Deep Hypothermic Circulatory Arrest Time Research Articles

Critical care therapies pre- and post-heart transplant and their impact: Analysis from the Pediatric Cardiac Critical Care Consortium

BackgroundFew studies highlighting the critical care management of patients after heart HTx (HTx) have been published to date. This analysis provides a contemporary representation of critical care burden pre- and post-HTx, describes care differences based on pre-transplant diagnosis and outlines the impact of intensive care unit (ICU) therapies on outcomes. MethodsData from PC4 Collaborative Registry was analyzed for pediatric patients undergoing HTx between 08/2014-04/2022. Results1877 HTx in 1857 patients were reported from 42 centers; 56.5% had congenital heart disease (CHD). Patients with CHD were younger, smaller, more likely male, White race, and publicly insured. Their pre-HTx ICU course was characterized by a higher need for catheterization, increased likelihood of inotropic support and mechanical ventilation with lower VAD rates. Their operative courses were significant for longer bypass and cross-clamp times. Postoperatively, CHD patients required more CPR and utilized more ICU therapies such as inotropes, ECMO and renal replacement. Those with CHD had a longer duration of ventilatory support (68.6 vs. 27.3 hours), total hospital stays (37.1 vs. 22.9 days) and higher hospital mortality (7.8% vs. 1.8%); all p<0.0001. Longer cardiopulmonary bypass and longer deep hypothermic circulatory arrest times and delayed sternal closure were independent risk factors for hospital mortality. Lastly, there was no association between total surgical volume for a center and outcomes but there was a significant relationship between center transplant volume and outcomes with higher volume centers demonstrating significantly lower mortality. ConclusionA diagnosis of CHD prior to HTx is associated with a greater use of ICU specific therapies compared non-CHD cohort. Operative factors, particularly in CHD patients, are independently associated with higher hospital mortality as was low transplant volume at the center. The study provides basis for further investigating ICU and operative factors that can be modified to improve transplant outcomes.

Predictive Value of Myocardial Markers for Early Postoperative Mortality in Children with Congenital Heart Disease.

To investigate the influencing factors of postoperative creatine kinase-MB (CK-MB) elevation in children with congenital heart disease and its peak value in predicting early postoperative mortality. The clinical data of 521 children with congenital heart disease under the age of 14 who underwent elective surgery in Beijing Children's Hospital from December 2018 to December 2020 were retrospectively analyzed. Stepwise multiple linear regression was used to analyze independent risk factors for postoperative CK-MB elevation, receiver operating characteristic (ROC) curve was used to determine the predictive value of postoperative CK-MB peak, CK peak, and LDH peak on mortality, and linear correlation and regression analysis were used to analyze the interdependence among postoperative CK-MB peak, CK peak, and LDH peak, and multivariate Logistic regression was used to identify independent risk factors for early postoperative mortality. Preterm birth (P = 0.004), ventriculotomy (P = 0.009), the re-establish of bypass (P = 0.007), cardiopulmonary bypass time (P = 0.024), deep hypothermic circulatory arrest time (P = 0.000), assisted ventilation time (P = 0.049), CK peak (P = 0.000), and LDH peak (P = 0.000) were independently associated with increased postoperative CK-MB elevation. The ROC curve showed that CK-MB peak had the strongest predictive value for death (AUC = 0.924), followed by LDH peak (AUC = 0.864) and CK peak (AUC = 0.758). The cut-off value of the postoperative CK-MB peak was 144.5IU/L, with a sensitivity of 87% and a specificity of 97%. CK-MB peak was moderately correlated with CK peak (Pearson Correlation coefficient r = 0.514, P = 0.000) and strongly correlated with LDH peak (Pearson Correlation coefficient r = 0.601, P = 0.000). Multivariate analysis showed that delayed chest closure (OR = 4.865, P = 0.004) and postoperative CK-MB peak (OR = 1.031, P = 0.000) were independent risk factors for postoperative mortality. The postoperative CK-MB peak has a certain predictive value for the early postoperative mortality of children with congenital heart disease. It is affected by many factors, and the risk of mortality is significantly increased in children with severely elevated postoperative CK-MB.

