Left Thoracotomy Research Articles

Video assisted thorascopic assisted correction of left partial anomalous pulmonary venous connection: one case report

IntroductionThe left partial anomalous pulmonary vein connection is a rare congenital heart disease, especially with intact atrial septum. Now we reported a case of the left superior pulmonary vein drainage to left innominate vein through a vertical vein, and corrected with video assisted thoracoscopy.Case presentationA-59-years old man diagnosed left anomalous partial pulmonary vein connection with presentation of short breathiness and palpation, and diagnosed with computer tomography pulmonary angiography. The operation was carried out under video assisted thoracoscopy with one manipulation incision and one observational incision, the vertical vein was dissected and anastomosis with left atrial appendage. The patients recovered smoothly and postoperative CTPA showed anastomosis ostium was unobstructed.ConclusionThe left lateral thoracotomy and video assisted thoracoscopic surgery is a feasible for correction of left PAPVC with intact interatrial septum without using CPB.

New approach for combined aortic valve and coronary procedures through the left anterior minithoracotomy.

We have developed a novel technique for accessing the aortic valve (AoV) through the left anterior minithoracotomy (LAmT). This approach has been used in patients requiring both AoV surgery and coronary artery bypass grafting (CABG). From April 2023 to July 2023, we performed 6 concomitant AoV procedures and CABG through the LAmT. The mean age was 71.5 [standard deviation (SD): 5.8; 64; 82] years, and the mean left ventricular ejection fraction was 53% (SD: 12.1; 30; 60). Surgical technique includes LAmT in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic cross-clamping using transthoracic clamp, cold blood cardioplegia, conventional oblique aortotomy and special surgical exposure manoeuvres, aimed to position the ascending aorta and AoV close to the surgical incision. AoV was effectively visualized and the procedure was performed as planned in all 6 patients. No conversion to sternotomy was required. AoV replacement with biological prosthesis was performed in 6 (100%) patients. Conventional surgical instruments were used in all cases. The long-shafted instruments were not required. Knot-pusher was used in 4 (67%)cases. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomosis was 2.0 (SD: 0.6; 1; 3). Total operation time was 371 (SD: 43; 300; 420) min, cardiopulmonary bypass time was 253 (SD: 36; 193; 284) min and cross-clamp time was - 162 (SD: 29; 128; 214) min. intensive care unit stay was-1.5 (SD: 0.55; 1; 2) days, total hospital stay was-7.3 (SD: 1; 6; 9) days. There were no revisions for bleeding, no strokes or other major complications, and no hospital or 30-days mortality. The simultaneous performance of AoV replacement and multivessel CABG through a single left anterior thoracotomy is technically feasible and can be carried out by experienced surgeons. However, a larger number of cases are required to fully comprehend the potential limitations of this procedure.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. We aimed to analyse clinical outcomes of robotic-assisted CABG. A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). Robotic-assisted CABG and HCR provides good long-term outcomes in patients who are not candidates for conventional CABG.

A rare complication of rupture of a mediastinal Teratoma into the bronchus: A case report

Background: Germ cell tumours (GCT) are tumours arising from primordial germ cells. Gonadal and extragonadal GCT are infrequent in childhood occurring at a rate of 2.4 cases per million children accounting for 2-3 % of paediatric malignancies with most common subtype being a matured Teratoma. Case presentation: We present a case of a 10-year-old female child who presented to the emergency department of a tertiary care centre with complaints of cough with massive expectoration of blood of approximately 200 ml in quantity which on imaging revealed a left anterior mediastinal mass which was managed by left lateral thoracotomy with a non-anatomical left sided pulmonary lobectomy which on histopathology was diagnosed to be a case of mature teratoma. Conclusion: This case report describes a unique presentation of extra-gonadal mediastinal teratoma which presented as a rare complication with rupture into the left bronchus. It emphasizes caution and a high clinical suspicion is required in managing cases of varied presentations of teratomas.

