Median Aortic Cross-clamp Times Research Articles

Totally 3D endoscopic aortic valve replacement: initial results and experience from a single center.

This study aimed to evaluate the feasibility and initial outcomes of totally endoscopic aortic valve replacement (TEAVR) performed via a single working port at the fourth intercostal space (ICS) utilizing a 3D endoscopic system. A retrospective observational study was conducted on 35 consecutive patients who underwent TEAVR over a six-month period from December 2023 to June 2024. Patient selection was based on the presence of isolated aortic valve disease without the need for ascending aorta replacement or aortic root enlargement. A 4 cm single working port was created at the 4th ICS, extending from the right mid-axillary to the anterior axillary line. A 10-mm trocar for a 3D endoscope was placed at the right anterior-axillary line. Peripheral cardiopulmonary bypass (CPB) was established. The primary outcomes investigated included the success rate of the procedure, in-hospital mortality, and perioperative complications. The mean age of the patients was 58.7 ± 12.8 years, with 22.9% being female. The majority of patients (77.1%) presented with aortic stenosis, often accompanied by severe calcification. The medianCPB time was 210 ± 43 min, and the median aortic cross-clamp time was 132 ± 41 min. The procedure was successfully completed in all patients using the endoscopic approach, with no conversions to full sternotomy. Two mortalities were recorded, attributed to postoperative complications including bleeding and cerebral infarctions. The early (30-day) mortality rate was 5.7%. Prolonged mechanical ventilation (>48 h) was required in 17.1% of patients, and reoperation for bleeding was necessary in 2.9% of patients. TEAVR is a feasible procedure with the potential to replace the traditional sternotomy approach for aortic valve replacement.

Upper Hemisternotomy Versus Full Sternotomy for Replacement of the Supracoronary Ascending Aorta and Aortic Valve.

Upper hemisternotomy (UHS) for supracoronary ascending aorta replacement (scAAR) with concomitant aortic valve replacement (AVR) results in less trauma and potentially faster convalescence compared with full sternotomy (FS). Direct head-to-head studies are lacking. We compared a group of UHS patients with a matched group of FS patients undergoing scAAR and AVR. There were 198 patients who underwent scAAR and AVR procedures by a single surgeon between 1999 and 2020. After matching 6 preoperative characteristics, there were 50 UHS and 50 FS patients. Patients who required acute type A aortic dissection repair, reoperations, concomitant procedures, or hypothermic circulatory arrest were excluded. In the matched sample, the hospital mortality rate was 1% (1 of 100). The median cardiopulmonary bypass time was 150 (interquartile range [IQR], 131 to 172) min and 164.5 (IQR, 138 to 190) min, respectively, for the UHS and FS groups (P = 0.08). The median aortic cross-clamp time was 121 (IQR, 107 to 139) min during UHS and 131 (IQR, 115 to 159) min during FS (P = 0.05). The median ventilation time was 7 (IQR, 3 to 14) h versus 17 (IQR, 10 to 24) h, respectively, after UHS and FS (P = 0.005). The median hospital length of stay was 7 (IQR, 6 to 9) days after UHS and 8 (IQR, 7 to 11) days after FS (P = 0.05). The low morbidity and mortality support the wider use of UHS for scAAR and AVR in appropriately selected patients. Larger studies are needed to confirm these initial findings.