Do obese patients with type A aortic dissection benefit from total arch repair through a partial upper sternotomy?

Minimal research has been performed regarding total arch replacement through partial upper sternotomy in patients with acute type A aortic dissection who are obese, and the safety and feasibility of this procedure need to be further investigated. The present study investigated the potential clinical advantages of using a partial upper sternotomy versus a conventional full sternotomy for total arch replacement in patients who were obese. This was a retrospective study. From January 2017 to January 2020, a total of 65 acute type A aortic dissection patients who were obese underwent total arch replacement with triple-branched stent graft. Among them, 35 patients underwent traditional full sternotomy, and 30 patients underwent partial upper sternotomy. The perioperative clinical data and postoperative follow-up results of the two groups were collected, and the feasibility and clinical effect of partial upper sternotomy in total arch replacement were summarized. The in-hospital mortality rates of the two groups were similar. The total operative time, cardiopulmonary bypass, aortic cross-clamp, cerebral perfusion, and deep hypothermic circulatory arrest times were also similar in both groups. The thoracic drainage and postoperative red blood cell transfusion volumes in the partial upper sternotomy group were significantly lower than those in the full sternotomy group. Mechanical ventilation time was shorter in the partial upper sternotomy group than that in the full sternotomy group. Additionally, the incidences of pulmonary infection, hypoxemia, and sternal diaphoresis were lower in the partial upper sternotomy group than those in the full sternotomy group. This study showed that total arch replacement surgery through a partial upper sternotomy in patients with acute type A aortic dissection who are obese is safe, effective, and superior to full sternotomy in terms of blood loss, postoperative blood transfusion, and respiratory complications.

Experience of the Postoperative Intensive Care Treatment of Stanford Type A Aortic Dissection.

To summarize the experience of the postoperative intensive care treatment of Stanford type A aortic dissection (STAAD) following Sun's procedure. A total of 124 patients with STAAD who underwent Sun's procedure from January 2014 to December 2021 at the General Hospital of Ningxia Medical University were retrospectively analyzed. All patients were admitted to the cardiac surgery intensive care unit (ICU) after surgery. According to the perioperative characteristics of the patients with STAAD, intensive care treatment was given to actively prevent the occurrence of postoperative complications. In all the cases enrolled in this study, the causes of aortic dissection comprised hypertension (105 cases), trauma (six cases), Marfan's syndrome (six cases), and aorto-arteritis (seven cases). The history of past illnesses comprised hypertension (105 cases), coronary disease (25 cases), diabetes mellitus (16 cases), and chronic obstructive pulmonary disease (six cases). There were some preoperative complications, such as cardiac insufficiency, acute liver insufficiency, acute renal insufficiency, pleural effusion, pericardial effusion, pulmonary infection, lower limb ischemia, mesenteric arterial embolism, and digestive tract hemorrhage. The average cardiopulmonary bypass time was 186 ± 32.1 min, the aortic clamp time was 74 ± 12.8 min, the deep hypothermic circulatory arrest time was 21 ± 2.6 min, and the mechanical ventilation time was 34 ± 2.8 h. The average ICU and hospital residence times were 7 ± 1.6 days and 12 ± 3.6 days, respectively. Postoperative complications comprised hypoxemia (34 cases), pulmonary infections (22 cases), tracheostomy (four cases), cerebral hemorrhage (four cases), cerebral infarction (four cases), transient delirium (eight cases), secondary thoracotomies due to bleeding (two cases), alimentary tract hemorrhage (eight cases), and acute renal insufficiency (38 cases). There was no occurrence of hoarseness or chylothorax. There were 15 cases of death, and the total mortality rate was 12.1%. In four cases, the cause of death was one postoperative complication (3.2%), and in 11 cases, the cause of death was multiple postoperative complications (8.9%). The other patients were discharged from the hospital with a good prognosis for full recovery. Postoperative intensive care treatment was an important part of the successful surgical treatment of STAAD.