Investigation of the effects of different drugs on the prevention of intrapleural adhesion in a rat model.

The aim of this study was to investigate the antifibrinolytic and anti-inflammatory effects of hesperidin, tenoxicam and enoxaparin on intrapleural adhesions in an experimental rat model. A total of 52 healthy adult male Wistar Albino rats from the same colony were randomly divided into six groups as sham (Group 1), surgical control (Group 2), low-dose hesperidin (Group 3), high-dose hesperidin (Group 4), tenoxicam (Group 5), and enoxaparin (Group 6). All subjects underwent left thoracotomy and except for the sham group, an adhesion model was applied and, postoperatively, the drugs were administered intraperitoneally. On Day 11 postoperatively, the rats were sacrificed and their blood levels of interleukin-1β and interleukin-10 were examined and they were evaluated for pleural adhesion area, adhesion severity score, mesothelial cell proliferation score, mononuclear cell infiltration score, and macrophage infiltration score in the collagen layer. The lowest adhesion area and adhesion severity score were found in Group 6. There was a statistically significant difference between Group 2 and Group 6 and between Group 3 and Group 6 in terms of both parameters (p=0.04 and p=0.02). As for adhesion area, a statistically significant difference was found between Group 5 and Group 6 (p=0.04). Statistically significant differences were also found between Group 2 and Group 5 in terms of mesothelial cell proliferation scores and between Group 1 and Group 4 in terms of mononuclear cell infiltration scores (p=0.03 and p=0.02). Enoxaparin, tenoxicam, and high-dose hesperidin act at different points to prevent adhesion in rats.

Pneumonectomy for severe post-tuberculosis bronchiectasis: A successful of case report and review of the long-term outcome.

Limited clinical intervention studies highlight the absence of evidence-based international guidelines for effectively managing post-tuberculosis lung disease, emphasizing bronchiectasis. The aim of this study was to describe a case of left pneumonectomy for severe post-tuberculosis cystic bronchiectasis and to provide a review of the post-surgical mortality rate, complications, survival rate, and the patient's quality of life following the pneumonectomy procedure. A 36-year-old Indonesian male smoker presented with worsening breathing difficulties and fever. The patient had a history of pulmonary tuberculosis six years ago and reported negative tuberculosis tests after completing TB treatment. However, lung function of the patient progressively declined over the years. Bronchoscopy, chest X-ray, and high-resolution computerized tomography (CT) scan revealed infected cystic bronchiectasis and identified a prominent left lung collapse with calcification in the left pleura. The patient underwent left pneumonectomy through left posterolateral thoracotomy under general anesthesia. The patient was discharged after seven post-operative days with no eventful course. No further complications were found after a one-year post-surgery follow-up, and the patient returned to normal activities, improved fitness, and was fitter in daily life. Based on the literature review, post-surgical mortality rates of pneumonectomy are acceptable, with bronchopleural fistula, cardiac arrest, and thoracic hemorrhage being common causes. Yet, the chances of a complete cure are high. Complications can occur in approximately one-third of patients, including arrhythmia, pulmonary infection, fever, and wound infections. The overall 5-year survival rate following pneumonectomy is generally favorable. Regarding the quality of life, pneumonectomy can have mixed effects. While it could improve symptoms and quality of life, it may impair the quality of life for certain patients, particularly elderly patients and those with lower preoperative quality of life. Although the post-surgical mortality rate, complications, and long-term survival rates of pneumonectomy are generally satisfactory, the expectation of improved post-surgical quality of life should be discussed with the patient prior to surgery.

Robot-Assisted Minimally Invasive Multivessel Coronary Bypass Guided by Computerized Tomography.

