Emergency Open Heart Surgery Research Articles

Very big left atrial myxoma: A case report

A 44-year-old patient was admitted with dyspnea and palpitation. Echocardiography revealed a very large (20 cm) mass in the left atrium. Emergency open-heart surgery was done. The most frequent primary heart tumor is myxoma. Their size varies greatly, and not much is known about how quickly they grow. The present case is unusual because of the size of the tumor (20 cm).

Effective Apixaban removal using hemoadsorption during emergent open-heart surgery: a case report and narrative literature review

BackgroundThe management of hemostasis in patients medicated with apixaban (Eliquis) undergoing emergency cardiac surgery is exceedingly difficult. The body’s natural elimination pathways for apixaban prove ineffective in emergency situations, and the impact of hemodialysis is limited. The application of Cytosorb® may attenuate the concentration of apixaban, thereby facilitating the stabilization of these patients.Case presentationAn 84-year-old man treated with apixaban, underwent emergency ascending aorta replacement surgery due to an acute type A aortic dissection. To address the challenges induced by apixaban, we integrated Cytosorb® cartridge into the Cardiopulmonary bypass circuit. There was a 63.7% decrease in perioperative apixaban-specific anti-factor Xa activity. The patient’s postoperative course was favourable.ConclusionHemoadsorption with Cytosorb® may offers a safe and feasible approach for reducing apixaban concentration in emergency cardiac surgery, thereby mitigating the risk of hemorrhagic complications.

Incidence and outcomes of emergency intraprocedural surgical conversion during transcatheter aortic valve implantation: Insights from a large tertiary care centre.

During a transcatheter aortic valve implant (TAVI) procedure, intraprocedural complications that are manageable only by conversion to emergency open-heart surgery (E-OHS) occasionally occur. Contemporary data on the incidence and outcome of TAVI patients undergoing E-OHS are scarce. This study aimed to evaluate early and midterm outcomes following E-OHS of patients undergoing TAVI in a large tertiary care centre with immediate surgical backup availability for all TAVI procedures over a 15-year period. Data from all patients undergoing transfemoral TAVI between 2006 and 2020 at the Heart Centre Leipzig were analysed. The study time was divided into 3 periods: 2006-2010 (P1), 2011-2015 (P2) and 2016-2020 (P3). Patients were grouped according to their surgical risk (high risk: EuroSCORE II ≥ 6%; low/intermediate risk: EuroSCORE II <6%). Primary outcomes were intraprocedural and in-hospital death and 1-year survival. During the study period, a total of 6903 patients underwent transfemoral TAVI. Among them, 74 (1.1%) required E-OHS [high risk, n = 66 (89.2%); low/intermediate risk, n = 8 (10.8%)]. The rate of patients requiring E-OHS was 3.5% (20/577 patients), 1.8% (35/1967 patients) and 0.4% (19/4359 patients) in study periods P1 to P3, respectively (P < 0.001). The proportion of patients who had E-OHS who were low/intermediate risk increased considerably over time (P1:0%; P28.6%; P3:26.3%; P = 0.077). Intraprocedural deaths occurred in 10 patients (13.5%), all of whom were high-risk. In-hospital mortality was 62.1% in high-risk patients and 12.5% in low/intermediate risk patients (P = 0.007). One-year survival was 37.8% in all patients undergoing E-OHS, 31.8% in high-risk patients and 87.5% in low/intermediate risk patients (log-rank P = 0.002). In-hospital and 1-year survival rates following E-OHS are higher in low/intermediate risk than in high-risk patients undergoing TAVI. An on-site cardiac surgical department with immediately available E-OHS capabilities is an important component of the TAVI team.

Prophylactic Awake Peripheral V-A ECMO during TAVR.

TAVR remains a complex procedure that may result in serious intraprocedural complications. In many of these circumstances, venoarterial extracorporeal membrane oxygenation (V-A ECMO) helps to manage complications, provides a hemodynamic back-up, and bridges to an emergency open heart surgery. The clinical outcomes of 27 patients who underwent prophylactic implantation of peripheral V-A ECMO (pV-A ECMO) during high-risk transcatheter aortic valve replacement (TAVR) cases are described. From June 2012 to October 2022, 590 consecutive patients underwent TAVR at our center. Of these, 27 patients (4.5%) underwent TAVR with pV-AECMO because they were deemed very high risk for periprocedural complications and formed the study population. There were no pV-A ECMO, hemodynamic or TAVR implantation complications. Decannulation of the ECMO system was performed in 92.6% of cases at the end of the procedure in the hybrid-operating theatre. The mean duration of pV-A ECMO for procedure support was 51.4 ± 10.3 min. There were no ECMO-related vascular or bleeding complications. This study shows that the prophylactic placement of awake peripheral V-A ECMO provides excellent temporary cardio-circulatory and pulmonary support during very high-risk TAVR procedures.