Double-arterial cannulation strategy in patients presenting with Type A aortic dissection

Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality. Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality. Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes. Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs. Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.

Clinical factors associated with microstructural connectome related brain dysmaturation in term neonates with congenital heart disease.

Term congenital heart disease (CHD) neonates display abnormalities of brain structure and maturation, which are possibly related to underlying patient factors, abnormal physiology and perioperative insults. Our primary goal was to delineate associations between clinical factors and postnatal brain microstructure in term CHD neonates using diffusion tensor imaging (DTI) magnetic resonance (MR) acquisition combined with complementary data-driven connectome and seed-based tractography quantitative analyses. Our secondary goal was to delineate associations between mild dysplastic structural brain abnormalities and connectome and seed-base tractography quantitative analyses. These mild dysplastic structural abnormalities have been derived from prior human infant CHD MR studies and neonatal mouse models of CHD that were collectively used to calculate to calculate a brain dysplasia score (BDS) that included assessment of subcortical structures including the olfactory bulb, the cerebellum and the hippocampus. Neonates undergoing cardiac surgery for CHD were prospectively recruited from two large centers. Both pre- and postoperative MR brain scans were obtained. DTI in 42 directions was segmented into 90 regions using a neonatal brain template and three weighted methods. Clinical data collection included 18 patient-specific and 9 preoperative variables associated with preoperative scan and 6 intraoperative (e.g., cardiopulmonary bypass and deep hypothermic circulatory arrest times) and 12 postoperative variables associated with postoperative scan. We compared patient specific and preoperative clinical factors to network topology and tractography alterations on a preoperative neonatal brain MRI, and intra and postoperative clinical factors to network topology alterations on postoperative neonatal brain MRI. A composite BDS was created to score abnormal findings involving the cerebellar hemispheres and vermis, supratentorial extra-axial fluid, olfactory bulbs and sulci, hippocampus, choroid plexus, corpus callosum, and brainstem. The neuroimaging outcomes of this study included (1) connectome metrics: cost (number of connections) and global/nodal efficiency (network integration); (2) seed based tractography methods of fractional anisotropy (FA), radial diffusivity, and axial diffusivity. Statistics consisted of multiple regression with false discovery rate correction (FDR) comparing the clinical risk factors and BDS (including subcortical components) as predictors/exposures and the global connectome metrics, nodal efficiency, and seed based- tractography (FA, radial diffusivity, and axial diffusivity) as neuroimaging outcome measures. A total of 133 term neonates with complex CHD were prospectively enrolled and 110 had analyzable DTI. Multiple patient-specific factors including d-transposition of the great arteries (d-TGA) physiology and severity of impairment of fetal cerebral substrate delivery (i.e., how much the CHD lesion alters typical fetal circulation such that the highest oxygen and nutrient rich blood from the placenta are not directed toward the fetal brain) were predictive of preoperative reduced cost (p < 0.0073) and reduced global/nodal efficiency (p < 0.03). Cardiopulmonary bypass time predicted postoperative reduced cost (p < 0.04) and multiple postoperative factors [extracorporeal membrane oxygenation (ECMO), seizures and cardiopulmonary resuscitation (CPR)] were predictive of postoperative reduced cost and reduced global/nodal efficiency (p < 0.05). Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. Total BDS was not predictive of brain network topology. However, key subcortical components of the BDS score did predict key global and nodal network topology: abnormalities of the cerebellum predicted reduced cost (p < 0.0417) and of the hippocampus predicted reduced global efficiency (p < 0.0126). All three subcortical structures predicted unique alterations of nodal efficiency (p < 0.05), including hippocampal abnormalities predicting widespread reduced nodal efficiency in all lobes of the brain, cerebellar abnormalities predicting increased prefrontal nodal efficiency, and olfactory bulb abnormalities predicting posterior parietal-occipital nodal efficiency. Patient-specific (d-TGA anatomy, preoperative impairment of fetal cerebral substrate delivery) and postoperative (e.g., seizures, need for ECMO, or CPR) clinical factors were most predictive of diffuse postnatal microstructural dysmaturation in term CHD neonates. Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. In contrast, subcortical components (cerebellum, hippocampus, olfactory) of a structurally based BDS (derived from CHD mouse mutants), predicted more localized and regional postnatal microstructural differences. Collectively, these findings suggest that brain DTI connectome and seed-based tractography are complementary techniques which may facilitate deciphering the mechanistic relative contribution of clinical and genetic risk factors related to poor neurodevelopmental outcomes in CHD.

