Duration Of Aortic Cross-clamping Research Articles

FACTORS AFFECTING MAJOR ADVERSE EFFECTS AFTER CORONARY ARTERY BYPASS SURGERY

OBJECTIVE: The present study aimed to evaluate the patient population who underwent coronary artery bypass grafting (CABG) operation in terms of mortality and major adverse effects (MAE) incidence and examine the factors affecting MAE incidence. MATERIAL AND METHODS: 169 consecutive patients who underwent CABG surgery between January 2017 and December 2019 were retrospectively analyzed. Mortality, myocardial infarction, reoperation, cardiac tamponade, stroke, renal failure, sternal infection, need for extracorporeal membrane oxygenator and cardio pulmonary resuscitation were defined as MAO. RESULTS: The mean age of the patients was 63.19 ±0.72 years, the mean duration of cardiopulmonary bypass (CPB) was 106.95 ±27 minutes, and the mean duration of aortic cross-clamp was 44.87 ±1.05 minutes. Extracorporeal membrane oxygenator support was provided to 11 (6.5%) patients, 7 (4.1%) patients underwent reoperation, 5 (3%) patients experienced a postoperative stroke, 5 (3%) patients required cardiopulmonary resuscitation, and postoperative myocardial infarction was observed in 1 (0.6%) patient. In total, MAE was determined in 28 (16.6%) patients. Mortality occurred in 9 (5.3%) patients. In the univariate analysis, Euroscore, mean arterial pressure during CPB, and ultrafiltration volume were associated with MAE (p=0.004, p=0.026, and p=0.037, respectively). However, in multivariate analysis, only Euroscore (odds ratio: 1.453, 95% CI 1.166-1.811 p=0.001) and ultrafiltration volume (odds ratio:-0.002, 95% CI 0.996-1 p=0.04) were correlated to MAE. CONCLUSIONS: In our study, we observed that high Euroscore levels increased not only mortality but also the incidence of MAO, and increased ultrafiltration volumes reduced the incidence of MAO. We believe that it should be kept in mind during CABG surgery that appropriate ultrafiltration and CPB strategy can reduce the incidence of MAO.

Risk Factors for Higher Postoperative Myocardial Injury in Minimally Invasive Mitral Valve Surgery Patients: A Cohort Study.

Background: Postoperative myocardial injury, as detected by an elevated concentration of high-sensitivity cardiac troponin I (hs-cTnI), is a common complication in cardiac surgery that may be linked to mortality. The primary aim of this study was to assess the risk factors associated with increased myocardial injury in patients undergoing minimally invasive mitral valve surgery. Methods: In this retrospective monocentric cohort study, we analyzed all patients who underwent elective minimally invasive mitral valve surgery between January 2019 and December 2022 and were subsequently admitted to our intensive care unit. The study population was divided into two groups based on the peak hs-cTnI level: the "lower myocardial injury" group comprised patients whose peak serum hs-cTnI level was less than 499 times the 99th percentile, while the "higher myocardial injury" group included those patients who exhibited hs-cTnI levels equal to or greater than 500 times the 99th percentile. A multivariable logistic regression analysis was performed to identify independent risk factors associated with higher myocardial injury. Results: In our final analysis, we enrolled 316 patients. Patients with higher myocardial injury (48; 15%) more frequently had a preoperative New York Heart Association (NYHA) class ≥3 compared to those with lower myocardial injury [33 (69%) vs. 128 (48%); p < 0.01-OR 2.41 (95% CI 1.24-4.64); p < 0.01]. Furthermore, cardiopulmonary bypass and aortic cross-clamp time were significantly longer in the higher myocardial injury group compared to the lower myocardial injury group [117 (91-145) vs. 86 (74-100) min; p < 0.01-OR 1.05 (95% CI 1.03-1.06); p < 0.01]. Moreover, patients who underwent robotic-assisted mitral valve surgery experienced lower myocardial injury rates [9 (19%) vs. 102 (38%); p = 0.01-OR 0.38 (95% CI 0.18-0.81); p = 0.01] than others. These findings remained consistent after adjustment in multivariate logistic regression. In terms of postoperative outcomes, patients with higher myocardial injury exhibited the highest lactate peak in the first 24 h, a higher incidence of postoperative acute kidney injury and a longer duration of mechanical ventilation. Although no patients died in either group, those with higher myocardial injury experienced a longer hospital length of stay. Conclusions: Higher myocardial injury is relatively common after minimally invasive mitral valve surgery. Prolonged aortic cross-clamp duration and higher NYHA class were independently associated with myocardial injury, while robotic-assisted mitral valve surgery was independently associated with lower postoperative myocardial injury.

