Mean Cross-clamp Time Research Articles

184 * BICUSPID AORTIC VALVE DISEASE AND ASCENDING AORTIC ANEURYSM: SHOULD THE AORTIC ROOT REPLACEMENT BE MANDATORY?

OBJECTIVES: The higher risk of adverse aortic events in patients with bicuspid aortic valve (BAV) disease and ascending aorta aneurysm is known, but the management of moderate aortic root dilatation in younger patients is a controversial issue. The aim of the study was to compare survival in patients with or without root replacement. METHODS: We reviewed 166 consecutive patients with BAV disease and concomitant ascending aorta aneurysm (mean ascending aorta diameter: 51.4 ± 7.2 mm) undergoing cardiac surgery from 1994 to 2010. A total of 77 patients underwent Bentall procedure (90.9% male, mean age: 55.7 ± 12.7 years, Bentall group), whereas the remaining 89 patients underwent aortic valve replacement with supracoronary ascending aorta replacement (SAAR 71.9% male, mean age: 60.5 ± 11.2 years, SAAR group, P= 0.002). The preoperative mean diameter of the root was 44.0 ± 7.2 mm in the Bentall, and 38.5 ± 4.8 mm in the SAAR group (P< 0.0001). RESULTS: In-hospital mortality was 2.6% in the Bentall, and 2.3% in the SAAR groups. Overall survival was 84 and 81% in the Bentall (median follow-up: 105 months) versus 89 and 88% in the SAAR (median follow-up: 73 months) groups at 10 and 15 years (P= 0.36), respectively. The mean cardiopulmonary bypass (CPB) time was 201 ± 56 min and 174 ± 58 min (P= 0.0016), the mean cross-clamp time 156 ± 42 min and 132 ± 38 min (P= 0.0008) in the Bentall and SAAR groups, respectively. Four sudden deaths have occurred in the Bentall group and in 2 in the SAAR group. Progressive dilatation of the aortic root in the SAAR group was not significat (postoperative mean diameter: 36.3 ± 4.4 mm). Neither subgroup of patients in the SAAR with preoperative moderate dilatation of aortic root had significat aortic dilatation at the mean follow-up of 73 ± 39 months (preoperative diameter: 43.5 ± 2.3 mm versus postoperative: 39.1 ± 4.2 mm). One patient in Bentall and 1 in the SAAR groups were reoperated for tubular graft infection. CONCLUSIONS: In patients with BAV disease, ascending aorta aneurysm and moderate dilatation of the root, the significat reduction of CPB and cross-clamp times, the stability of the residual root at long term and the low risk of adverse aortic events associated with SAAR compared with the Bentall procedure have led us to consider the isolated aortic valve replacement with supracoronary aorta replacement an alternative strategy to the Bentall procedure, especially in high-risk and older patients.

Minimally invasive mitral valve surgery via minithoracotomy and direct cannulation.

To reduce the morbidity of mitral valve operations, a right anterolateral minithoracotomy under direct vision was introduced. We report our experience with this procedure. From July 2001 to December 2013, 320 consecutive patients underwent direct minimally invasive mitral valve surgery through a right anterolateral minithoracotomy at our institution. Evidence of rheumatic disease was observed in 231 (72%) patients, and 89 (28%) repaired valves had myxomatous changes. Tricuspid valve repair was performed in 80 (25%) patients and radiofrequency ablation in 80 (25%) with chronic atrial fibrillation. All cannulas were introduced through the thoracotomy incision, eliminating femoral cannulation. No new instruments, retractors, or ports were used. Pleural and pericardial drainage was accomplished through a single drain. There was no hospital death. Conversion to sternotomy was needed in 3 patients because we were unable to obtain satisfactory arterial cannulation. Eight patients required reoperation: 7 for mitral insufficiency and one for postoperative bleeding. Mean cardiopulmonary bypass and crossclamp times were 55.3 ± 17.0 and 43.0 ± 13.4 min, respectively. Mean intensive care unit stay was 29 h, and hospital stay was 4.3 days. Based on our experience, this minimally invasive approach is safe, rapid, cost-effective, and more comfortable for the patients, in addition to its cosmetic benefits. It may be the preferred approach in young females.