Do antibacterial or antiviral filters protect operating room staff by preventing COVID-19 virus spread from cardiopulmonary bypass machine during open hear surgeries? A case report

Open heart surgeries are inevitable during pandemic and there is the possibility of corona virus transmission through oxygenated exhaust during cardiopulmonary bypass (CBP). In this study, researchers try to test the hypothesis by placing an antiviral and antibacterial filter in the air outlet of the oxygenator in order to prevent spread of COVID-19 virus in operating room. The COVID-19 positive patient needed emergency open-heart surgery due to her critical situation. The patient was under cardiopulmonary bypass for almost two hours. Antibacterial and antiviral filters were placed in oxygenator outlet. At the end of the procedure, polymerase chain reaction (PCR) swab was taken from both sides of the filter. The result of the test behind the filter was positive, but at the other side of the filter was negative. This may suggest, the exhaust air from the oxygenator can spread viruses into the room and the antibacterial and antiviral filters may be able to prevent operating room contamination. The installation of filter in the oxygenator exhaust can prevent the spread of COVID-19 viruses into the operating room air. Using this cheap and affordable method, operating room staff safety can be assured.

Does an Early Implantation of Extracorporeal Membrane Oxygenator in High-Risk Emergency Open Heart Surgery Patients Improve the Outcome in Comparison with Elective Patients? A Prospective Cohort Comparative Study.

Extracorporeal membrane oxygenator (ECMO) has been implemented in refractory postcardiotomy cardiogenic shock (PCCS) patients to maintain excellent oxygenation and hemodynamic support. The aim of this study is to compare the results of early ECMO implantation to treat refractory PCCS in emergency versus elective patients who developed univentricular or biventricular pump failure. Between January 2019 and June 2021, 35 patients received ECMO after refractory PCCS. Patients have been categorized into two groups: Group A contains 18 patients who were urgently operated on and Group B, which includes 17 patients who were electively operated on. ECMO was implanted through central cannulation (right atrium and ascending aorta), or through peripheral cannulation (femoral vessels or through axillary artery). There was no statistically significant difference between the two ECMO groups in the preoperative patient's characteristics, complication rate, duration of mechanical ventilation, post-ECMO weaning hospital stay, duration of ICU stay, in-hospital mortality, and number of patients discharged from the hospital or in 1-year survival on follow up. Early use of ECMO in high-risk emergency cardiac surgery should be taken into consideration when possible, without hesitance. Emergency and elective patients benefit equally from ECMO implantation and show comparable complication rates.

Thromboembolic complications in Takotsubo Syndrome during Covid-19 outbreak. A review with case report

New coronavirus (COVID-19) outbreak, which started in Wuhan, China and spread rapidly all over the world, has become the most important cause of the emotional distress for susceptible people. Because the people also remained in fear and anxiety during the period when the elderly population in the whole country was desperate due to the COVID-19 outbreak and was asked to stay at home in fear of death. In addition, the fact that the patients were hospitalized together with COVID-19 patients caused his psychological distress to be experienced even more. Takotsubo Syndrome (TTS) is known as a distress-induced transient left ventricular dysfunction. In our patient with TTS, it was found that a new apical thrombus, which was not seen in the left ventricle, was seen in previous echo and computerized tomographic investigation, and that it was a source of thromboemboli, by stress triggering neurocardiac reactions. While under the medical treatment of viral pneumonia, under the Coronavirus transmission measures, thrombus in the LV was removed by being taken to the emergency open heart surgery. Our case is the first patient in the literature where a new thrombus developed in the LV and splenic infarction in TTS triggered by the pandemic. In this article; We have presented the experience of TTS triggered by pandemic, etiopathogenesis of left ventricular thrombus, open heart surgery indications when COVID-19 is suspected, coronavirus transmission measures in the surgical approach, the postoperative treatment and literature is reviewed.