Preoperative hypoalbuminemia and postoperative acute kidney injury in adult patients after elective on-pump cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background An earlier published prospective cohort study evaluating the impact of malnutrition on cardiac surgery outcomes showed serum albumin ≤42 g/dL to be associated with a poor prognosis [1]. However, the association with kidney outcomes was not studied. The adverse effect of preoperative hypoalbuminemia on postoperative kidney injury and its cut-off value in on-pump cardiac surgery patients is still controversial [2]. Methods A retrospective matched case-control study based on the secondary analysis of the open-access dataset [3] was conducted. The research hypothesis was that preoperative hypoalbuminemia is independently associated with a higher risk of acute kidney injury (AKI) requiring postoperative new-onset dialysis. We defined cases as patients treated with new-onset dialysis for AKI and controls as those who did not. Hypoalbuminemia was defined as serum albumin of ≤42 g/L based on findings from the original study. The dataset counted 1178 adults from multiple centers who underwent elective cardiopulmonary bypass (CPB) cardiac surgery in 2011. We excluded patients with missing data and compared key demographic and medical history characteristics. Following the hypothesis, subjects were matched on the type of surgery they received (coronary, valvular, or combined) in a multiple conditional logistic regression model that included the hypoalbuminemia status, diabetes history, CPB time, and logistic EuroScore. Additionally, univariate regression with and without conditional matching was performed. Results In total, 831 (39 cases and 792 controls) subjects were included. Subjects shared similar demographics and medical history. Expectedly, cases had prolonged CPB and aortic cross-clamp time. The median CPB time in cases and controls was 120 and 79 min, respectively (p=0.001). The median aortic cross-clamp time was 79 in cases and 54 in controls (p=0.001). Hypoalbuminemia was observed in 18 cases (46%) in cases compared to 241 (30%) in controls (p=0.038). Multiple conditional regression demonstrated that the risk of postoperative AKI requiring dialysis was not associated with preoperative hypoalbuminemia (OR 1.43, [0.70, 2.89]). Similarly, univariate conditional regression showed no association (OR 1.84 [0.95, 3.53]). Only univariate unmatched regression resulted in statistical significance(OR 1.96 [1.03, 3.74]). The higher logistic EuroScore (OR 1.11, [1.06, 1.15]) and the longer cardiopulmonary bypass time (OR 1.01, [1.01, 1.02]), but not the history of diabetes (OR 0.61, [0.19, 1.88]), increased the odds of renal replacement therapy requirement. Conclusion In our study, preoperative hypoalbuminemia was not independently associated with a higher risk of postoperative AKI requiring new-onset dialysis after elective on-pump cardiac surgery. Patients who required dialysis had lower preoperative albumin levels, but the association between hypoalbuminemia ≤ 42 g/L and kidney outcomes could be confounded.

Outcomes of Mitral Valve Repair Among High- and Low-Volume Surgeons Within a High-Volume Institution

BackgroundVolume-outcome relationships have been described for mitral valve repair at the institution and surgeon level. We aimed to assess whether this relationship is mitigated at high-volume (HV) mitral repair centers between HV and low-volume (LV) surgeons. MethodsAll mitral repair cases at an HV mitral center (mean, 192 annual repairs) from 1992 to 2018 were considered. Cases with concomitant procedures other than tricuspid and atrial fibrillation procedures were excluded. Surgeons who performed ≥25 repairs per year were considered HV. The primary outcome was operative mortality; secondary outcomes were operative complications, long-term mortality, and reoperation. ResultsIn total, 2653 mitral repairs from 19 surgeons were included. The mean age of the patients in the HV and LV groups was 59.6 years and 61.8 years, respectively (P = .005), with no difference in other baseline characteristics. HV surgeons had significantly shorter median aortic cross-clamp times (80 vs 87 minutes; P < .001) compared with LV surgeons; however, there was no significant difference in operative mortality (0.9% vs 1.6%; P = .19), reoperation, perioperative complications, or length of stay. LV surgeons had higher repair conversion to replacement than HV surgeons did (9.0% vs 3.4%; P < .001). In the risk-adjusted analyses, surgeon volume group did not have an impact on longitudinal survival or reoperation. ConclusionsAt an HV mitral repair institution, LV surgeons appear to have short- and long-term outcomes similar to those of HV surgeons despite increased conversion rates. These findings suggest that institutional volume may mitigate the surgeon volume outcome. However, complex repairs may benefit from referral to HV surgeons, given the lower conversion rate.