Robot-assisted minimally invasive coronary bypass surgery is one of the least invasive approaches that offers multivessel revascularization and accelerated recovery. We investigated the benefits of computed tomography angiography (CTA) guidance in robotic coronary bypass (RCAB) by analyzing perioperative outcomes. Between April 2022 and April 2023, 60 consecutive patients who underwent RCAB under preoperative CTA guidance were included. The intercostal space of the minithoractomy incision was determined based on the distance from the thoracotomy site to the midsection of the left anterior descending artery (LAD) on preoperative CTA. Peripheral vascular findings on preoperative CTA guided the decision for the cannulation site. Perioperative parameters and early outcomes were evaluated. The mean age of the patients was 62.3 ± 10.5 years, and 51 patients were male (85.0%). The mean number of revascularized vessels was 2.9 ± 1.1. Left thoracotomy guided by CTA measurements was performed in the fourth intercostal space in 37 patients (61.7%) and in the third intercostal space in the remaining patients. Axillary cannulation was performed in 28 (46.7%) patients because of prohibitive findings in the iliac vessels and aorta. All target coronary arteries with an indication for bypass were revascularized with CTA-guided RCAB. The left internal mammary artery (LIMA) was anastomosed to the LAD in all patients, and the LIMA was anastomosed sequentially to the diagonal artery in 17 patients (28.3%). No operative mortality or cerebrovascular event was observed. One patient underwent reoperation due to bleeding. Robot-assisted minimally invasive multiple-vessel coronary bypass under preoperative CTA guidance is safe and can be performed with excellent results.

Erysipelothrix rhusiopathiae: An Emerging Organism Causing Pleural Effusion in an Immunocompetent Child

Aims: Erysipelothrix rhusiopathiae is a Gram-positive bacillus attributed to zoonotic infections primarily. In humans they usually cause localized cutaneous infections namely erysipeloid, occasionally becomes diffuse and may lead to septicemia and endocarditis in opportunistic immunocompromised individuals. The growing and evolving disease spectrum of this organism in human beings is a potential future threat. This case report addresses a common disease manifestation with this unusual organism which is needs to be highlighted.&#x0D; Presentation of Case: Herein we report a case of 1year 9month old immunocompetent male child belonging to a shepherd family who presented with long standing left sided pleural effusion. Pleural fluid culture yielded Erysipelothrix rhusiopathiae. Despite a culture sensitive antibiotic therapy a sequelae of residual effusion with subpleural collapse and fibrous septations developed, hence left lateral thoracotomy along with decortication surgery was performed.&#x0D; Discussion: This case report highlights the drug sensitivity and resistance pattern in detail and also points out the prognosis and possible sequelae of the disease which in turn can increase treatment awareness regarding the organism.&#x0D; Conclusion: Erysipelothrix rhusiopathiae is an unusual organism which was found in our patient causing pleural effusion is a very unlikely coalition and needs a separate mention as this emerging microbe can be a cause of concern due to its novelty and scarce medical evidence.

Persistent right aortic arch in the cat: a case report from a late surgical approach

Aortic arch anomalies can give rise to vascular rings, such as persistent right aortic arch (PRAA), a rare vascular anomaly in cats with significant health implications. Here, we report late surgical correction in a case of PRAA, an almost 12-month-old cat with the clinical syndrome of dysphagia and postprandial regurgitation. The patient was presented to the veterinary hospital at FMVZ-USP with a history of chronic regurgitation since puppyhood after weaning, with a significant worsening of the clinical condition 10 days ago. Computed tomography had a potential role in diagnosing and detecting complications of PRAA, allowing surgical planning. Approach via left thoracotomy and section of the arteriosus ligament resulted in the successful resolution of extrinsic esophageal compression due to PRAA with the restoration of normal swallowing of a dry diet by the cat and absence of esophageal sequelae on radiographic assessment in a six-month clinical follow-up.