Risk factors for postoperative delirium in elderly patients undergoing heart valve surgery with cardiopulmonary bypass

BackgroundThe aim of this study was to identify the risk factors for postoperative delirium (POD) in elderly patients undergoing heart valve surgery with cardiopulmonary bypass (CPB).MethodsElderly patients undergoing elective heart valve surgery with CPB in The First Affiliated Hospital of Wenzhou Medical University between March 2022 and March 2023 were selected for this investigation. They were divided into a POD group and a non-POD group. Their baseline information was collected and recorded, and the patients were subjected to neurocognitive function assessment using the Mini-Mental State Examination and the Montreal Cognitive Assessment scales before surgery. We also recorded their intraoperative indicators such as duration of surgery, duration of CPB, duration of aortic cross-clamp, blood transfusion, and postoperative indicators such as duration of mechanical ventilation, postoperative 24-hour drainage volume, and pain score. Regional cerebral oxygen saturation was monitored intraoperatively by near-infrared spectroscopy based INVOS5100C Regional Oximeter. Patients were assessed for the occurrence of POD using Confusion Assessment Method for the Intensive Care Unit, and logistic regression analysis of risk factors for POD was performed.ResultsThe study finally included 132 patients, with 47 patients in the POD group and 85 ones in the non-POD group. There were no significant differences in baseline information and preoperative indicators between the two groups. However, marked differences were identified in duration of surgery, duration of CPB, duration of aortic cross-clamp, duration of postoperative mechanical ventilation, postoperative length of stay in cardiac intensive care unit, postoperative length of hospital stay, intraoperative blood transfusion, postoperative pain score, and postoperative 24-hour drainage volume between the two groups (p < 0.05). Additionally, the two groups had significant differences in rScO2 at each intraoperative time point and in the difference of rScO2 from baseline at each intraoperative time point (p < 0.05). Multivariate logistic regression analysis showed that duration of surgery > 285 min (OR, 1.021 [95% CI, 1.008–1.035]; p = 0.002), duration of postoperative mechanical ventilation > 23.5 h (OR, 6.210 [95% CI, 1.619–23.815]; p = 0.008), and postoperative CCU stay > 3.5 d (OR, 3.927 [95% CI, 1.046–14.735]; p = 0.043) were independent risk factors of the occurrence of POD while change of rScO2 at T1>50.5 (OR, 0.832 [95% CI 0.736–0.941]; p = 0.003) was a protective factor for POD.ConclusionDuration of surgery duration of postoperative mechanical ventilation and postoperative CCU stay are risk factors for POD while change of rScO2 at T1 is a protective factor for POD in elderly patients undergoing heart valve surgery with CPB.

Comparison of definitive approaches for conotruncal defects following bidirectional Glenn procedure

BackgroundStaged repair is common for complex conotruncal defects, often involving bidirectional Glenn (BDG) procedure. Following the cavopulmonary shunt, both Fontan completion and biventricular conversion (BiVC) serve as definitive approaches. The...

Navigating the challenges of minimally invasive mitral valve surgery: a risk analysis and learning curve evaluation

BackgroundThis study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution.MethodsFrom January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment.ResultsOverall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61–11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81–7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65–100 procedures.ConclusionsMitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve.Trial Registration: The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020).