Bilateral internal thoracic artery use in two-vessel disease does not increase the perioperative risk—A propensity score matched analysis

BackgroundBilateral internal thoracic arteries (BITA) are uncommonly used in the every-day practice due to safety concerns and technical challenges with Y-grafts. We hypothesized that in-situ BITA use during coronary artery by-pass grafting (CABG) for two vessel disease is equally safe to standard strategy with left internal thoracic artery-left anterior descending artery revascularization and venous graft to other target vessels.MethodsA propensity score matched analysis was used to compare elective on-pump CABG patients who received in-situ BITA (BITA-group), versus left internal thoracic artery graft to the left anterior descending artery plus vein (SITA-group). Primary end points were 30-days all-cause-mortality, major adverse cardiac events and incidents and deep sternal wound infections.ResultsA total of 50 matched pairs (c-statistics 0.769) were selected from patients operated on between January 2015 and April 2020 using BITA (n = 50) and SITA (n = 2170). There were no inter-group differences in demographics and basic clinical characteristics. The total operation time was longer in the BITA-group (4.0 vs 3.6 hours; p = 0.004). The rate of complete revascularization was similar, as was median aortic cross-clamp time, median extracorporeal circulation time, rate of re-explorations for bleeding, deep sternal wound infections or length of stay. One patient died in BITA group, 3 days after surgery, from a non-cardiac cause. After 36 months, the survival rate was 98% for BITA-group and 96% for controls (log-rank, p = 0.577).ConclusionsIn-situ use of BITA during coronary revascularization for two-vessel disease is as safe and effective, as use of single ITA and vein graft. In-situ strategy abolishes allows to avoid the technically demanding composite graft configuration.

Impact of concomitant replacement of the ascending aorta in patients undergoing aortic valve replacement on operative morbidity and mortality.

The aim of this study was to evaluate the impact of concomitant ascending aortic replacement on operative morbidity and mortality in patients undergoing aortic valve replacement (AVR). We retrospectively analysed our institutional database for all patients undergoing elective isolated AVR and AVR with concomitant replacement of the ascending aorta between January 2009 and May 2020. Patients undergoing surgery for infective endocarditis or requiring hypothermic circulatory arrest were excluded. A 3:1 propensity matching was performed for 688 patients to compare isolated AVR (120 patients) with AVR + ascending aortic replacement (40 patients). There were significant differences in median cardiopulmonary bypass (CPB) time [92.5 (75-114) vs 118.5 (104-131) min; P < 0.001], median aortic cross-clamp time [65.0 (51.5-78.5) vs 84.5 (77-94) min; P < 0.001] and median intensive care unit stay [1 (1-3) vs 2 (1-6) days; P < 0.01]. There was no significant difference in the use of intraoperative and postoperative blood products, re-exploration for bleeding, postoperative atrial fibrillation, acute renal failure, incidence of stroke, perioperative myocardial infarction and 30-day mortality. Concomitant replacement of the ascending aorta significantly prolongs CPB and aortic clamp times but does not increase operative morbidity and mortality. Therefore, replacement of a dilated ascending aorta appears to be the most durable and safest treatment option in patients undergoing AVR with an aneurysmatic ascending aorta.

Utilization and Outcomes of the Nikaidoh, Rastelli, and REV Procedures: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

BackgroundAortic root translocation (Nikaidoh), Rastelli, and réparation à l’etage ventriculaire (REV) are repair options for transposition of the great arteries (TGA) with ventricular septal defects and left ventricular outflow tract obstruction (VSD-LVOTO) or double outlet right ventricle TGA type (DORV-TGA). MethodsThis retrospective study using The Society of Thoracic Surgeons Congenital Heart Surgery Database evaluates surgical procedure utilization and outcomes of patients undergoing repair of TGA-VSD-LVOTO and DORV-TGA with a Nikaidoh, Rastelli, or REV procedure. ResultsA total of 293 patients underwent repair at 82 centers (January 2010 to June 2019). Most patients underwent a Rastelli (n = 165, 56.3%) or a Nikaidoh (n = 119, 40.6%) operation; only 3.1% (n = 9) underwent a REV. High-volume centers performed the majority of the repairs. Fewer Nikaidoh than Rastelli patients had prior cardiac operations (n = 57 [48.7%] vs n = 102 [63.0%]; P = .004). Nikaidohs had longer median cardiopulmonary bypass time (227 [interquartile range (IQR), 167-299] minutes vs 175 [IQR, 133-225] minutes; P < .001) and median aortic cross-clamp times (131 [IQR, 91-175] minutes vs 105 [IQR, 82-141] minutes; P = .0015). Operative mortality was 3.1% (95% confidence interval [CI], 1.0%-7.0%; n = 5) for Rastelli, 4.4% (95% CI, 1.4%-9.9%; n = 5) for Nikaidoh, and 11.1% (95% CI, 0.3%-48.3%, n = 1) for REV. The rates of cardiac arrest, unplanned reoperation, mechanical circulatory support, prolonged ventilation, and permanent pacemaker placement were higher in the Nikaidoh population but with 95% CIs overlapping those of the other procedures. ConclusionsRastelli and Nikaidoh procedures are the prevalent repair strategies for patients with DORV-TGA and TGA-VSD-LVOTO. Most are performed at high-volume institutions, and early outcomes are similar.