Robotic Mitral Valve Replacement for Severe Rheumatic Mitral Disease: Perioperative Technique, Outcomes, and Early Results

We report a case series of robotic mitral valve replacement in patients with severe rheumatic mitral disease. From March 2010 to June 2013, a total of 63 patients underwent robotic cardiac procedures. Robotic procedures were performed using the da Vinci Si surgical systems (Intuitive Surgical, Inc, Sunnyvale, CA USA). Eighteen of the patients (28.5%) underwent robotic mitral valve replacement. Rheumatic disease was the underlying pathology in all patients. The mean (SD) follow-up period was 18 (10) months. The mean (SD) age and EuroSCORE of the patients were 51.2 (11) years and 4.1% (4%), respectively. Seven patients (38.8%) had an additional cardiac procedure. No operative and hospital mortality were observed. The mean (SD) cross-clamp time and cardiopulmonary bypass time were 116 (30) and 178 (54) minutes, the mean (SD) drainage was 430 (350) mL, the mean intubation time was 9.4 (7) hours, the rate of patients extubated within 6 hours or less was 94.4%, and the mean (SD) intensive care unit stay time was 30 (12) hours. Sixteen of the patients (88.8%) were discharged from the intensive care unit within the first 24 hours postoperatively. During the intensive care unit stay, one patient (5.5%) needed inotropic support. There was one early reoperation for bleeding (5.5%), one (5.5%) intensive care unit readmission, and one (5.5%) hospital readmission observed. During the midterm follow-up, there was no mortality and no need for reoperation or reintervention. Robotic mitral valve replacement for severe rheumatic mitral disease is technically feasible. Early results are encouraging. Patient selection criteria for robotic mitral valve surgery may be expanded to include valve replacements.

Outcomes of peripheral perfusion with balloon aortic clamping for totally endoscopic robotic mitral valve repair

Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well described, few reports have examined the results of peripheral perfusion with balloon clamping. We analyzed the outcomes of TERMR performed using this strategy. A total of 108 consecutive patients underwent TERMR by a 2-surgeon team. The preoperative evaluation included chest computed tomography and abdominal and pelvis computed tomography. Additional procedures included appendage exclusion in 96, patent foramen ovale closure in 29, cryoablation in 16, tricuspid valve repair in 2, and septal myectomy in 2. The mean patient age was 59 years (range, 21-86). Central venous drainage was obtained with a long cannula. Arterial return was achieved with femoral cannulation, when possible. An endoballoon catheter was placed through the femoral artery. Transesophageal echocardiography was used to position all catheters. Femoral artery perfusion was possible in 103 of 108 patients (95.3%). The subclavian artery was used in 5 patients (4.6%) with contraindications to retrograde perfusion. An endoballoon clamp was placed by way of the femoral artery. In 105 of 108 patients (97.2%), endoaortic occlusion was successfully used; the mean crossclamp time was 87.4 minutes. The coronary sinus cardioplegia catheter was placed successfully in 81 of the 108 patients (75%). Postoperatively, no or mild inotropic support was needed in 94 (87%) and moderate support in 14 (13.0%). Of the 108 patients, 55 (50.9%) were extubated in the operating room. No hospital mortality, aortic injury, vascular complications, or wound infections occurred. Complications included 2 strokes (no residual deficit) (1.8%) and atrial fibrillation in 18 (16.7%). The median hospital stay was 4 days. Eighty patients (74.1%) were discharged by postoperative day 5. A preoperative image-guided perfusion strategy and aortic balloon clamping permit routine TERMR with excellent myocardial preservation and minimal complications.