Surgical Treatment of Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair.

Data are scarce regarding retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR). This study aimed to investigate the clinical characteristics and surgical treatment outcomes of patients who developed RTAD after TEVAR.From January 2015 to January 2020, 25 consecutive patients (aged 52 ± 11.69 years) of RTAD after TEVAR received open surgery. All patients received total arch replacement (TAR) with the frozen elephant trunk (FET). The proximal part of the TEVAR stent was removed using a wire scissor. The distal part of the TEVAR stent in the descending aorta was preserved. Data of 50 random patients of type A aortic dissection without prior TEVAR were collected during the same period. We compared the perioperative and midterm follow-up outcomes between patients with prior TEVAR and patients without prior TEVAR.The mean cardiopulmonary bypass time, aortic cross-clamp time, and deep hypothermic circulatory arrest time were 173.7 ± 44.1, 109.5 ± 31.4, and 21.6 ± 6.8 minutes in the RTAD group, respectively. These times are similar to those of the no-RTAD group. The median interval between the initial TEVAR procedure and RTAD was 8.5 months (range, 0-72 months). New entry tears that were induced by the proximal end of the TEVAR stent were found in 23 (92%) patients of the RTAD group. There were no significant differences in major adverse events and overall survival between the two groups.TAR with the FET technique was feasible for the treatment of RTAD after TEVAR, with acceptable early and midterm results.

Association between Duration of Deep Hypothermic Circulatory Arrest and Surgical Outcome in Patients with Acute Type A Aortic Dissection: A Large Retrospective Cohort Study

(1) Background: Deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (ACP) is an established cerebral protection technique for the conduction of complex surgical procedures involving the aortic arch. It is controversial whether the duration of DHCA is associated with adverse outcome in patients with acute type A aortic dissection (AAAD). Our goal was to investigate whether DHCA time was associated with surgical outcome in patients undergoing a surgical treatment of AAAD. (2) Methods: A total of 410 patients were divided into two groups based on the DHCA time less than 60 min and equal to or longer than 60 min. (3) Results: Patients with longer DHCA times were significantly younger (p = 0.001). Intraoperatively, complex procedures with aortic arch surgery were more common in patients with longer DHCA times (p < 0.001). Accordingly, cardiopulmonary bypass (p < 0.001), cross-clamping (p < 0.001) and DHCA times (p < 0.001) were significantly longer in this group. Postoperatively, only the duration of mechanical ventilation (p < 0.001) and the rate of tracheotomy were significantly higher in these patients. Thirty-day mortality was satisfactory for both groups (p = 0.746). (4) Conclusions: Our results showed that improvements in perioperative management including ACP allow for the successful performance of surgical treatment of AAAD under DHCA with a duration of even longer than 60 min.

Fontan procedure on deep hypothermic circulatory arrest: Short-term results and technique.