Aortic Coarctation Associated with Distal Aortic Arch Hypoplasia in Neonates Can Be Effectively Repaired through Left Thoracotomy

Objectives. Aortic coarctation in neonates remains a clinical challenge. Low weight, arch hypoplasia and ductal dependence have been identified as risk factors for recurrent coarctation. We hypothesized that a tailored surgical technique may prevent recurrence. Methods. Retrospective evaluation of neonates treated for coarctation through thoracotomy was done. No primary percutaneous procedure was performed and repairs through sternotomy were excluded. Aortic hypoplasia was defined as a ratio arch diameter (mm)/patient’s weight (kg) &lt; 1. Extended end-to-end anastomosis (EEEA), subclavian flap (Waldhausen) and Amato aortoplasty were performed. Mortality and recurrent obstruction requiring re-intervention were assessed. Results. Records of 340 consecutive patients (2003–2019) were analyzed. Preoperative median age and weight were, respectively, 10 days (1–30) and 3080 grams (1400–5180). Arch hypoplasia was documented in 31 patients (9.1%). Prostaglandin was infused in 220 (65.3%). Critical preoperative status was documented in 35 (10.8%). EEEA repair was performed in 273 (80.3%), Waldhausen was performed in 42 (12.4%), and Amato was performed in 25 (7.4%). The last two were more likely to be performed in the presence of arch hypoplasia ( p &lt; 0.0001). Hospital mortality occurred in 2 patients (0.6%). Thirty-six procedures (31 percutaneous/5 surgical) were performed for recurrent arch obstruction in 33 patients. Three late deaths occurred. Low-weight, hypoplastic arch, and ductal dependency did not influence the outcome. All survivors were free from residual coarctation at a mean follow-up of 3.6 ± 3.4 years postoperatively. Conclusions. Surgical repair remains the procedure of choice for neonatal coarctation. A tailored approach using alternative techniques seemed to offer comparable results even in presence of associated risk factors.

New approach to the mitral valve through the left anterior minithoracotomy for combined valve and coronary surgical procedures

ObjectiveWe have developed a new technique for accessing the mitral valve through the left anterior minithoracotomy. This approach has been used in patients requiring both mitral valve surgery and coronary artery bypass grafting. MethodsFrom October 2020 to September 2022, we performed 24 concomitant mitral valve procedures and coronary artery bypass grafting through the left anterior minithoracotomy. The average age of the patients was 65.5 years, and the mean left ventricular ejection fraction was 44.5%. Computed tomography angiography was routinely performed preoperatively. The surgical technique included a left anterior minithoracotomy in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic crossclamping using a transthoracic clamp through the additional port in the left second intercostal space, the administration of cold blood cardioplegia, a right atrial transseptal approach to the mitral valve, and special surgical exposure maneuvers. These maneuvers were designed to displace the heart into the left pleural space by pulling the inferior vena cava tape and the ascending aorta tape to the left. Conventional mitral valve surgical techniques were used. The mitral valve repair or replacement was performed after the distal anastomoses to the right and circumflex coronary system were completed. Subsequently, after the mitral valve procedure, coronary anastomosis to the left anterior descending artery was performed. ResultsThe mitral valve was effectively visualized, and a planned procedure was successfully completed in all patients. There was no need for conversion to a sternotomy. mitral valve repair was performed in 22 patients (91.7%), and mitral valve replacement was performed in 2 patients (8.3%). Conventional surgical instruments were used in 10 cases (41%), and long-shafted instruments were used in 14 cases (59%). A knot-pusher was required in 9 cases (37.5%). A computed tomography distance from the skin level to the mitral valve posterior annulus of more than 14 cm was identified as a technical difficulty marker, necessitating the use of long-shafted instruments. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomoses was 2.54 ± 0.7 (1; 4). Total operation time was 341 ± 41 (285; 420) minutes, cardiopulmonary bypass time was 231 ± 38 (172; 316) minutes, and the crossclamp time was 127 ± 23 (80; 169) minutes. Patients had a mean intensive care unit stay of 1.87 ± 0.69 (1; 4) days, and their total hospital stay averaged 6.54 ± 1.86 (4; 10) days. There were no reoperations due to bleeding, no occurrences of strokes, and no other major complications. There were no instances of hospital mortality or mortality within 30 days after the procedures. ConclusionsMitral valve repair or replacement through the left anterior thoracotomy and transseptal approach is a valuable and effective technique that can be used for concomitant procedures performed through a single minithoracotomy incision in selected patients.