Correlation between optic nerve sheath diameter and extracorporeal life support time

IntroductionThe objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD). Patients and methodsStudy in a cohort of patients aged 0–15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24 h post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report. ResultsWe analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60 min; the median aortic cross-clamp time was 32 min. The median baseline ONSD was 3.1 mm. ONSD values had increased a median of 0.015 mm at 6 h post surgery (P = .03). We found a positive correlation between ECLS time and ONSD values (r = 0.476, P < 0,05). The ONSD values returned to baseline by 24 h post surgery. None of the patients developed signs or symptoms of increased intracranial pressure. ConclusionOur study found a correlation between ECLS time and ONSD at 24 h post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased ICP. Further research is required to identify the factors related to these variations.

Correlación del diámetro de la vaina del nervio óptico y el tiempo de circulación extracorpórea

IntroductionThe objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD). Patients and methodsStudy in a cohort of patients aged 0 to 15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24hours post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report. ResultsWe analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60minutes; the median aortic cross-clamp time was 32minutes. The median baseline ONSD was 3.1mm. ONSD values had increased a median of 0.015mm at 6hours post surgery (P=.03). We found a positive correlation between ECLS time and ONSD values (r=0.476, p<,05). The ONSD values returned to baseline by 24hours post surgery. None of the patients developed signs or symptoms of increased intracranial pressure. ConclusionOur study found a correlation between ECLS time and ONSD at 24hours post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased increased intracranial pressure. Further research is required to identify the factors related to these variations.

Anterior Right Thoracotomy for Rapid-Deployment Aortic Valve Replacement

Minimally invasive aortic valve replacement through anterior right thoracotomy (ART) has shown to be safe and feasible. However, acceptance within the surgical community is low. Rapid-deployment aortic valves may be a game changer due to simplified surgical technique and shorter operative times. Therefore, the combination of advanced surgical techniques like the ART access with rapid-deployment aortic valves was assessed in this study. We retrospectively analyzed all patients undergoing ART with the Edwards Intuity Elite (Edwards Lifesciences, Irvine, CA) valve system between 2011 and 2018. Patient data were collected prospectively in an ongoing, single-center registry. Data analysis regarding valve outcome was performed according to current guidelines. In all, 165 patients underwent aortic valve replacement through ART access with the Edwards Intuity valve system (age 73 ± 9 years, 49% female, median European System for Cardiac Operative Risk Evaluation II score 1.6 [range, 0.6 to 10.6]). Median cardiopulmonary bypass time was 114 minutes (range, 61 to 310) and median aortic cross-clamp time was 80 minutes (range, 45 to 230). Thirty-day as well as inhospital mortality was 0.6% (n= 1). Postoperative neurologic events occurred in 3%, resulting in major neurologic deficit in 1 patient. Intermediate and long-term survival was 99%, 98%, and 93% after 6 months, 1 year, and 3 years, respectively. Implantation of the Edwards Intuity valve system through ART is safe, feasible, and reproducible. The overall results of this single center experience are excellent compared with contemporary series ofboth surgical and transcatheter aortic valve replacements.