Mitral valve surgery via minimally invasive and conventional access

To compare the immediate results of mini-thoracotomy and sternotomy in patients with mitral valve disease. The study included 52 patients who underwent mitral valve surgery (25 cases - mini-thoracotomy, 27 cases - sternotomy). Aortic cross-clamping time was significantly longer in sternotomy compared to mini-thoracotomy group - 110 vs 94 min (p=0.03). Ventilation time was also significantly longer in the sternotomy group (12 vs. 8 hours, p=0.01). Postoperative morbidity was similar (postoperative wound infection, neurological complications, coronavirus disease, overall in-hospital mortality). In addition to cosmetic effect, minimally invasive approach in mitral valve surgery has some other advantages including less duration of aortic cross-clamping and mechanical ventilation, availability of reconstructive interventions due to better exposition of the mitral valve and subvalvular structures.

Leucoglycemic index predicts post-operative vasopressor-inotropic requirement after adult cardiac surgery (LEUCOGLYPTICS): A retrospective single-center study.

Cardiac surgery often necessitates considerable post-operative vasoactive-inotropic support. Given an encouraging literature on the prognostic potential of leucoglycemic index (LGI) [serum glucose (mg/dl) × total leucocytes count (cells/mm3)/1000], we aimed to evaluate whether intensive care unit (ICU)-admission LGI can predict post-operative vasopressor-inotropic requirements following cardiac surgery on cardio-pulmonary bypass (CPB). The data of patients undergoing cardiac surgery at our tertiary care center between January 2015 and December 2020 was retrospectively reviewed. The vasopressor-inotropic requirement was estimated using the VIS (vasoactive-inotropic score) values over the first post-operative 72 hrs. Subsequently, VISi (indexed VIS) was computed as maxVIS[0-24hrs] + maxVIS[24-48hrs] +2 × maxVIS[48-72hrs]/10), and the study participants were divided into h-VISi (VISi ≥3) and l-VISi (VISi <3). Out of 2138 patients, 479 (22.40%) patients categorized as h-VISi. On univariate analysis: LGI, age, European System for Cardiac Operative Risk Evaluation score (EuroSCORE II), left-ventricle ejection fraction, prior congestive heart failure (CHF), chronic renal failure, angiotensin-converting enzyme inhibitors, combined surgeries, CPB and aortic cross-clamp (ACC) duration, blood transfusion, and immediate post-operative glucose were significant h-VISi predictors. Subsequent to multi-variate analysis, the predictive performance of LGI (OR: 1.09; 95% CI: 1.03-1.14; P = 0.002) prior CHF (OR: 2.35; 95% CI: 1.44-3.82; P = 0.001), CPB time (OR: 1.08; 95% CI: 1.02-1.14; P = 0.019), ACC time (OR: 1.03; 95% CI: 1.02-1.04; P = 0.008), and EuroSCORE II (OR: 1.14; 95% CI: 1.06-1.21; P < 0.001) remained significant. With 1484.75 emerging as the h-VISi predictive cut-off, patients with LGI ≥ 1484.75 also had a higher incidence of vasoplegia, low-cardiac output syndrome, new-onset atrial fibrillation, acute kidney injury, and mortality. LGI additionally exhibited a significant positive correlation with duration of mechanical ventilation and ICU stay (R = 0.495 and 0.564, P value < 0.001). An elevated LGI of greater than 1484.75 independently predicted a VISindex ≥3 following adult cardiac surgery on CPB.

IMMEDIATE AND LONG-TERM RESULTS OF MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT: SINGLE CENTER RETROSPECTIVE STUDY