IBC-Oxford University2023_BJSPoster_10Surgical management of intra-gastric balloon complications

Abstract In Saudi Arabia, the intra-gastric balloon (IGB) is the most used endoscopic modality. Surgical management for IGB complications has been reported for gastrointestinal perforation and/or obstruction. However, the literature seems to underestimate these complications. We aim to report our experience as a tertiary university hospital in the Eastern Province of Saudi Arabia in dealing with different complications of IGBs that necessitated any type of surgical interventions. A retrospective descriptive study was conducted in a tertiary hospital in Saudi Arabia for 5 years to include all patients with complicated IGB who necessitated any surgical procedure. Exclusion criteria were patients with complicated IGBs that were only managed conservatively, and any complications related to other bariatric procedures. Six patients were referred due to IGB complications that necessitated operative intervention. All patients were young females. Three patients had gastric wall perforation and were managed by endoscopic removal of the IGBs followed by exploratory laparotomy. One patient had an intestinal obstruction on top of a migrated IGB that was surgically removed. One patient had failed endoscopic retrieval of IGB and required a laparoscopic gastrostomy. Another patient had esophageal rupture that required left thoracotomy, pleural flap and insertion of an esophageal stent. All cases were discharged and followed up with no related complications.

Protective effects of hydrogen rich saline solution in rats with experimental myocardial ischemia reperfusion injury

AimThe aim of our study is to show whether the administration of hydrogen-rich saline solution (HRSS) intraperitoneally before left main coronary artery (LAD) ischemia protects the myocardium against ischemia-reperfusion (IR) injury. Materials and methodsAfter ethics committee approval, 24 Wistar Albino rats were divided into 4 groups, 6 rats in each group. For experimental IR, myocardial ischemia was performed by LAD ligation. Left thoracotomy was performed without ischemia in the Control group (Group C). Left thoracotomy was performed without myocardial ischemia to the rats in the HRSS group, and HRSS was given intraperitoneally (ip) at a rate of 10 ml/kg throughout the procedure. In the MIR-HRSS group, a single dose of 10 ml/kg HRSS was administered 5 min before reperfusion. Histopathological and biochemical parameters were compared in myocardial tissue samples taken at the end of the reperfusion period. ResultsWhen the groups were compared among themselves in terms of TOS and TAS levels, there was a significant difference between the groups (p = 0.006, p = 0.002). The severity of cardiomyocyte degeneration was significantly greater in MIR group than that in the control and HRSS groups (p = 0.002 and p = 0.001, respectively), as well as severity score of cardiomyocyte degeneration was higher in MIR-HRSS group compared with HRSS group (p = 0.035). ConclusionOur study shows that HRSS is protective in IR injury, with the application of HRSS 5 min before reperfusion, interstitial edema severity, subendocardial haemorrhage are reduced, and oxidant status parameters are increased, while antioxidant status parameters are decreased. We believe that when it is supported by other studies, the protective effects of HRSS on IR damage will be shown in detail and its indications will be expanded.