Radiofrequency ablation of atrial fibrillation during mitral valve surgery

Atrial fibrillation is the most common form of arrhythmia in mitral valve disease. Radiofrequency ablation is most commonly used for atrial fibrillation ablation during mitral valve surgery. This prospective study evaluated the midterm outcomes of intraoperative radiofrequency atrial fibrillation ablation during mitral valve surgery. 52 patients were eligible for the study. Fifteen (28.8%) had a transseptal approach and 37 had a left atriotomy. Mitral valve replacement was performed in 16 patients, mitral valve repair in 31, and tricuspid repair in 8. Mean crossclamp time was 58.14.± 20.08 min, and mean cardiopulmonary bypass time was 71.28 ± 20.31 min. The mean ablation time was 6.41 ± 0.21 min. There was no postoperative mortality. Sinus rhythm was documented in 44 (84.6%) patients on discharge, and 8 (15.4%) were discharged with atrial fibrillation; 2 of them returned to sinus rhythm after 3 months. After 12 months of follow-up, 46 (88.5%) patients were in sinus rhythm. Left atrial monopolar radiofrequency ablation during mitral valve surgery is a safe procedure with a high success rate.

Does Coronary Endarterectomy Increase Early Mortality and Morbidity Compared with Coronary Artery Bypass Surgery Alone-Single Centre Experience

Background: With increasing incidence of coronary artery disease (CAD) in Saudi Arabia and its fatal co-morbidity, this has resulted in a more complex pool of cases referred to cardiac surgeons. In selected cases, achieving optimal revascularization of diffuse CAD necessitates adjunctive techniques such as coronary endarterectomy (CE). The aim of our study is to evaluate the early mortality and post-operative morbidity related to CE. Method: Retrospective study from Jan 2009 to Dec 2010. Inclusion of 186 patients: 38 patients had CABG with CE and 148 patients had CABG alone. Results: Pre-operative percutaneous coronary intervention (PCI) was higher in the CE with CABG group (25.8%) compared with CABG alone (8.9%) (p = 0.009). Intra-operative data showed a higher mean cardiopulmonary bypass time (CBT) of 160 minutes and a mean cross-clamp time (XCT) of 109 minutes in the CE with CABG, compared to a mean CBT of 129 minutes and a mean XCT of 87 minutes in the CABG alone group (p = 0.001). The most common vessel endarterectomized was left anterior descending artery (LAD) (47%) followed by right coronary artery (RCA) (22%). Post-operatively, the mortality amongst the CE with CABG group (7.9%) was higher than CABG only group (1.4%), however it wasn’t statistically significant (p = 0.06). With regards to morbidity, hemodynamic instability requiring intra aortic balloon pump (HIR-IABP) was higher in the CE with CABG group (10.5%) compared to the CABG only group (1.4%) (p = 0.018). Conclusion: Our study showed that CE when combined with CABG wasn’t associated with a higher mortality rate when compared with CABG alone.

Does Pulmonary Artery Venting Decrease the Incidence of Postoperative Atrial Fibrillation after Conventional Aortocoronary Bypass Surgery?

In this study, we tested the hypothesis that pulmonary artery venting would decrease the incidence of atrial fibrillation after coronary artery bypass surgery. This prospective study included 301 patients who underwent complete myocardial revascularization with cardiopulmonary bypass in our department during a 2-year period. The patients were randomly divided into 2 groups: group I included 151 patients who underwent aortic root venting and group II included 150 patients who underwent pulmonary arterial venting for decompression of the left heart. Pre-, peri-, and postoperative risk factors for atrial fibrillation were assessed in both groups. The mean age was similar in the 2 groups. The mean number of anastomoses was significantly higher in group I (2.8 ± 0.8) than in group II (2.4 ± 0.8) (P = 0.001). The mean cross-clamp time was 42.7 ± 17.4 minutes in group I and 54.1 ± 23.8 minutes in group II (P = 0.001). The mean cardiopulmonary bypass time was 66.4 ± 46.1 minutes in group I and 77.4 ± 28.6 minutes in group II (P = 0.08). The incidence of atrial fibrillation was 14.5% (n = 21) in group I and 6.5% (n = 10) in group II (P = 0.02). Multivariate regression analysis showed that pulmonary artery venting decreased the postoperative incidence of atrial fibrillation by 17.6%. Pulmonary arterial venting may be used as an alternative to aortic root venting during on-pump coronary bypass surgery, especially in patients at high risk of postoperative atrial fibrillation.

Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction

The deep hypothermic circulatory arrest (DHCA) technique has been used in aortic arch and isthmus hypoplasia for many years. However, with the demonstration of the deleterious effects of prolonged DHCA, selective cerebral perfusion (SCP) has started to be used in aortic arch repair. For SCP, perfusion via the innominate artery route is generally preferred (either direct innominate artery cannulation or re-routing of the cannula in the aorta is used). Herein, we describe our technique and the result of arch reconstruction in combination with selective cerebral and myocardial perfusion (SCMP) and short-term total circulatory arrest (TCA) (5-10 min) through ascending aortic cannulation. Thirty-seven cases with aortic arch and isthmus hypoplasia accompanying cardiac defects were operated on with SCMP and short TCA in Baskent University Istanbul Research and Training Hospital between January 2007 and Sep 2012. There were 17 cases with ventricular septal defect (VSD)-coarctation with aortic arch hypoplasia (CoAAH), 4 cases of transposition of the great arteries-VSD-CoAAH, 4 cases of Taussing Bing Anomaly-CoAAH, 2 cases complete atrioventricular canal defect-CoAAH, 3 cases single ventricle-CoAAH, 3 cases of type A interruption-VSD, 2 subvalvular aortic stenosis-CoAAH and 2 cases of isolated CoAAH. The aorta was cannulated in the middle of the ascending aorta in all cases. The cross-clamp was applied to the aortic arch distal to either the innominate artery or the left carotid artery. In addition, a side-biting clamp was applied to the descending aorta. The aorta between these two clamps was reconstructed with gluteraldehyde-treated autogeneous pericardium, using SCMP. The proximal arch and distal ascending aorta reconstructions were carried out under short TCA. The mean age of the patients was 2.5 ± 2 months. The mean cardiopulmonary bypass and cross-clamp times were 144 ± 58 and 43 ± 27 minutes, respectively. The mean SCMP and descending aorta ischemia times were 22.6 ± 4.8 and 27 ± 6.3 minutes, respectively. Mean TCA time was 7.6 ± 2.1 minutes (min: 4, max 10 min). The mean in-hospital stay time was 8.6 ± 1.9 days. None of the cases operated with this technique had neurological defects. The mortality rate was 2.7% (1 patient). SCMP with aortic cannulation and short TCA (under 10 minutes) in aortic reconstruction is safe and practical in this high-risk patient group.

Minimally Invasive Aortic Valve Surgery. A Safe and Useful Technique Beyond the Cosmetic Benefits

Introduction and objectivesThe aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. MethodsBetween 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). ResultsNo significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. ConclusionsIn terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results.

Cirugía mínimamente invasiva para el recambio valvular aórtico. Una técnica segura y útil más allá de lo estético

Introduction and objectivesThe aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. MethodsBetween 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). ResultsNo significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8.0] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. ConclusionsIn terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results.Full English text available from:www.revespcardiol.org/en

Four different strategies for repair of aortic coarctation accompanied by cardiac lesions