Complications Associated With Femoral Cannulation During Minimally Invasive Cardiac Surgery

Different types of cannulation techniques are available for minimally invasive cardiac surgery. At our institution, we favor a femoral platform for most minimally invasive cardiac procedures. Here, we review our results utilizing this cannulation approach. We retrospectively reviewed all minimally invasive valve surgeries that were performed at our institution between January 2009 and January 2015. Operative times, lengths of stay, postoperative complications, and mortality were analyzed. We identified 2,645 consecutive patients. The mean age was 69.7 ± 12.77 years, and 1,412 patients (53.4%) were male. Three hundred fifty-eight patients (13.5%) had a history of cerebrovascular accident, 422 (16%) had previous heart surgery, and 276 (10.4%) had a history of peripheral vascular disease. The procedures performed were isolated aortic valve replacements (42.1%), isolated mitral valve operations (40.6%), tricuspid valve repairs (0.57%), double valve surgery (15%), triple valve surgery (0.3%), and ascending aortic aneurysm resection with and without circulatory arrest (5%). Femoral cannulation and central cannulation were utilized in 2,400 patients (90.7%) and 244 patients (9.3%), respectively. The median aortic cross-clamp time and cardiopulmonary bypass time were 81 minutes (interquartile range, 65 to 105) and 113 minutes (interquartile range, 92 to 142), respectively. The median postoperative hospital length of stay was 6 days (interquartile range, 5 to 9). There were 31 cerebrovascular accidents (1.17%), no aortic dissections, two compartment syndromes, two femoral arterial pseudoaneurysms, and 174 (6.65%) groin wound seromas. The overall 30-day mortality was 57 patients (2.15%). Minimally invasive cardiac surgical procedures utilizing femoral cannulation techniques have a low risk of complications.

A Novel Minimally Invasive Approach for Surgical Septal Myectomy

BackgroundTransaortic septal myectomy is the gold standard for the treatment of symptomatic hypertrophic obstructive cardiomyopathy that is refractory to medical therapy. The aim of this study was to assess early outcomes of minimally invasive septal myectomy performed through a right anterior minithoracotomy. MethodsBetween 2011 and 2014, 24 consecutive patients underwent isolated septal myectomy through a 4-5–cm right parasternal minithoracotomy. Perioperative clinical and echocardiographic outcomes in these patients were compared with those of a historical cohort of 26 consecutive patients who underwent isolated septal myectomy performed through a median sternotomy between 2002 and 2010. ResultsAge and sex distribution were similar between the groups. Median aortic cross-clamp time was 57 minutes in the minithoracotomy group vs 43 minutes in the sternotomy group (P = 0.149). There was no in-hospital mortality in either group. Intraoperative conversion to sternotomy was required in 1 patient. Postoperative permanent pacemaker implantation was required in 5 patients from each group (P = 0.999). Both groups demonstrated similar reductions in left ventricular outflow tract gradient and septal thickness. Residual obstructive systolic anterior motion of the mitral valve was observed in 2 patients (8%) in the minithoracotomy group and 1 patient (4%) in the sternotomy group (P = 0.602). ConclusionsThis study demonstrates the feasibility of transaortic septal myectomy through a right minithoracotomy. Our early results suggest that this technique yields clinical and echocardiographic outcomes similar to those obtained with standard sternotomy.

Experience with the superior approach (Tucker’s repair) for repair of supracardiac total anomalous pulmonary venous connection (TAPVC)

There are different surgical techniques employed in re-routing of supracardiac total anomalous pulmonary venous connection (TAPVC) with varying degrees of outcome. This study was designed to analyse the clinical data of patients who underwent Tucker’s repair and to demonstrate potential advantages of this technique. The clinical records of patients who underwent Tucker’s repair from September 2012 to November 2014 were reviewed retrospectively. The Tucker’s Repair involves anastomosis between the roof of the left atrial appendage and the common pulmonary venous chamber on cardiopulmonary bypass without cardiac displacement. Out of 54 patients who presented with TAPVC, 34 (63.0 %) had supracardiac type, 8 (14.8 %) cardiac type, 3 (5.6 %) infracacardic type, and 9 (13.4 %) mixed type. Out of these, 40 underwent Tucker’s repair. There were 24 males and 16 females. The patients aged from 2 days to 23 months (modal age group 0–3 months). The median weight was 3.7 kg (range 2.3–9.0 kg). The median aortic cross-clamp time (AXC) and cardiopulmonary bypass time (CPB) were 49 min (range 27–86 min) and 91 min (range 57–146 min), respectively. The median duration of intensive care unit (ICU) stay was 7 days (range 1–30 days). The immediate postoperative complications were refractory ventricular fibrillation (1), anastomotic site haemorrhage (1) and left diaphragmatic palsy (2). Other complications were chylothorax (1) and pulmonary venous obstruction at the anastomotic site (1). There were 3 deaths (7.5 %) resulting from pulmonary hypertensive crisis and sepsis. At a median follow up of 8 months (range 5–12 months), we did not find arrhythmias or pulmonary venous obstruction in any patient. Our results have demonstrated that Tucker’s repair has a low morbidity and mortality. We therefore recommend this as an alternative for the repair of some variants of TAPVC.