A rare and challenging case of intrapericardial hydatidosis

BackgroundHydatid cysts are most frequently located in the liver and lungs and very rarely can be found in the pericardium. Diagnosis and treatment are quite challenging, as the disease can present itself in many forms depending to the location and the complications that it might cause.Case presentationA 22-year-old man presented to our hospital with ongoing dry cough for more than 1 month prior to admission. Other symptoms included chest pain, fatigue, low grade fever, and night sweats, which have worsened in the past 2 weeks. Physical examination revealed normal respiratory and heart function. Chest X-ray demonstrated mediastinal enlargement and left pleural effusion. Contrast-enhanced computed tomography images showed a walled cystic mass lesion measuring up to 56 × 50 mm in close proximity to the upper left atrium, ascending aorta and pulmonary artery, potentially localized in the pericardium, with a 10 mm endoatrial filling defect, findings were compatible with hydatid cyst, left pleural effusion and peripheral pulmonary upper left lobe consolidation. Cardiac involvement was excluded on magnetic resonance imaging and trans-esophageal ultrasound. The patient underwent fine needle aspiration of the affected lung and thoracocentesis. No malignancy was found, meanwhile the biopsy confirmed the presence of pulmonary infarction. In view of the imaging findings were highly suspicious of a hydatid cyst, we performed a test of antibody titers that was negative. The patient underwent left anterolateral thoracotomy, and after the opening of the pericardium, a cystic mass of 5 cm in diameter was found next to the left atrium and in close proximity with the left pulmonary veins. The content of the cyst was completely removed after the surgical area was isolated with gauze impregnated with hypertonic solution (NaCl 10%). The mass resulted to be an echinococcal cyst with multiple daughter cysts within it that did not penetrate/involve (perforate) the cardiac wall.ConclusionPericardial echinococcosis is a very rare pathology in which a high expertise multidisciplinary approach is required. The compression mass effect caused by the cyst can lead to complications, such as in our case where the pulmonary vein was compressed, leading to pulmonary infarction. The value of radiology studies and transoesophageal ultrasound are very important in the diagnosis. Surgery in these cases is always recommended, but preferred surgical approach is questionable. In cases such as ours, we recommend anterolateral thoracotomy.

Management of esophageal cancer in patients with a right aortic arch or double aortic arch: a case series of 34 cases.

Few cases describing patients with a right aortic arch (RAA) or double aortic arch (DAA) and esophageal cancer (EC) have been reported. We analyzed RAA and DAA cases treated with esophagectomy in our center's database and reported in English-language studies until April 1, 2023. Our study assessed the malformation characteristics and surgical details of EC patients with RAA and DAA. We extracted data of 24 EC patients with RAAs and 10 EC patients with DAAs. In both groups, the patients were more likely to be Japanese and male, to have squamous cell carcinoma and to have tumors located in the upper thoracic esophagus or middle thoracic esophagus. Left thoracotomy was commonly applied for RAA patients. For DAA patients, the proportions of left-sided and right-sided approaches were similar. Esophagectomy under video-assisted thoracoscopic surgery (VATS) in RAA or DAA patients had been performed on a routine basis in recent years. There were two anastomotic leakages in each group. Specifically, Kommerell diverticulum rupture occurred in 1 RAA patient; gastric tube dilation occurred in 1 DAA patient; and recurrent laryngeal nerve (RLN) injury occurred in 2 RAA patients. The postoperative course was uneventful for most patients in both cohorts. Esophageal carcinoma is rarely seen in patients with an RAA or DAA. To adequately dissect superior mediastinal LNs, an auxiliary incision (such as sternotomy), the left door open method or a preceding cervical procedure should be used appropriately. Esophagectomy, whether via thoracotomy or thoracoscopic surgery, can be performed safely for both RAA and DAA.

Sternotomy or Thoracotomy: Which One?

Abstract: Penetrating injuries to the chest present a frequent and challenging problems. Median sternotomy and thoracotomy are two choices to explore any trauma to the chest. We report a 37-year-old man with wound and pain in his left chest due to being stabbed with a knife one hour ago. On physical examination, an open wound measured 5x1.5 cm as high as the third rib parallel to the left parasternal line, the edges of the wound bed were flattened by the periosteum. Laboratory examination showed leukocytosis. FAST showed an important left pleural effusion and pericardial fluid. CTA study showed the presence of air in the anterior mediastinum and the left pleural cavity. In the fifth intercostal space, a left anterolateral thoracotomy was performed and 800 ml of blood was evacuated from the left chest. The left lung was lowered to open the pericardium, which caused a further drop in blood pressure; then, the pericardium was opened and a blood clot (1500 ml) was removed. An epicardial wounds were found on the anterior surface of the right ventricle. The left anterior coronary artery was actively bleeding. The hemorrhagic lesion was stitched with 4.0 polypropylene reinforced with a Teflon strip. The patient recovered uneventfully on the sixth postoperative day. During the 14-month follow-up, the patient was fine and back to work. In conclusion, surgeon must be able to decide the technique of approach in the operating room considering the site of injury and the presence of involving organ. Thoracotomy patient can also receive median sternotomy if the cardiac injuries could not be repaired through thoracotomy. In addition, some patients with median sternotomy also received additional thoracotomy due to their pulmonary injuries. Keywords: penetrating injuries; thoracotomy; sternotomy; cardiac injury