Coarctation accompanied by cardiac lesions is a complex clinical situation due to the presence of two different pathologies that necessitate surgical treatment. An individual strategy, according to the severity of the disease, is important to reduce perioperative mortality and morbidity. We report here on 25 patients with coarctation accompanied by cardiac lesions who were treated by various surgical approaches. Coarctation and associated disease were treated in 14 patients in a single stage by an ascending-to-descending bypass (n = 11) or by a hybrid procedure (n = 3). The remaining 11 patients underwent a two-stage operation for their treatment. Six of these 11 patients who had coronary artery disease or signs of congestive heart failure were first operated for their cardiac disease, whereas in the remaining five patients, who did not have any congestive signs, coarctation repair was performed first. All the patients were male, between the ages of 20 and 24 years, except for one 45-year-old woman. The mean cross-clamp times, cardiopulmonary bypass times and operation times were 52 ± 14.5, 102.3 ± 28.5 and 174 ± 24.8 min in the extra-anatomical bypass group; 29.8 ± 11.7, 55.5 ± 17.6 and 116 ± 22 min in the two-stage groups and 49 ± 19.8, 63 ± 18.7 and 159 ± 21.3 min in the hybrid patients, respectively. One patient who underwent extra-anatomical bypass died on the 14th postoperative day. There were no events during the follow-up period for the other patients. Also, there were no gradients between the extremities and no graft-related complications. As a consequence of the progress in the development of endovascular techniques, hybrid treatment is becoming a more popular option for the treatment of coarctation accompanied by cardiac diseases. Two-stage procedures and extra-anatomical bypass might be alternative techniques if endovascular procedures are contraindicated or failing.

Aortic valve replacement in octogenarians: Impact of less invasivity on postoperative outcome

Objective Due to increasing life expectancy in industrialized countries, the number of octogenarian patients undergoing an open heart procedure is increasing. In these patients with high comorbidity less invasive procedures could probably improve the postoperative outcome. The aim of this study was to determine the effects of minimal access aortic valve replacement (AVR) in octogenarians on postoperative morbidity and mortality. Methods Partial upper sternotomy has become the standard approach to isolated aortic valve surgery in patients without any previous cardiac surgery at our institution. Almost 20% of the 353 patients who underwent AVR through a partial upper sternotomy between 1998 and 2006 were octogenarians. These 70 patients (16 male, 54 female) had a mean age of 81.8years (80–95years). We reviewed retrospectively data on these patients. Results The patients had a mean logistic Euroscore of 9.1 (0.9–29.2) and a mean left ventricular ejection fraction of 54.7% (20–70%). Mean cross clamp time and mean bypass time were 63.3 min (33–149min) and 108.5min (52–290min), respectively. In 3 patients (4.3%) a conversion into full median sternotomy was necessary due to bleeding ( n =2) and low cardiac output ( n =1). Mean ICU and total hospital stay were 2.8 and 11.7days, respectively. Postoperative bleeding complications were not observed. Deep sternum infection occured in 2 patients (2.8%). None of the patients had to be reoperated for prosthetic valve dysfunction or endocarditis. The hospital mortality rate was 5.7%. Conclusions AVR through a partial upper sternotomy in octagenarians is a safe and effective technique with less invasivity resulting in satisfying postoperative morbidity and mortality.

Total anomalous pulmonary venous connection repair; risk factors and outcome

Background Repair of total anomalous pulmonary venous connection (TAPVC) is associated with high mortality and morbidity. Age of presentation, low birth weight, type of TAPVC, pre-operative infection, clinical situation, pulmonary venous obstruction, pulmonary hypertension and associated lesions are very important factors affect the outcome of TAPVC repair. Methods Seventy patients underwent TAPVC repair from 2000 to 2012 with a median age of 33 days and mean weight of 4.6 kg. Twenty-six patients (48.6%) had supracardiac type, 23 patients (32.8%) had intracardiac type, and nine patients (8.6%) had infracardiac type, while seven patients (10%) had mixed TAPVC. Results Operative mortality was 5.7% (4 patients), while late deaths was 4.3% (3 patients). Four patients out of these 7 deaths were due to pulmonary hypertensive crises (4/7, 57.1%). Obstruction and single-ventricle physiology were associated with a higher mortality rate (3/7, 42.8%).Mean CPB time was 104.3 min (range, 70–190 min) and mean cross-clamp time was 42.4 min (range, 29–70 min). Three patients had recurrent pulmonary venous obstruction. (4.3%) which required early re-intervention. Conclusion Mortality rate in TAPVC repair is higher in those patients who had single-ventricle physiology or pulmonary venous obstruction at time of repair. Pulmonary hypertension is another risk factor affecting the post-operative course of infants with TAPVC, particularly patients with obstructed, infracardiac TAPVC.

