1.239, 2.218], p &lt; .001), simultaneous coronary artery bypass graft + valve procedures (OR 1.825, 95% CI [1.382, 2.382], p &lt; .001) and CPB time longer than 240 min (OR 3.384, 95% CI [2.413, 4.705], p &lt; .001). Stroke patients managed by the multidisciplinary team demonstrated significantly higher rates of survival at discharge (87.3% vs. 61.9%, p = .001).ConclusionsPerioperative stroke can be debilitating immediately long term. The involvement of specialist stroke teams plays a key role in reducing the long‐term burden and mortality of this condition.

Total aortic arch debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR) in acute non-A non-B aortic dissection

BackgroundThe surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios when thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention.Case presentationWe present a 38-year-old patient with a physically demanding lifestyle as a professional wrestler, uncontrolled hypertension due to history of medical non-adherence, and family history of aortic dissection who presented with acute non-A non-B aortic dissection. He was spared a total arch replacement by undergoing a hybrid approach of complete aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of aortic cross clamp, circulatory arrest, and hypothermic circulation.ConclusionsThis patient’s unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention that would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR.

Early and Long-Term Results of Minimally Invasive Mitral Valve Repair in Young and Middle-Aged Patients

The aim. To analyze the early and long-term results of minimally invasive mitral valve repair in young and middle-aged patients and compare the outcomes with mitral valve repairs performed through standard sternotomy. Materials and methods. From 2016 to 2021, 128 patients with mitral insufficiency were operated in the Ukrainian Children’s Cardiac Center. Exclusion criteria included patients under 18 or over 59 years old and patients with concomitant pathology of the aortic valve, aorta, and coronary arteries. Results. In the investigated group, the average duration of cardiopulmonary bypass and aortic cross-clamping time was longer than in the comparative group. However, the average duration of mechanical ventilation, average time in theintensive care unit, and average length of hospitalization were shorter in the investigated group. Patients in the investigated group less frequently required red blood cell transfusion (5.6% vs. 14.6%) and plasma transfusion (9.4% vs. 14.6%). The percentage of postoperative complications was almost half lower in the investigated group (3.6% vs. 6.6%). None of the patients in the investigated group showed a severe degree of mitral insufficiency, while two patients in the comparative group had severe mitral insufficiency. Conclusions. Minimally invasive mitral valve repair is associated with a lower percentage of postoperative complications. Early and long-term observation results indicate the high effectiveness and safety of the minimally invasive method.

Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study

BackgroundAn optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting.MethodsThis retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications.ResultsWe included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39–11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups.ConclusionImplementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA.Trials registrationThe study protocol was registered in the Australian New Zealand Clinical Trials Registry (https://www.anzctr.org.au/ACTRN12623000060640.aspx, retrospectively registered on 17/01/2023).