Surgical treatment for severe pulmonary valve stenosis

Objective To evaluate the effectiveness of urgent surgical procedures for severe pulmonary valve stenosis in infants and children. Methods Seventy-four (51 male, 23 female) children with severe pulmonary valve stenosis who received surgical correction were collected from Oct.2006 to Jan.2013.The age of patients ranged from 2 months to 13 years(median age was 26 months), and the body weight was 5-47 kg (median weight was 16 kg). Patients had other cardiac deformities, and among them 20 patients were associated with the patent ductus arteriosus(PDA), 22 cases with patent foramen ovale (PFO), 32 cases with atrial septal defect (ASD), 13 cases with ventricular septal defect (VSD), and 4 cases with double-chambered right ventricle.Radical corrections were performed in all patients under hypothermic general anaesthesia with cardiopulmonary bypass.There were 46 patients undergoing transannular patching with autologous pericardial flake and 28 patients undergoing transarterial pulmonary valvotomy. Results Urgent operations were performed in all patients and no death occurred during surgery.Median bypass time was 72 minutes(ranging from 40 to 100 minutes) and median aortic cross-clamp time was 43 minutes(ranging from 13 to 79 minutes). The time for the use of respirator was 4-128 h (median time was 15 h), and ICU stay lasted 4-18 days(median time was 5 days). Perioperative complications: included 1 case of ventricular fibrillation during operation, after electrical shock the patient returned to normal; postoperative complications included low cardiac output syndrome(4 cases), refractory hypoxemia(8 cases), acute renal failure(1 case), pneumothorax(2 cases), hydrothorax(2 cases), atelectasis(1 case). All patients received chest radiography, electrocardiogram and echocardiography during hospital stay.As a result, postoperative cardiac function was improved significantly. Conclusions Low cardiac output syndrome and hypoxemia aften exist in severe pulmonary stenosis.If severe pulmonary stenosis is diagnosed and operated early, the prognosis is good.The key to this kind of surgery is the application of autologous pericardium or disc pericardium patching for widening pulmonary artery appropriately, which fully rescind the right ventricular outflow tract obstruction.At the same time, the level of postoperative monitoring should be improved, and postoperative complications must be handled timely. Key words: Severe pulmonary valve stenosis; Cardiac surgical treatment; Congenital heart disease

Atrial Myxomas: A Single Unit's Experience in the Modern Era

Although an atrial myxoma is the commonest cardiac tumor, it is still relatively rare, with an annual incidence of approximately 0.5 per million. In our unit, which performs 1000 major cardiac procedures per year, this equates to approximately 3 patients annually. We therefore sought to evaluate our experience of managing this type of tumor over the last 5 years.A retrospective review was performed of prospectively collected data from the departmental database. We analyzed consecutive patients who were operated upon between 2002 and 2007. Three patients with a papillary fibroelastoma on histological examination were excluded from this study.We have performed excision of atrial myxoma in 18 patients. Twelve patients (66%) were female; the median age was 64 years (range, 35-80 years), and the median logistic euroSCORE was 5.22% (range, 1.51-27.82%). Fifteen patients (83%) were deemed urgent, 2 elective, and 1 emergency. Sixteen tumors (89%) were left sided. Symptoms attributable to the tumor were found in 16 of the 18 patients (embolic, n = 9; chest pain, n = 3; palpitations, n = 2; incidental finding, n = 2, others n = 4), and the mean time from diagnosis to operation was 3 days (range, 0-22 months). The median cardiopulmonary bypass time was 87 minutes (range, 28-228 minutes), with the median aortic cross clamp time being 61 minutes (16-175 minutes).The approaches used were transeptal via right atriotomy (n = 8), biatrial/Dubost (n = 4), left atrial (n = 4), and right atrial (n = 2); the interatrial septum was involved in 14 patients. The resultant defect was closed using a pericardial (n = 8) or prosthetic patch (n = 5) or directly sutured (n = 5). Concomitant procedures were performed in 8 patients (coronary artery bypass graft [CABG], n = 4; mitral valve replacement [MVR], n = 2; valve + grafts, n = 2). All tumors were completely excised.Postoperatively there were no deaths within 30 days of the procedure. Indeed, only 2 patients have died at 4 and 25 months postoperatively, respectively, both of unrelated causes. Median intensive therapy unit (ITU) stay was 2 days (range, 1-9 days), and median hospital stay was 10 days (range, 5-20 days). A permanent pacemaker was required in only 1 patient, and median blood loss was 340 mL (range, 140-1760 mL). Atrial fibrillation was the commonest complication affecting 6/18 patients (33%).Excision of atrial myxoma can be performed using a variety of intraoperative approaches and closure techniques, all with acceptable postoperative morbidity and low mortality rates. To date, no recurrences have been found at median 2-year follow-up.