Pooled Estimates of Immediate and Late Outcome of Mitral Valve Surgery in Octogenarians: A Meta-analysis and Meta-regression

The authors evaluated the outcome of patients≥80 years undergoing mitral valve (MV) surgery. Systematic review of the literature and meta-analysis. None. None. None. Twenty-four studies reporting on 5,572 patients ≥80 years of age who underwent MV surgery were included in this analysis. Pooled proportion of operative mortality was 15.0% (95% confidence interval [CI] 11.9-18.1), stroke was 3.9% (95% CI 2.6-5.2), and dialysis was 2.7% (95% CI 0.5-4.9). Early date of study (p = 0.014), increased age (p = 0.006), MV replacement (p = 0.008), procedure other than isolated MV surgery (p = 0.010), MV surgery associated with coronary artery surgery (p = 0.029), aortic cross-clamping time (p<0.001), and cardiopulmonary bypass time (p<0.001) were associated significantly with increased operative mortality. MV repair had lower operative mortality compared with MV replacement (7.3% v 14.2%, relative risk 0.573, 95% CI 0.342-0.962). Random-effects metaregression showed that prolonged aortic cross-clamping time (p = 0.005) was the only determinant of increased operative mortality, even when adjusted (p<0.001) for date of study (p = 0.004). Operative mortality was significantly higher in studies reporting a mean cross-clamp time >90 minutes (17.0% v 7.4%, p<0.001). Survival rates at 1, 3, and 5 years were 76.1%, 67.7%, and 56.5%, respectively. MV surgery in patients ≥80 years of age is associated with operative mortality, which has decreased significantly during recent years. Prolonged aortic cross-clamp time is a major determinant of operative mortality. MV repair may achieve better results than MV replacement in the very elderly. Five-year survival of these patients is good and justifies surgical treatment of MV diseases in octogenarians.

A clinical evaluation of the Maquet Quadrox-i Neonatal oxygenator with integrated arterial filter

High-performance, low-prime-volume oxygenators for the pediatric patient population have become a growing market among manufacturers. In the summer of 2011, our institution clinically evaluated the performance of the newly released Maquet Quadrox-i Neonatal oxygenator with integrated arterial filter. The static priming volume, including the integrated arterial filter, is 40 ml and the maximum rated blood flow is 1.5 liters per minute (LPM). The device was used on seven pediatric patients, ranging from 3.2 to 14 kg, undergoing various congenital heart defect repairs. Data were collected to calculate gas transfer, trans-oxygenator pressure drop, and heat exchange performance. The mean cardiopulmonary bypass time was 85 minutes and the mean cross-clamp time was 56 minutes. The average oxygen transfer was 34.3 ± 22.8 ml/O2/min and increased with both blood flow and FiO2. The average carbon dioxide transfer was 22.3 ± 17.8 ml/min and increased with both blood flow and gas sweep to blood flow ratio. The average trans-oxygenator pressure drop per blood flow was 53.3 ± 15.5 mmHg/L/min and increased with flow. The average heat exchanger performance factor was 47.6 ± 11.6% and decreased with flow. The heat exchange performance factor at maximum observed clinical flow, 1.42 LPM, was 36.4%. During this evaluation, the Maquet Quadrox-i Neonatal oxygenator adequately performed within its operational flow in the clinical setting.