Surgery of Patent Ductus Arteriosus in Soavinandriana Hospital: Our Experience

Introduction: The missionaries of Doctors of the World began performing the surgical closures of patent ductus arteriosus in Madagascar in 2004. The Malagasy team has been completely autonomous in surgical closures of an isolated patent ductus arteriosus since 2018. The aim of this study was to report on the Malagasy team's experience in the first 5 years of surgical closure of an isolated patent ductus arteriosus at Soavinandriana Hospital. Methods: This was a retrospective and descriptive study, during the five-year period, from January 2018 to December 2022, performed at the Cardiac surgery unit of Soavinandriana Teaching Hospital, including all children underwent surgical closures of an isolated PDA. Demographic data, birth weight, clinical signs, diagnostic imaging, diameter of the ductus, the surgical waiting time after diagnosis, and hospital left stays were analyzed. Results: A total of 104 children underwent surgery of closures of PDA, including 36 boys (34.62%) and 68 girls (65.38%), giving a sex ratio of 52%. The average age was 29.75 months. Fifteen children were born with low birth weight (14.42%). PDA was symptomatic in 84.65% of patients. The commonest symptoms were recurrent pulmonary infections (51.92%) and failure to thrive (25.96%). The mean age at diagnosis was 18 months. Echocardiography showed pulmonary hypertension in 73.25% of cases. The ductus was large in 97.67% of cases, with a mean diameter of 5.17 mm. Chest X-rays showed cardiomegaly (75%) and increased pulmonary vascularization (39.42%). The mean time to surgery after diagnosis was 7.28 months. All patients underwent left posterolateral thoracotomy with sectioning and suturing of the ductus arteriosus. The average hospital stay was 7.33 days. Conclusion: PDA was the most common symptomatic (83.65%) and large (90.38%). Surgical closures of PDA were satisfied in our practice.

Abstract 16714: An Injectable Thermo-Responsive Hydrogel as a Tool for Cardiac Tissue Engineering Efforts: In vitro and in vivo Biocompatibility Assessment

Background: Heart failure (HF) is a major contributor to the global burden of cardiovascular disease. Current treatments for HF do not regenerate muscle nor function and so cardiac transplantation remains the only definitive treatment for HF. Thus, novel therapies for HF are still needed. To overcome this limitation, we engineered an injectable thermo-responsive hydrogel that transitions from a liquid-solution to a gel-based matrix upon reaching body temperature allowing for a liquid injection rapidly followed by gel localization. Previously, we demonstrated the potential of our hydrogel for cardiac tissue applications using primary cardiomyocytes. Goal: The goal of this project is to assess the biocompatibility of the thermo-responsive hydrogel with human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) and its effect on mice heart tissue. Methods: 3D cell culture: 9x104 hiPSC-CM were encapsulated for 21 days using 150μl of hydrogel solution (1.5% w/w) and cell function was assessed afterwards. Mouse intracardial injection: a left thoracotomy was performed via the fourth intercostal space in an adult C57BL/6 mouse model. Then, three injections of 10 μl of either (i) lipofectamine, (ii) hydrogel (1% w/w) or (ii) saline were injected into the left ventricle anterior wall. After injections, the thoracotomy site was closed, and the animals recovered. Four weeks post inject the tissues were harvested and prepared for studies. Results: We found that our hydrogel promotes hiPSC-CMs alignment, elongation with increased Cx43 localization and improved contraction function when compared with traditional 2D fibronectin controls. Furthermore, the in-vivo biocompatibility in mice (intracardial injection) proved that our hydrogel is well tolerated by cardiac tissue. Conclusion: Our results indicated that the injectable thermos-responsive hydrogel is a biocompatible material with potential to be used in cardiac tissue engineering efforts.