HighlightsWe have conducted a retrospective analysis of patients who underwent minimally invasive aortic valve replacement, and evaluated immediate and long-term results of the surgery. AbstractAim. To study the immediate and long-term results of minimally invasive aortic valve (AV) replacement.Methods. The retrospective study included 208 patients with AV stenosis undergoing minimally invasive aortic valve replacement in the period from 2010 to 2019. The ratio of men to women was 1:1. The mean age of the patients was 63 (58–68) years old, with the minimum age being 29 years and the maximum being 81 years. The median follow-up period was 45.5 (11–68) months. Endpoints were as follows: hospital mortality, postoperative complications, long-term outcome (long-term survival, freedom from reoperation). Inclusion criteria were as follows: patients aged 18 years and older undergoing minimally invasive aortic valve replacement. Exclusion criteria were as follows: AVNeo, Ross procedure and AV replacement with aortic homograft, combined interventions (except for intervention on the ascending aorta), and standard access site.Results. The majority of patients (199 (95.7%) underwent “J”-shaped ministernotomy through the III-IV intercostal space. As a part of the combined intervention, ascending aorta replacement was performed in 6 (2.9%) patients. The duration of cardiopulmonary bypass and aortic cross-clamping was 91 (78–106) min and 68 (60–78) min, respectively. Due to conduction disorders, implantation of a pacemaker was performed in 5 (2.4%) patients, stroke was diagnosed in 1 (0.5%) patient, resternotomy for bleeding was performed in 4 (1.9%) patients, cardiac tamponade in 2 (1 %) patients, sternal infection was found in 1 (0.5%) patient. There were no complications such as AKI, perioperative MI, or hospital mortality in any patient. Five- and ten-year survival after surgical treatment of patients was 88.2% and 80.5%, respectively. Five- and ten-year freedom from reoperation on AV was 96.2% and 96.2%.Conclusions. Minimally invasive AV replacement is a measurable procedure with negligible complication rates. Minimally invasive aortic valve replacement has shown its effectiveness in the long-term period with acceptable rates of survival and freedom from reoperation.

Evaluation of retinal and peripapillary vessel density and subfoveal choroidal thickness changes in patients undergoing cardiopulmonary bypass: An OCTA study.

We aimed to investigate hemodynamic changes in the retina, peripapillary area, and choroid in patients undergoing coronary artery bypass grafting (CABG). This prospective case series included 35 eyes of 35 patients. Vessel density (VD) of superficial capillary plexus, deep capillary plexus, radial peripapillary capillary, foveal avascular zone area, and subfoveal choroidal thickness changes were evaluated using optical coherence tomography angiography (OCTA) 1 day before and 2 weeks after surgery. The correlation of these parameters with aortic cross-clamp (ACC) duration and cardiopulmonary bypass (CPB) duration was evaluated. There were no differences in the OCTA measurements of the patients after CABG compared to before surgery (P > 0.05). Inside-disc VD showed a negative correlation with both ACC (P = 0.036) and CPB duration (P = 0.048); peripapillary inferior hernia showed a negative correlation with both ACC (P = 0.042) and CPB duration (P = 0.027). Another negative correlation was observed between mean peripapillary VD and CPB duration (P = 0.039). The CPB procedure had no permanent effect on retinal choroid and optic disc blood flow postoperatively. Prolonged ACC and CPB times seem to be important in terms of optic nerve blood flow. Clinicians should be alert for postoperative ocular complications after long surgeries.

Aortic root enlargement in patients undergoing mitral and aortic replacement: early outcomes in a sub-Saharan population.

Aortic root enlargement (ARE) is often required to avoid patient-prosthesis mismatch (PPM) in young patients undergoing aortic surgery, including those undergoing combined mitral and aortic valve replacement (double valve replacement, DVR). Adding ARE to DVR may increase the operative risk by extending the surgical time. Herein, we review our experience with ARE in patients who underwent DVR. The medical records of 69 patients who underwent DVR at our institution between February 2008 and November 2021 were retrospectively reviewed. The patients were divided into two groups according to the ARE procedure (ARE-DVR: 25 patients; DVR: 44 patients). Descriptive and comparative analyses of demographic, clinical, and surgical data were performed. Among the 69 patients who underwent DVR, 35 were women (sex ratio, 0.97). The mean age at surgery was 26.7 ± 13.9 years (range: 7-62 years). Among the 47 patients aged ≤30 years, 40.4% (19/47) were aged between 10 and 20 years, and 6.3% (3/47) were aged <10 years. Patients in the ARE-DVR group were younger (23.3 ± 12.9 years vs. 28.5 ± 14.2 years, p < 0.05). The New York Heart Association Class ≥III dyspnea was the most common symptom (89.9%), with no differences between the two groups. Of all the patients, 84.1% had sinus rhythm. Rheumatic disease was the most common etiology in the entire cohort (91.3%). The mean aortic annulus diameter was 20.54 mm, with smaller sizes found in the ARE-DVR group (18.00 ± 1.47 mm vs. 22.50 ± 2.35 mm, p < 0.05). The aortic cross-clamping duration was greater in the ARE-DVR group (177.6 ± 37.9 min vs. 148.3 ± 66.3 min, p = 0.047). The operative mortality rate was 5.6% for the entire cohort (ARE-DVR: 8% vs. DVR: 4.5%, p = 0.46). Among the patients who underwent echocardiographic control at follow-up, the mean aortic gradient was 19.6 ± 7.2 mmHg (range: 6.14-33 mmHg), with no differences among the groups. The association between ARE and DVR did not significantly affect operative mortality. ARE can be safely used whenever indications arise to reduce the occurrence of PPM, especially in young patients with growth potential.