Early postoperative hemodynamics and clinical outcomes of patients receiving freedom solo aortic calve replacement; the Asian Experience

Aim: Freedom SOLO (FS) valve (Sorin Group, Saluggia, Italy) is a stentless aortic valve bioprosthesis that use a single running suture line implanted in supra-annular position. Current study aims to assess the early postoperative hemodynamics and clinical outcomes of patients receiving FS aortic valve replacement (AVR). Methodology: 4 patients (2 male; 2 female; mean age 49.25 ± 23.78 years; range: from 25 to 73) who underwent AVR with FS valve in a single center were enrolled in the study. 2 patients underwent AVR for aortic stenosis and 2 patients for aortic regurgitation. Clinical and biological outcomes were recorded. Echocardiographic parameters were compared between preoperative and 5 months postoperative observation. Results: There was no early mortality reported. Late death was reported in one patient which was non valve related. There were 2 patients who developed early postoperative complication but it was not attributed to the valve itself. The mean transvalvular pressure gradient was 26.50 ± 11.90 mmHg preoperatively and 15.25 ± 10.11 mmHg postoperatively. The mean aortic valve area (AVA) for patients having stenosis improved from 0.74 ± 0.23 cm2 preoperatively to 1.50 ± 0.57 cm2 postoperatively. Preoperatively, the mean left ventricular ejection fraction (LVEF) was 65.75 ± 6.29 % and postoperatively 61.25+_11.84 %. The mean cross-clamp time (CCT) for isolated valve replacement was 80.5 ± 21.92 minutes and 147.00 ± 26.87 minutes. The mean lowest postoperative platelet count recorded was 24.50 ± 6.19 (x109/L). The mean platelet count at discharge was 128.75 ±10.11 (x109/L). Conclusion: The result demonstrated good short-term clinical and hemodynamic outcomes in patients underwent FS aortic valve replacement. However, the study also showed the occurrence of severe thrombocytopenia after FS valve implantation.

Hypothermic Circulatory Arrest Using Antegrade Cerebral Perfusion Is Safe for Elective Aortic Arch Surgery

We hypothesized that hypothermic circulatory arrest (HCA) can be performed with a low operative risk and does not add to the morbidity in elective procedures. A total of 178 patients with a mean (± SD) age of 62 (± 10) years underwent HCA for elective aortic surgery from April 2008 to September 2011. Pre- and postoperative clinical data were collected prospectively. Hemiarch replacement was performed in 97% patients. Mean logistic Euroscore I was 17% (± 15). HCA was performed at 26°C bilateral tympanic temperature. Mean HCA duration was 17 (±) min. Mean cross-clamp time was 106 (± 39) min. Overall 30-day mortality was 2% and stroke occurred in 4% of patients. Overall 6-month survival was 96%. Cox regression analysis for 6-month survival revealed four variables with significant influence: the logistic Euroscore I (p = 0.008), age (p = 0.04), cross-clamp time (p = 0.008), and reoperation for bleeding complications (p = 0.04). HCA with open distal anastomosis for elective aortic repair can be performed with low operative mortality, even in the elderly, and seems not to add to the morbidity of the procedure.

Open heart surgery in dialysis-dependent patients with end stage renal failure

Objective: Patients with chronic renal insufficiency remain a risky subgroup in open heart surgery because of various reasons. The incidence of cardiovascular disease in hemodialysis dependent renal failure is found to be higher when compared with the normal population. Chronic dialysis is still a very important independent risk factor for mortality and morbidity despite of many studies. In this study, we retrospectively evaluated the outcome of patients with chronic renal failure who had undergone to open cardiac surgery. Methods: The medical charts of 36 patients on maintenance dialysis who underwent cardiovascular surgery were retrospectively analyzed. Peroperative findings of these patients were analyzed from patients’ hospital records. Results: Twenty-seven men (75%) and nine women (25%) totally 36 patients were included to study. The mean age was 58.3±8.5 (range, 44-76) years. 12 patients underwent coronary artery bypass surgery, 10 had concomitant coronary artery bypass surgery and valve replacements, five had valve replacements, three had concomitant coronary artery bypass surgery and left ventriculectomy, four had valve replacement with other valve repair, two had aortic surgery due to ascending aortic aneurysms. The mean cross clamp time was 78.1±31.3 min and the mean perfusion time was 158.8±92.2 min. The mean intensive care unit stay was 60±41 hours, and the mean hospital stay was 12±5 days. Hospital mortality rate was %38.8. Conclusions: Cardiac and renal functions are closely associated with each other. Cardiac surgery operations can be applied to patients with end-stage renal failure under acceptable risks. Appropriate preoperative preparation with good postoperative patient follow-up is necessary to have acceptable levels of morbidity and mortality rates.