Various operative strategies are described for the Fontan procedure. In this study, we describe our short-term results and technique of Fontan procedure on cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). This was a retrospective study of 32 patients, median age of 6 years (4-19 years) and median weight of 20 kg (13-51 kg), who underwent Fontan procedure on CPB and DHCA from July 2016 to July 2021. The median CPB time was 125 min (77-186 min), the median DHCA time was 42 min (27-50 min), and the median Fontan pressure was 14 mmHg (10-18 mmHg). The median time to extubation was 4 h (1-20 h), the duration of chest tube drainage was 8 days (5-24 days), and the median intensive care unit stay was 4 days (3-8 days). The presence of heterotaxy was associated with longer duration of pleural drainage (P = 0.01). There was no operative mortality and no major adverse events such as seizures, gross neurological deficits, or arrhythmias in the postoperative period. Fontan procedure can be safely performed on CPB and DHCA with good operative results. This operative strategy may be used in special circumstances like in patients with situs and systemic venous anomalies and those requiring repair of a complex intracardiac defect. Long-term follow-up will be required to evaluate if this strategy has any impact on the neurodevelopmental outcome and the long-term sequelae of Fontan.

Abstract 9023: Post-Operative Ectopic Atrial Tachycardia in Congenital Heart Disease

Introduction: Ectopic atrial tachycardia (EAT) is relatively common in infants following surgery for congenital heart disease (CHD). There is limited data regarding this arrhythmia. Hypothesis: Operative factors, including CHD diagnosis, can identify risk factors for post-operative EAT. Methods: This was a retrospective analysis of patients undergoing CHD surgery in the first year of life between January 2007 and July 2020. Patients and surgeries with EAT were compared to those without EAT. Results: Out of 5,792 infant CHD surgeries, 129 (2.2%) developed postoperative EAT. The onset of EAT occurred at a median of 9 days (IQR 5-14 days) after CHD surgery. Compared to controls, the EAT cohort was younger (median 7 vs 85 days, p &lt;0.01) and had lower weight (3.3 vs 4.3 kg, p &lt;0.01) with no gender difference. EAT occurred following 24/265 (9%) total anomalous pulmonary venous connection (TAPVC) repairs (relative risk of 4.7, p&lt;0.001), 22/351 (6%) arterial switch operations (RR 3.2, p&lt;0.001), 6/90 (7%) interrupted arch repair (RR 3.1, p=0.004), and 23/460 (5%) Norwood operations (RR 2.5, p&lt;0.001). EAT patients had longer cardiopulmonary bypass (median 64 vs 58 min, p=0.008) and deep hypothermic circulatory arrest times (15 vs 0 min, p&lt;0.001) but no statistically significant difference in cross clamp times (25 vs 31 min). Antiarrhythmics were given to 109 patients (84%), but treated patients were more likely to be identified for study inclusion potentially biasing this percent-treated value. Propranolol (60%), amiodarone (22%), and flecainide (4%) were the most frequently used antiarrhythmics during hospitalization. On discharge, 60% of EAT patients were on antiarrhythmics, most commonly propranolol (55%), amiodarone (4%), and flecainide (4%). Although 15 patients did not survive to hospital discharge, EAT was not directly implicated in any deaths. Conclusions: In this study of a large cohort of postoperative EAT patients, the arrhythmia occurred in 2.2% of cases with a median onset of 9 days after surgery. TAPVC repair carried the highest risk of postoperative EAT, followed by arterial switch, interrupted aortic arch repair, and Norwood operations. Patients with EAT were younger, smaller, and had longer bypass and circulatory arrest times than controls.

Risk factors of cerebral complications after Stanford type A aortic dissection undergoing arch surgery

To explore the risk factors of cerebral neurological complications after surgery for Stanford type A aortic arch surgery. One hundred sixteen patients who received Stanford type A aortic dissection from January 2012 to December 2019 were recruited. All patients received surgery under deep hypothermic circulatory arrest (DHCA) and general anesthesia. They were grouped by degree of postoperative cerebral neurological complication. The related factors of cerebral neurological complications were analyzed by single-factor analysis and multi-factor logistic regression. Postoperative neurological complications were observed in 31 cases (26.72%). Two groups were identified: permanent neurological dysfunction (PND) was observed in seven cases, and temporary neurological dysfunction (TND) was observed in 24 cases. In-hospital mortality was 9.48% (11/116), with six in the cerebral complication groups and five in the non-complication group. Single-factor analysis showed the associated factors were age, stroke history, carotid plaque or stenosis, emergency surgery, renal dysfunction, hypotension, aortic clamping time, deep hypothermic circulatory arrest time, postoperative hypoxemia, postoperative low cardiac output and plasma transfusion >800ml, and erythrocyte suspension transfusion >6 U. Multi-factor logistic analysis showed the independent predictive factors were DHCA time >40min, plasma transfusion >800ml, erythrocyte suspension transfusion >6 U, history of stroke, and carotid plaque or stenosis. The factors independently associated with neurological complications are DHCA time >40min, plasma transfusion >800ml, erythrocyte suspension transfusion >6 U, history of stroke, and carotid plaque or stenosis. Our findings suggest that patients with these risk factors should receive intervention during treatment to reduce cerebral neurological complications.