Severe aortopulmonary collaterals are associated with lower transplant-free survival in patients undergoing staged single ventricle palliation

ObjectiveTo identify risk factors for aortopulmonary collateral (APC) development and assess the impact of severe APCs in children undergoing staged single ventricle palliation. MethodsChildren undergoing a bidirectional Glenn operation between January 1, 2016, and March 31, 2021, at our center were included. All underwent angiography prior to Glenn and Fontan; APC flow was graded on a scale of 0 (no appreciable collateral flow) to 4 (severe burden). Demographic data, congenital diagnosis, clinical history, and outcomes were stratified by Glenn assessment; Fontan outcomes were stratified by pre-Fontan grade. ResultsSixty patients met the inclusion criteria, all of whom had angiographic evidence of APCs. There were 7 transplants and 9 deaths in the cohort. There were no significant differences in demographics among the patients. Right ventricular morphology was more common in patients with severe pre-Glenn collaterals (24 of 44 vs 2 of 6 vs 7 of 8; P = .014). Longer stage 1 aortic cross-clamp duration was associated with greater severity pre-Glenn (44 minutes vs 34 minutes vs 66 minutes; P = .023). Patients with grade 3 pre-Glenn collaterals more commonly required transplantation than those with grade 1 collaterals (P < .001) and had lower overall transplant-free survival than those with grade 1 (P = .005) or grade 2 (P = .04) collaterals. ConclusionsThe ubiquity of APCs in this study demonstrates their prevalence in single ventricle disease. Right ventricular morphology and prolonged aortic cross-clamp duration are associated with higher burden. Greater severity was associated with decreased transplant-free survival. These data emphasize the negative long-term impact of these collaterals.

Early postoperative results after surgical aortic valve replacement concomitant with different methods of myocardial revascularization

The aim – to analyze the results of the early postoperative period of surgical aortic valve replacement (SAVR) combined with endovascular or surgical methods of myocardial revascularization.Materials and methods. For this retrospective study, a selection of medical records of adult patients (over 18 years of age) who underwent SAVR concomitant with myocardial revascularization in the period from 2018 to 2022 was carried out.Results and discussion. We selected 95 patients who were treated with SAVR with concomitant myocardial revascularization (the first group (n = 31) – a combination of SAVR and percutaneous coronary intervention (PCI); the second group (n = 48) – a combination of SAVR and CABG). In patients of the first group, lesions of the main left coronary artery and the circumflex artery were recorded, respectively, by 24.85 % (p = 0.011) and by 23.7 % (p = 0.033) less often. Moreover, the patients of the first group required intraoperative use of more than two doses of blood red cell mass by 21.4 % less often (p = 0.046). In the early postoperative period, a lower level of bleeding was observed in patients of the first group compared to the second group (180 (150; 250) ml vs. 250 (200; 305) ml, p = 0.008).Conclusions. Patients who underwent PCI before SAVR were characterized by a shorter duration of surgery, cardiopulmonary bypass, and aortic cross-clamping, while no significant difference in major early postoperative complications was observed between the study groups.

A modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement.

One of the crucial aspects of ascending aorta replacement is to achieve hemostasis of the proximal anastomosis. This study aimed to describe a modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement and compare its operative outcomes with the conventional prosthesis eversion technique. We conducted a retrospective analysis of all consecutive patients who had ascending aortic aneurysm and underwent ascending aorta replacement with the modified or conventional prosthesis eversion technique between January 2019 and December 2022 in our center. A total of 108 patients were included: 55 in the modified group and 53 in the conventional group. The durations of cardiopulmonary bypass, aortic cross-clamping and total operation in the conventional group were longer than those in the modified group. Furthermore, perioperative blood loss and the incidence of re-exploration for bleeding were significantly lower in the modified group. Accordingly, patients in the conventional group accepted more blood transfusion. The modified group had a shorter duration in intensive care unit (ICU) and hospital, and lower total hospitalization costs than those in the conventional group. The modified prosthesis eversion technique is an effective alternative for proximal anastomosis in ascending aorta replacement, with less blood loss, shorter operation time, and lower rate of postoperative complications compared with the conventional technique.