Right anterolateral thoracotomy a minimally invasive approach to mitral valve replacement

Background: The objectives of this study were to analyze the results of the right anterolateral thoracotomy approach for primary mitral valve replacement with reference to length of incision, surgical exposure, mean cross-clamp time, mean bypass time, intensive care unit (ICU) stay, hospital stay, overall comorbidity sepsis, dehiscence, healing cosmesis and cost-effectiveness. Materials and Methods: Thirty-three patients were operated for mitral valve disease in the Department of Cardiovascular and Thoracic Surgery at the Sher-i-Kashmir Institute of Medical Sciences from September 2009 to August 2011 and all patients underwent mitral valve replacement. Results: Of the 33 patients, 13 were male (40.6%) and 19 were female (59.4%). The length of incision was 14.8 ± 2.3 cm and, in thoracotomy, there was a significantly lesser duration of ICU stay the entire hospital stay. Scar visibility was around 25% in case of thoracotomy. Conclusion: Approach through a right anterolateral thoracotomy proved to be easy to perform while maintaining maximum security for the patients. Besides its better cosmetic result, especially in female patients, this approach proved to have several advantages. It offered a better exposure to the mitral apparatus even in patients with small left atrium, allowing mitral valve replacement to be performed easily. The shorter hospital stay and cost-effectiveness of thoracotomy approach is an additional relief to the family.

Whole blood assessment of neutrophil gelatinase–associated lipocalin versus pediatricRIFLE for acute kidney injury diagnosis and prognosis after pediatric cardiac surgery

To assess the ability of a single whole blood neutrophil gelatinase-associated lipocalin measurement in predicting acute kidney injury occurrence, its severity, and the need for postoperative renal replacement therapy after pediatric cardiac surgery. Single-center prospective cross-sectional study. Tertiary care pediatric cardiac intensive care unit. Consecutive children <1 yr old with congenital heart diseases undergoing cardiac surgery with cardiopulmonary bypass. None. Neutrophil gelatinase-associated lipocalin levels were measured after pediatric cardiac intensive care unit admission. Pediatric score indicating level of renal damage by Risk, Injury, Failure, Loss of function and End-stage kidney disease (pRIFLE) was used as the reference method. Acute kidney injury was diagnosed in 90 (56%) of the 160 enrolled patients. The number of abnormal neutrophil gelatinase-associated lipocalin samples (above the cutoff level of 150 ng/mL) was 12 over 90 (13%) in acute kidney injury population and 6 over 70 in non-acute kidney injury patients (8%) (odds ratio 1.6; 95% confidence interval 0.6-4.7; p = .31). Sensitivity of neutrophil gelatinase-associated lipocalin for acute kidney injury detection was 0.13 and specificity 0.91. The number of patients with abnormal neutrophil gelatinase-associated lipocalin samples was not significantly different within pediatric score indicating level of renal damage by pRIFLE (p = .69); furthermore, we found abnormal neutrophil gelatinase-associated lipocalin levels in 4 (30%) over 13 renal replacement therapy patients and in 14 (10%) over 133 children without renal replacement therapy need (odds ratio 4.2; 95% confidence interval 1.2-10.2; p = .02). Mean cross-clamp time (p = .28), inotropic score (p = .19), surgical risk score (p = .3), mean length of mechanical ventilation (p = .48), and pediatric cardiac intensive care unit stay (p = .57) did not significantly differ between children with abnormal and normal neutrophil gelatinase-associated lipocalin values. Neutrophil gelatinase-associated lipocalin measured at pediatric cardiac intensive care unit arrival does not accurately predict acute kidney injury diagnosis, according to pediatric score indicating level of renal damage by pRIFLE classification. In these patients, neutrophil gelatinase-associated lipocalin might be helpful for renal replacement therapy prediction.