Risk Factors for Prolonged Mechanical Ventilation After Pulmonary Endarterectomy: 7 Years' Experience From an Experienced Hospital in China.

Background: Prolonged mechanical ventilation (PMV) is common after cardiothoracic surgery, whereas the mechanical ventilation strategy after pulmonary endarterectomy (PEA) has not yet been reported. We aim to identify the incidence and risk factors for PMV and the relationship between PMV and short-term outcomes.Methods: We studied a retrospective cohort of 171 who undergoing PEA surgery from 2014 to 2020. Cox regression with restricted cubic splines was performed to identify the cutoff value for PMV. The Least absolute shrinkage and selection operator regression and logistic regressions were applied to identify risk factors for PMV. The impacts of PMV on the short-term outcomes were evaluated.Results: PMV was defined as the duration of mechanical ventilation exceeding 48 h. Independent risk factors for PMV included female sex (OR 2.911; 95% CI 1.303–6.501; P = 0.009), prolonged deep hypothermic circulatory arrest (DHCA) time (OR 1.027; 95% CI 1.002–1.053; P = 0.036), increased postoperative blood product use (OR 3.542; 95% CI 1.203–10.423; P = 0.022), elevated postoperative total bilirubin levels (OR 1.021; 95% CI 1.007–1.034; P = 0.002), increased preoperative pulmonary artery pressure (PAP) (OR 1.031; 95% CI 1.014–1.048; P < 0.001) and elongated postoperative right ventricular anteroposterior dimension (RVAD) (OR 1.119; 95% CI 1.026–1.221; P = 0.011). Patients with PMV had longer intensive care unit stays, higher incidences of postoperative complications, and higher in-hospital medical expenses.Conclusions: Female sex, prolonged DHCA time, increased postoperative blood product use, elevated postoperative total bilirubin levels, increased preoperative PAP, and elongated postoperative RVAD were independent risk factors for PMV. Identification of risk factors associated with PMV in patients undergoing PEA may facilitate timely diagnosis and re-intervention for some of these modifiable factors to decrease ventilation time and improve patient outcomes.

Pulmonary Thrombo-Endarterectomy for Chronic Thromboembolic Pulmonary Artery Hypertension: 17 Years Single Center Experience. Impact of Multidisciplinary Team Approach