An analysis of preoperative bed bath for emergency open heart surgery, entering the operating room within 24 hours from the ICU

An analysis of preoperative bed bath for emergency open heart surgery, entering the operating room within 24 hours from the ICU

Dislodged Interatrial Septum Occluder was Found in an Incredible Place: A Case Report

Secundum type atrial septal defect (ASD) is the most common type of interatrial septum defects. Transcatheter closure of secundum ASD has replaced traditional surgical ASD closure in most cases. Embolization of device is relatively uncommon (0.3%), but it can be a life-threatening situation that needs emergency open heart surgery. We presented a 44-year-old woman who underwent a successful ASD device closure, but the day after procedure, she presented with dyspnea and frequent paroxysmal supraventricular tachycardia with absence of device in interatrial septum (IAS) position. Further investigation by transesophageal revealed atrial septal occluder in the right pulmonary artery that extracted by surgery successfully.

Combined treatment for a large primary cardiac sarcoma: a case report

BackgroundUndifferentiated pleomorphic sarcoma (UPS) as a primary cardiac tumor is rare, with extremely poor prognosis owing to high recurrence and invasion. We encountered a patient who presented with a primary cardiac tumor incarcerating the mitral valve and who was in a shock state.Case presentationA 41-year-old man was transported emergently to our hospital owing to acute respiratory distress and hemoptysis. He was diagnosed with acute left heart failure caused by a large mass in the left atrium (LA) that obstructed cardiac blood flow, as revealed by imaging study findings, and he underwent an emergency open-heart surgery for tumor resection. He was pathologically diagnosed with UPS invading the muscle layer of the LA. However, after receiving combined therapy for local recurrence and distant metastasis, including proton beam radiotherapy and chemotherapy with molecularly targeted drugs, he could return to work for 2 more years after surgery.ConclusionIn this study, we reported the case of a patient who was in a state of shock state owing to the presence of UPS in the LA. The patient underwent an emergency surgery and received combined therapy. He survived for 2 more years after an initial diagnosis, without active local recurrence and distant metastasis.

Management of aortic valve disease during pregnancy: A review.

Cardiovascular disease represents a significant portion of pregnancy-related complications and is associated with high rates of morbidity and mortality in this cohort. Cardiac valvulopathy, and aortic valve pathologies, in particular, pose a significant challenge to women who are pregnant and to the health care professionals who look after them. Depending on the type and severity of aortic valve pathology, pregnancy may exacerbate or accelerate the progression of valvulopathy sequelae because of the hemodynamic changes that occur from conception, throughout gestation, up to Labor and postpartum. Management of such patients ranges from basic conservative measures such as bed-rest, extending to high-risk emergency open heart surgery. This nonstructured review aims to highlight the current evidence available relating to the management of aortic valve disease in pregnancy, with a key focus on cases which requires intervention beyond that of medical therapy. In conclusion, the management of aortic valvulopathy in pregnancy is a challenging field with only a small amount of clinical experience and retrospective study supporting evidence-based decisions in this field. A greater understanding of the most recent advances is recommended to support decision making in this specialist field of clinical medicine.

Bailout surgical explantation of a transcatheter valve-in-valve for subacute thrombosis: When there is no time for anticoagulation

Trancatheter heart valve (THV) thrombosis is effectively treated with anticoagulation but alternative therapies are required when a faster gradient reduction is needed. Open heart surgery has been rarely performed due to the high perioperative mortality and only five cases have been described so far. Here we describe a case of emergent surgical explantation for THV thrombosis after a valve-in-valve. A 67years old man underwent transcatheter aortic valve implantation for a failed surgical bioprosthesis Epic 21mm (St. Jude Medical; St. Paul, Minnesota, US). A CoreValve 23mm (Medtronic, Minneapolis, Minnesota, US) was implanted through femoral access under conscious sedation without complications. Mean transvalvular gradient was effectively reduced (33mmHg vs 16mmHg) with no more than mild residual aortic regurgitation. After 8days the patient was discharged on dual antiplatelet therapy but was readmitted to the intensive care unit for pulmonary oedema 13days later. Echocardiography showed a raised transvalvular mean gradient (mean gradient change from discharge=15mmHg) without aortic regurgitation. Heart Team decided for emergent open heart surgery for the hemodynamic instability. On direct inspection THV was well positioned inside the surgical bioprosthesis but two cusps were covered by thrombus which markedly restricted their mobility. The THV and the former surgical valve were explanted and a new larger stented bioprosthesis was implanted. Thrombosis of the THV was confirmed on microscopic examination which showed no signs of inflammation or degeneration. The patient was discharged after 1month and the 3month follow up showed stable transvalvular gradients.