Abstract 13623: In Silico Comparison of Pressure Head Loss for Outflow Variations of a Novel LVAD Accessory Compared to Generic LVAD Pump Outflow

Introduction: Left ventricular assist device (LVAD) implantation is a treatment option for end-stage heart failure, requiring a sternotomy. A novel accessory, redirecting the outflow via the left ventricular apex into the ascending aorta, allows for LVAD implantation via left thoracotomy. Pressure distribution within accessory designs is unknown. Our goal was to compare three different outflow designs with a generic LVAD outflow (Control) to optimize the accessory’s outflow design. Hypothesis: We hypothesize that the LVAD accessory leads to higher pressure head loss than Control and that there are relevant differences among varied designs. Methods: Volume models of the LVAD accessory variations (A–C) and Control were created using computer aided design. Computational fluid dynamics (CFD) was used to simulate blood flow through the accessories and generic outflows. A verification study was performed to optimize numerical parameters. Pressure head loss (mmHg) was calculated for each outflow while changing the LVAD flow rate continuously (2–7 L/min). Pressure loss was compared by mean differences (MD). Results: Pressure head loss increased with higher LVAD flow rate among all groups. Addressing the accessories’ outflow designs, Design B revealed the lowest increase in pressure loss revealing a mean slope of 2.3 mmHg/L/min compared to 4.6 and 3.0 for Design A and C. Referring to a flow rate of 5.5 L/min, a common flow rate among clinical LVAD patients, and comparing pressure head loss with Control, we found an additional pressure loss of 15.5, 6.4 and 8.3 mmHg in Design A, B and C, respectively. Conclusion: There is a trade off between fitting the outflow design to the cardiac geometry and the pressure head loss. Continued optimization of the LVAD accessory could allow minimally invasive LVAD implantation with minimal changes in LVAD performance. Potential compromise between improved design and performance renders CFD an important tool for medical device development.

Abstract 18817: Dysregulation of Key Calcium Cycling Genes Does Not Drive Right Heart Maladaptation in a Porcine PH Model

Introduction: Pulmonary hypertension (PH), a complex disease characterized by an elevated pulmonary artery pressure, causes maladaptation in patients. Maladaptation, or the hemodynamic and functional changes involved in RV/PA uncoupling, leads to poorer outcomes in patients. Dysregulation of calcium cycling controlled by SERCA2a and modulators, PLN and SUMO1, has been shown to cause left heart failure (HF), however its role in right heart maladaptation is unclear. Hypothesis: The dysregulation of the key calcium cycling genes, SERCA2a, PLN, and SUMO1 contributes to the maladaptation in PH. Methods: In this retrospective study, tissues of a porcine Yorkshire model of post-capillary PH were analyzed to understand molecular differences in right ventricular (RV) remodeling resulting in refractory symptom presentation (maladaptive group, n =6) or symptom absence (adaptive group, n =5). Pulmonary and cardiac hemodynamics, functional assessment, echocardiography, and pressure-volume relationship data were collected. Sham control group, ( n =5) received left thoracotomy only. Results: Calcium cycling genes known to be dysregulated in left HF did not display significant differences in group or spatial expression across RV, septal, and LV tissues (Figure). Other significant findings include increases in RV hypertrophy (p&lt;0.001) and stroke work (p=0.0036) when comparing maladaptive and sham group ( n =5) with RV dilation only in maladaptive group (p=0.0004). Conclusions: Dysregulation of calcium cycling genes in the RV does not explain symptom presentation in the maladaptive group and suggests different processes underlie left and right HF. RV dilation is likely a key driver of maladaptive symptom presentation in a porcine model of PH.