Purpose Chronic thromboembolic pulmonary hypertension (CTEPH) is the only type of pulmonary hypertension (PH) with a surgical resolution which is the Pulmonary Thrombo-Endarterectomy (PTE) operation. Fibrotic thrombus extraction allows pulmonary vascular resistances (PVR) reduction until normalisation in most of cases. However, this sentence might be controversial since results are conditioned by the center experience on patients's selection, operation's timing, skills and management of such complex pathology. Seventeen years performing PTE and our multidisciplinary approach allowed us to obtain very good results. In here we report our data progress and results of PTE for CTEPH. Methods A total of 177 patients underwent PTE from 2003 until 2020. From 2003 to 2012 (Group 1) 96 patients were operated avoiding Deep Hypothermic Circulatory Arrest (DHCA) being applied only when blood bronchial flow ruled out a complete endarterectomy. Group 2, included 81 patients operated rom 2012 until the present, when DHCA was routinely adopted. Furthermore, the event of the Balloon Pulmonary Angioplasty (BPA) in 2015, conceded us a therapeutic alternative in high risk or unsuitable PTE patients. The impact of these and other variables in patients population profile and results of both groups have been retrospectively compare and analysed. Results Most relevant preoperative differences were related to worst clinical status and associated pathologies in Group 1 and wider use of specific pulmonary vasodilator in Group 2. Cross clamp time as well as time of cardiopulmonary bypass were significantly shorter in Group 2 in spite of a mean DHCA time of 33 minutes. In-hospital mortality and need of postoperative ECMO was respectively 15.6% vs 3.7% and 15.6% vs 8.6% in group 1 and 2 (p 0.001). Pulmonary hemodynamic as well as long term outcome equally and significantly improved in both groups. Conclusion Our reported results demonstrate that, DHCA is the best approach to perform PTE for CTEPH. Certainly experience, protocols and a multidisciplinary approach contribute to obtain the best hemodynamics, surgical and clinical outcomes.

H-repair in supravalvular aortic stenosis.

H-repair in supravalvular aortic stenosis.

Three-Dimensional Printing-Assisted Fabrication of Stent Graft to Reconstruct the Total Aortic Arch

There is a high incidence of complications after conventional open thoracic aortic arch replacement. Stent graft thoracic endovascular repair for aortic aneurysms has few complications. Vascular variability of the aortic arch branch is high and individualized aortic arch stent graft is required. We present our experience using 3-dimensional print-assisted fabrication of individualized stent grafts. According to the patient's computed tomography angiography results before surgery, the aortic arch was printed 3-dimensionally and then an individualized stent graft was sewn. The prepared stents were placed in the descending aorta and the partial branches of the arch, and then released. Intraoperative stent placement was successful. The deep hypothermic circulatory arrest time was only 5 minutes. The patient recovered well after surgery and no neurological complications occurred. Postoperative computed tomography angiography showed good stent expansion and no endoleak. Three-dimensional printing-assisted fabrication of a stent graft can be used for endovascular repair of the total aortic arch. This technology can be employed to construct individualized aortic arch stents accurately for different patients before surgery.

Early Outcomes of Neonatal Cardiac Surgery in India

To assess outcomes and factors influencing outcomes in neonates requiring cardiac surgery in India. This study reports on review of hospital data from a tertiary care cardiac surgical institute from January-2009 to December-2015. A total of 200 neonates were included; of them, 5% of the cases were antenatally diagnosed and most of them had unmonitored transport (111, 55.5%). The overall mortality rate was 13.5%, (n=27) and 178 (89%) underwent complete defect repair. There was a significant association of mortality with shock, the number of inotropes, intra-operative procedure, residual lesion, aortic cross-clamp and deep hypothermic circulatory arrest time (all P<0.05). Logistic regression analysis showed ventilation duration, cardiac-bypass time, shock, and residual cardiac lesion as independent predictors of mortality. Cardiac defects were found to have late detection and most transports were unmonitored. Complete surgical repair and shorter cardiac bypass time can potentially improve neonatal cardiac surgical outcomes.

A New Graft for Total Arch Replacement With Frozen Elephant Trunk in Type A Dissection

In this study, we propose a novel Sutureless Integrated Stented graft, greatly simplifying the distal aortic anastomosis and reducing the deep hypothermic circulatory arrest time in the setting of total arch replacement with frozen elephant trunk for type A aortic dissection.