Circular mapping catheter entrapment in mitral valve apparatus requiring emergency surgery: a rarely reported complication of pulmonary vein isolation procedure for atrial fibrillation

Lasso catheter (Biosense Webster) is one of the most commonly employed circular mapping catheters during pulmonary vein isolation (PVI) procedure for atrial fibrillation (AF). Although this catheter has greatly facilitated...

Timing of Conduction Abnormalities Leading to Permanent Pacemaker Insertion After Transcatheter Aortic Valve Implantation—A Single-Centre Review

BackgroundTranscatheter aortic valve implantation (TAVI) is the preferred alternative to traditional surgical aortic valve replacement; however, it remains expensive. One potential driver of cost is the need for postprocedural monitoring for conduction abnormalities after TAVI. Given the paucity of literature on the optimal length of monitoring, we aimed to determine when clinically significant conduction abnormalities leading to permanent pacemaker (PPM) insertion after TAVI were first identified. MethodsWe identified all patients in the Sunnybrook Health Sciences Centre TAVI registry (Toronto, Canada) who underwent TAVI between 2009 and 2016, excluding those with pre-existing PPMs or those who underwent emergency open heart surgery. Through dedicated chart review, the timing and type of conduction abnormalities leading to PPM were recorded. Patients were divided according to the timing of conduction abnormality: during the procedure vs after the procedure. ResultsThe overall PPM insertion rate was 15.6% (80 of 512 cases), with all but 1 patient receiving a PPM for class I indications. PPMs were inserted for complete heart block/high-grade atrioventricular block (91.3%), severe sinus node dysfunction (3.8%), and alternating bundle branch block (3.8%). Of these conduction abnormalities, 55.0% occurred during the procedure (intraprocedure; n = 44 patients). The mean time to the development of a conduction abnormality necessitating PPM was 1.2 days (interquartile range, 0-2 days), with 88.8% occurring within 72 hours of the procedure (n = 71 patients). In the entire TAVI cohort, < 3% had conduction abnormalities beyond 48 hours after the procedure leading to PPM. ConclusionsThe majority of conduction abnormalities leading to PPM insertion after TAVI occur in the very early periprocedural period, suggesting that early mobilization and discharge will be safe from a conduction standpoint.

Salvage transcatheter aortic valve implantation for severe acute aortic regurgitation complicating percutaneous transluminal aortic valvuloplasty

With the advent of transcatheter aortic valve implantation (TAVI), percutaneous transluminal aortic valvuloplasty (PTAV) has experienced a recent renaissance. The roles of PTAV range widely from bridging to definitive therapy to palliation. In general, PTAV is performed without major trouble, but fatal complications including acute aortic regurgitation (AR) are occasionally encountered. We describe a case of severe acute AR complicating PTAV conducted for palliative purposes. Conversion to salvage TAVI bailed out this critical condition. This case demonstrates a new potential use of TAVI.<Learning objective: Acute aortic regurgitation is a rare fatal complication of percutaneous transluminal aortic valvuloplasty. Emergent open heart surgery had been the only treatment option for this complication to date. In our case, we bailed out this critical complication by converting to salvage transcatheter aortic valve implantation (TAVI). This case suggests a new potential use of TAVI.>

Emergency Surgery for Acute Mitral Valve Obstruction Resulting From Rapidly enlarging Left Atrial Myxoma

Left atrial myxomas are benign, slow-growing primary cardiac tumors. They present with gradual onset of one or more of a triad of obstructive, embolic, or constitutional symptoms. Echocardiography aids in the detailed preoperative and intraoperative evaluation of the myxoma for surgical strategy planning. We describe a case of interstitial hemorrhage in a left atrial myxoma leading to rapid expansion of the tumor with features of acute, mitral valve obstruction. Echocardiography showed a cystic area in the left atrial tumor that corresponded to an area of recent hemorrhage confirmed on surgical removal. A 42 yrs old housewife presented with severe dyspnoea, cough and chest pain for 7 days, after detail evaluation she was diagnosed as a case of left atrial myxoma with heart failure. Subsequently she underwent emergency open heart surgery under cardiopulmonary bypass; removal of a huge LA myxoma was done, and recovered uneventfully.Cardiovasc. j. 2016; 8(2): 155-157

Life-threatening Acute Heart Failure due to Primary Cardiac Undifferentiated Pleomorphic Sarcoma

A 41-year-old man was admitted with acute heart failure and shock status. An echocardiogram showed a mobile tumor obstructing blood flow through the mitral valve with a stalk on the posterior left atrium (LA) wall. Emergent open-heart surgery was performed to resect the tumor (77×36×30 mm). Histological examination confirmed that it was an undifferentiated pleomorphic sarcoma. Unfortunately, positron emission tomography performed five months after surgery demonstrated a local recurrence around the right pulmonary vein and LA. We performed proton beam radiotherapy to treat the local recurrence, and it was effective. The patient has survived more than one year since the first life-threatening heart failure episode.