Isolated Minimally Invasive Mitral Valve Surgery in Octogenarians: Perioperative Outcome

Introduction: Despite the feasibility, safety, and excellent outcomes of mitral valve surgery through a right mini-thoracotomy, there is data paucity about its use in octogenarians. In this study, we assess the outcomes of mitral valve surgery via right mini-thoracotomy in octogenarians. Methods: We performed a retrospective analysis of the in-hospital perioperative data of 38 octogenarian patients with severe mitral regurgitation undergoing isolated mitral valve surgery via right mini-thoracotomy from 2013 to 2021 in our institution. Results: The median patient age was 82 (81–83) years, and the median EuroSCORE II was 3.1% (2.3–4.9). A total of 19 (50%) patients underwent mitral valve repair. The median cardiopulmonary bypass duration was 78 (54–100) min and the median aortic cross-clamping duration was 57 (40–70) min. Two (5.3%) patients were converted to sternotomy, 1 (2.6%) underwent renal replacement therapy, 5 (13.2%) underwent reexploration for bleeding or tamponade, and 12 (31.6%) underwent permanent pacemaker implantation. The surgical repair success rate was 89.5%, with 2 (10.5%) patients requiring reoperation due to repair failure. No other patients required reoperation on the mitral valve. The median intensive care unit stay was 1 (1–2) day, and the median postoperative stay was 9.5 (8–14) days. There was no perioperative stroke or death. Conclusion: Despite a relatively increased risk of pacemaker implantation and reexploration for bleeding, our data support the feasibility of mitral valve surgery via a right mini-thoracotomy in octogenarians, with short ischemic times, low overall in-hospital morbidity, and no mortality. Preferring replacement in mitral diseases with a high risk for repair failure could minimize reoperations in this high-risk subgroup.

Short-term outcomes following congenital heart surgery in children with Down syndrome

Background Children with Down syndrome (DS) differ from typical children because of many genetic-related aspects that may affect outcomes after congenital heart surgery. To date, there have been no studies on outcomes after congenital heart surgery on pediatric DS patients in Indonesia.&#x0D; Objective To determine outcomes and mortality in DS patients who underwent heart surgery at Dr. Cipto Mangunkusumo Hospital, Jakarta.&#x0D; Methods A prospective and retrospective cohort study was conducted in DS patients aged &lt;15 years who underwent heart surgery from July 2007 to April 2015. The control group were patients in the same age range without DS who underwent heart surgery for various types of heart defects.&#x0D; Results There were 57 DS and 43 non-DS patients during study period. The types of heart defects found in DS patients were atrioventricular septal defect (AVSD) and ventricular septal defect (VSD) in 18/57 (31.6%) patients each, tetralogy of Fallot (12/57; 21%), atrial septal defect (ASD) (4/57; 7%), patent ductus arteriosus (PDA) (4/57; 7%) and transposition of the great arteries with VSD (TGA-VSD) (1/57; 1.8%). DS patients showed an increased incidence of preoperative PH (63.1%) compared to non-DS patients (25.6%). Median duration of surgery was longer in DS [2.9 (range 0.5-5.8) hours] than in non-DS [2.2 (range 0.7-4.7) hours]. DS patients have a longer mean cardiopulmonary bypass duration [79.5 (SD 33.9) minutes] compared to non-DS [59.9 (SD 23.6) minutes], longer mean aortic cross-clamp duration [45.3 (SD 23.7) minutes] compared to non-DS [34.8 (SD 15.7)]. There were significant differences in the incidence of preoperative pulmonary hypertension, surgical time, duration of cardiopulmonary bypass (CPB), and length of the aortic cross-clamp in DS patients compared to non-DS (P&lt;0.05). Median length of ICU stay was 1.9 (range 0.6 to 34) days in DS and 1 (range 0.3 to 43) day in non-DS patients (P=0.373). Median duration of mechanical ventilation [19.9 (range 3-540) vs. 8 (range 3-600) hours (P=0.308)], rate of pulmonary complications [14/57 (24.6%) vs. 6/43 (14%) patients (P=0.216)], and incidence of sepsis [16/57 (28.1%) vs. 6/43 (14%) patients (P=0.143)] were not significantly different between DS and non-DS patients. However, complete atrioventricular (AV) block only occurred in DS patients [6/57 (10.5%)]. In the DS group, 5/57 (8.8%) patients died. There was no mortality in the non-DS group.&#x0D; Conclusion Morbidity and mortality after cardiac surgery in were higher in DS than in non-DS patients. DS patients may have problems related to preoperative PH, AV block, longer surgical time, duration of CPB, and aortic cross-clamp compared to non-DS.