Preoperative platelet count, preoperative hemoglobin concentration and deep hypothermic circulatory arrest duration are risk factors for acute kidney injury after pulmonary endarterectomy: a retrospective cohort study

BackgroundAcute kidney injury (AKI) is a major postoperative morbidity of patients undergoing cardiac surgery and has a negative effect on prognosis. The kidney outcomes after pulmonary endarterectomy (PEA) have not yet been reported; However, several perioperative characteristics of PEA may induce postoperative AKI. The objective of our study was to identify the incidence and risk factors for postoperative AKI and its association with short-term outcomes.MethodsThis was a single-center, retrospective, observational, cohort study. Assessments of AKI diagnosis was executed based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria.ResultsA total of 123 consecutive patients who underwent PEA between 2014 and 2018 were included.The incidence of postoperative AKI was 45% in the study population. Stage 3 AKI was associated with worse short-term outcomes and 90-day mortality (p < 0.001, p = 0.002, respectively). The independent predictors of postoperative AKI were the preoperative platelet count (OR 0.992; 95%CI 0.984–0.999; P = 0.022), preoperative hemoglobin concentration (OR 0.969; 95%CI 0.946–0.993; P = 0.01) and deep hypothermic circulatory arrest (DHCA) time (OR 1.197; 95%CI 1.052–1.362; P = 0.006) in the multivariate analysis.ConclusionThe incidence of postoperative AKI was relatively high after PEA compared with other types of cardiothoracic surgeries. The preoperative platelet count, preoperative hemoglobin concentration and DHCA duration were modifiable predictors of AKI, and patients may benefit from some low-risk, low-cost perioperative measures.

Risk factors for postoperative hyperlactatemia in patients with type A aortic dissection

Objective To identify the risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection. Methods Medical records of patients with type A aortic dissection who underwent cardiovascular surgery from January 2012 to October 2017 were retrospectively collected.The patients were divided into hyperlactatemia group and non-hyperlactatemia group according to the occurrence of hyperlactatemia (blood lactic acid ≥6 mmol/L) at 8 h after surgery.The variables of which P values were less than 0.05 in univariate analysis would enter the logistic regression analysis to stratify the risk factors for postoperative hyperlactatemia in this type of patients. Results A total of 295 patients were included, of which 80 cases developed postoperative hyperlactatemia, and the incidence was 27.1%.Logistic regression analysis showed that preoperative acute pericardial tamponade, intraoperative deep hypothermic circulatory arrest time>35 min) and massive transfusion of blood (>1 000 ml) within 8 h after operation were independent risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection. Conclusion Preoperative acute pericardial tamponade, intraoperative deep hypothermic circulatory arrest time>35 min and massive transfusion of blood (>1 000 ml) within 8 h after operation are independent risk factors for postoperative hyperlactatemia in the patients with type A aortic dissection. Key words: Aneurysms, dissection; Hyperlactatemia; Risk factor

Perfusion strategy and mid-term results of 58 consecutive pulmonary endarterectomy.

The aim of this retrospective study was to review and report short-term and mid-term outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at our institute in the recent 2 years and to describe perfusion strategy. A total of 58 consecutive patients with chronic thromboembolic pulmonary hypertension underwent pulmonary endarterectomy under deep hypothermia circulatory arrest with an established perfusion practice between November 2015 and December 2017. Peri-operative data and patients' outcome were retrospectively analyzed. Mean pulmonary artery pressure was decreased (49 (40-56) mmHg vs 27 (20-31) mmHg, p < 0.001), and pulmonary vascular resistance (724 (538-1108) vs 206 (141-284) dyn second cm-5, p < 0.001) improved significantly after surgery. In-hospital mortality was 1.7% and postoperative complication rate was 27.6%. Antipsychotic medication of olanzapine was prescribed for 36 patients (62.1%), which was independently related to total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit. The majority of patients recovered uneventfully with good mid-term cardiac function (New York Heart Association I-II: 98.1%) and neurological outcome (Glasgow Outcome Scale-Extended Upper Good Recovery: 74.1% and Lower Good Recovery: 20.3%). Mid-term neurological outcome was associated with post-pulmonary endarterectomy antipsychotic medication. Short-term and mid-term outcome after pulmonary endarterectomy was comparable to high-volume centers. Incidence of post-pulmonary endarterectomy delirium was relatively high and associated with mid-term neurological outcome. Total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit were independent risk factors of postoperative olanzapine medication. More efforts and further research are required to optimize the neuroprotection of perfusion practice.