Patent foramen ovale

Intentional or unintentional placement of a pacemaker lead into the left ventricle is an uncommon clinical entity that is associated with a high risk for systemic embolization and enormous difficulties in case of explantation. Unintentional implantation through a patent foramen ovale via the mitral valve is the usual pathway for this malposition. We report a case where a pacemaker lead was placed intentionally into the left ventricle via a patent foramen ovale for biventricular pacing for resynchronization therapy. Later, the patient developed life-threatening pacemaker lead-associated endocarditis with sepsis. Emergency open heart surgery for lead removal was necessary in the form of a reoperation after bypass graft surgery a number of years earlier. Although it is technically feasible to implant the pacemaker lead into the left ventricle via a patent foramen ovale, we consider this option to be obsolete for use with a biventricular pacemaker, due to the multitude of risks, which can, in part, be life-threatening for the patient.

Potentially fatal tricuspid valve aspergilloma detected after laparoscopic abdominal surgery

Fungal endocarditis accounts for 1.3-6% of all cases of infective endocarditis. The most common causative organism is Candida, followed by Aspergillus and other mould fungi. Aspergillus endocarditis is usually associated with high morbidity and mortality. Establishing a definitive and timely diagnosis remains difficult and there are many reports of undetected aspergillomas leading to fatalities in the perioperative period. We present a case report of preoperatively undiagnosed large mobile tricuspid valve aspergilloma obstructing the right ventricular inlet, diagnosed incidentally on the second postoperative day after laparoscopic pancreatic abscess drainage. The patient was successfully managed with emergency open-heart surgery and systemic antifungal agents in the postoperative period.

Impact of culprit vessel location in acute myocardial infarction on clinical outcome

Among 3,548 patients undergoing a percutaneous transluminal coronary angioplasty procedure, 714 had multilesion angioplasty (1,550 lesions) in a single session. Acute occlusion occurred in 22 patients (3.1%) and 29 lesions (1.9%). The patients were classified into a group undergoing multivessel angioplasty (348 patients, 785 lesions) and a group undergoing multilesion single vessel angioplasty (366 patients, 765 lesions). The rate of acute occlusion was similar in both patient groups. The multivessel angioplasty group had a 2.9% rate per patient (n = 10) and a 1.7% rate per vessel; the multilesion single vessel group had a 3.3% rate per patient (n = 12) and a 2.1 % rate per lesion.Five of the 10 patients from the multivessel group with acute occlusion, but only 1 of the 12 patients with occlusion in the single vessel multilesion group, required emergency open heart surgery. No patient in either group died as a consequence of coronary angioplasty. Occlusion occurred during angioplasty in 15 of the 22 patients, and 1 to 24 h after angioplasty in 7 of 22 patients. In the group with multivessel angioplasty, acute occlusion during the procedure was mainly linked with hypotension during the second vessel dilation, whereas in this group with delayed vessel closure and in the multilesion single vessel group, existence of intimal tearing constituted the most important factor for acute occlusion (12 of 16 patients). Closure of vessel per major coronary system was evenly distributed in the multivessel group, whereas significantly more left circumflex vessels closed in the single vessel multilesion group (6.1% versus 1.3% in the left anterior descending coronary artery and 1.1 % in the right coronary artery; p < 0.02). Maximal increase in serum creatine kinase after angioplasty was significantly lower in the single vessel multilesion group than in the multivessel group (563 versus 1,749 U/liter; p < 0.01).The multilesion angioplasty procedure is associated with acceptable risk. However, with an increasing amount of myocardium at risk, procedural risk is higher if more than one vessel system is dilated. Staged multivessel angioplasty with serial angioplasty on different vessel systems on separate days should be considered if factors predisposing to acute occlusion, such as hypotension or intimal tear, are present after the first dilation.