Influence of Congenital Heart Defect Types over Cardiopulmonary Bypass, Aortic Cross-Clamping, and Intensive Care Unit Length of Stay and Their Association with Genetic Factors

Aim: Surgical correction of congenital heart defects (CHD) often requires interruption of blood flow through cardiopulmonary bypass (CPB) and aortic cross-clamping (ACC), for which duration(s) are considered to be prognostic factors, along with intensive care unit (ICU) length of stay (ICULOS). The aim of this study was to evaluate these surgical prognostic factors in pediatric patients with different types of CHD regarding their type of lesion and associated genetic factors.&#x0D; Study Design: Cross-sectional cohort study with 307 pediatric patients.&#x0D; Place and Duration of Study: Pediatric Intensive Care Unit (ICU) of Hospital da Criança Santo Antônio, in Porto Alegre/RS, Brazil, from 2006-2009 (3 years)&#x0D; Methodology: After inclusion criteria, we studied 266 pediatric patients admitted for the first time in a reference cardiac pediatric ICU from Southern Brazil following cardiac surgery. Intraoperative prognostic factors such as duration of CPB, ACC and ICULOS, in addition to dysmorphological and cytogenetic examinations were compiled and analyzed. P-values of &lt;0.05 were considered significant.&#x0D; Results: CPB time was associated to four outflow tract defects (Tetralogy of Fallot [ToF], transposition of the great arteries [TGA], double outlet right ventricle, and truncus arteriosus [TA]), atrioventricular septal defect, and hypoplastic left heart syndrome (HLHS) (P &lt; 0.001). ACC duration was associated with three outflow tract defects (ToF, TGA, and TA) and HLHS (P &lt; 0.001). Moreover, CPB and ACC times showed an association with cyanotic and complex heart defects, as well as prolonged ICULOS (P &lt; 0.001). There was no relationship between these prognostic factors and syndromic aspects or cytogenetic findings.&#x0D; Conclusions: CHD type has an impact over CPB and ACC duration and ICULOS, whereas genetic factors are not associated with those prognostic factors.

Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms

ObjectiveWe aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms, defined as aneurysms confined to the segment below the diaphragm. MethodsThis retrospective analysis included 721 extent IV thoracoabdominal aortic aneurysm repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 cases (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms. ResultsOperative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II thoracoabdominal aortic aneurysm repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer crossclamp times during surgery were independently associated with operative mortality. Among early survivors (n = 672), competing risk analysis revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% confidence interval, 71.4%-78.5%) and 3.3% (95% confidence interval, 2.2%-5.1%), respectively. ConclusionsAlthough patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic crossclamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV thoracoabdominal aortic aneurysms will enable clinicians to establish best practices and improve patient outcomes.

Impact of Steroid on Macrophage Migration Inhibitory Factor During and After Cardiopulmonary Bypass.

Macrophage migration inhibitory factor (MIF) is a proinflammatory cytokine released in response to glucocorticoids, which counter-regulates the effects of glucocorticoids. This study was performed to determine the impact of steroids on the expression of MIF and other pro- and anti-inflammatory cytokines during and after cardiopulmonary bypass (CPB). Twenty adult patients (10 men, 64 ± 8 years old) who underwent elective cardiac surgery by CPB were given either 2000 mg (group-H, n = 10) or 500 mg of methylprednisolone (group-L, n = 10) during CPB. The serum concentrations of MIF, interleukin (IL)-1β, IL-8, IL-10, and tumor necrosis factor-alpha (TNF-α) were measured at eight time points until 36 hours after skin closure. The early postoperative course was uneventful for all patients. There were no significant differences in duration of operation, CPB, or aortic cross-clamping (AXC) between the two groups. MIF and IL-10 levels peaked just after the conclusion of CPB and decreased gradually thereafter. IL-1β, IL-8, and TNF-α were undetectable throughout the study period. There were no significant differences in MIF or IL-10 levels between the two groups. Peak levels of MIF in all patients were significantly correlated with the duration of CPB and AXC, whereas no such correlation was observed for IL-10. MIF or IL-10 levels were significantly elevated during and after CPB, but there were no differences between the two doses of steroid administration. Both steroid doses sufficiently suppressed proinflammatory cytokines. MIF better reflected the invasiveness of the operation than IL-10.

Novel cfDNA Methylation Biomarkers Reveal Delayed Cardiac Cell Death after Open-heart Surgery.

The use of cardiopulmonary bypass (CPB) is thought to cause delayed cardiac damage. DNA methylation-based liquid biopsies are novel biomarkers for monitoring acute cardiac cell death. We assessed cell-free DNA molecules as markers for cardiac damage after open-heart surgery. Novel cardiomyocyte-specific DNA methylation markers were applied to measure cardiac cfDNA in the plasma of 42 infants who underwent open-heart surgery. Cardiac cfDNA was elevated following surgery, reflecting direct surgery-related tissue damage, and declined thereafter in most patients. The concentration of cardiac cfDNA post-surgery correlated with the duration of CPB and aortic cross clamping. Strikingly, cardiac cfDNA at 6 h predicted duration of mechanical ventilation and maximal vasoactive-inotropic score better than did maximal troponin levels. Cardiac cfDNA reveals heart damage associated with CPB, and can be used to monitor cardiac cell death, to predict clinical outcome of surgery and to assess performance of cardioprotective interventions.

Early Outcomes of Endoscopic Papillary Muscle Relocation for Secondary Mitral Regurgitation Type IIIb in Patients With Severe Left Ventricular Dysfunction.

Objective: Subannular mitral valve (MV) repair techniques have been developed to address increased rates of recurrent mitral regurgitation (MR) in patients with secondary MR (SMR) type IIIb. Endoscopic papillary muscle relocation (PMR) is feasible via minithoracotomy. Nevertheless, the periprocedural outcome of patients with severe left ventricular (LV) dysfunction remains unknown. Methods: A total of 98 consecutive patients with SMR type IIIb underwent PMR at our institution. Due to concomitant coronary artery bypass grafting, 62 patients underwent sternotomy and were excluded from the current analysis, whereas 36 patients were treated by a minimally invasive technique using 3-dimensional endoscopy. Of these, 18 patients had severely depressed LV ejection fraction (LVEF) ≤35% (study group) and were compared to the remaining 18 patients with LVEF >35% (control group). Periprocedural outcome was retrospectively analyzed. Results: Although LVEF was significantly worse in the study group (30% ± 4% vs 43% ± 6%, P < 0.001), the severity of SMR and the degree of MV leaflet tethering were similar. The prevalence of concomitant procedures and the duration of surgery, cardiopulmonary bypass, and aortic cross-clamp were comparable. Periprocedural low cardiac output syndrome was favorably low in both groups (16.7% vs 5.6%, P = 0.29). Postoperative ventilation time (5.7 h [4.2 to 8.7 h] vs 6.0 h [4.6 to 9.8 h], P = 0.43) and duration of intensive care unit stay (2 days [1 to 3 days] vs 2 days [1 to 3 days], P = 0.22) were similar. There was no 30-day mortality in either group. Conclusions: Standardized endoscopic PMR resulted in favorable periprocedural outcomes in patients with severe LV dysfunction, suggesting that minimally invasive surgery can safely be extended to this patient population.