Ministernotomy for repair of congenital cardiac disease☆

We report our experience with repair of a variety of congenital heart defects utilizing a ministernotomy incision. A ministernotomy was used in 79 patients with a variety of congenital heart diseases from November 2004 to August 2007. Patients included 36 males and 43 females with ages ranging from 1 month to 122 months (median age, 22 months). The weight ranged from 3.5 kg to 40 kg (median weight, 10.9 kg). There were no deaths, and one conversion to full median sternotomy (1/79, 1.3%). The median cardiopulmonary bypass time was 59 min, and median aortic cross-clamp time was 38 min. One patient underwent atrial septal defect (ASD) repair with fibrillatory arrest time of 35 min. The operating time ranged from 103 min to 312 min (median operating time, 168 min). The intensive care unit (ICU) stay ranged from 1 to 21 days (median ICU stay, 1 day) and the hospital stay ranged from 2 to 56 days (median hospital stay, 4 days). There were no reinterventions for residual cardiac defects. We demonstrate the safety and efficacy of ministernotomy for the correction of a range of congenital heart defects with improved cosmetic results.

Comparison of Spinal Cord Protection Utilizing Left Atrial‐Femoral with Femoral‐Femoral Bypass in Patients with Traumatic Rupture of the Aortic Isthmus

Postoperative paraplegia remains a dreaded complication of repair of traumatic rupture of the aortic isthmus. Claims have been made that left atrial-femoral bypass provides better spinal cord protection. To test the hypothesis that left atrial-femoral bypass is better than femoral vein-to-femoral artery bypass in regard to postoperative paraplegia, we concurrently compared the two techniques. We compared the occurrence of paraplegia in 18 patients whose ruptures were repaired utilizing left atrial-femoral bypass with 10,000 units of systemic heparin (group A) and 72 patients with femoral-femoral bypass with heparin 300 units/kg and an oxygenator (group B) operated on between January 1995 and July 2004. The mortality rate was 5.6% (5/90), with no statistical difference between the two groups. Postoperative paraplegia was present in three (16.7%) group A patients and five group B (6.9%) patients. However, the specific etiology of the neurologic defect was not clear, as one patient's paraplegia was transient following a period of cardiac arrest, and four others had had neurologic injuries prior to the aortic repair. Median aortic cross-clamp times were shorter in group A (34 minutes vs. 49 minutes). No patient required reexploration for bleeding, and no patient developed a graft infection. Paraplegia rates were higher in the left atrial-femoral group, but the difference was not statistically significant. This occurred despite the decreased cross-clamp times in this group. In patients undergoing repair of traumatic rupture of the aortic isthmus, left atrial-femoral bypass does not provide better spinal cord protection than femoral-femoral bypass.

Totally laparoscopic aortobifemoral bypass: A review of 22 cases

Laparoscopic aortobifemoral bypass (LABF) has been performed for diffuse aortoiliac occlusive disease in a few large centers. We hypothesize that in selected patients LABF can be performed safely and is a viable, minimally invasive approach to aortoiliac occlusive disease. We conducted a retrospective review of all individuals undergoing LABF over a 2.5-year period in a community-based vascular surgery practice. From January 2002 to August 2004, LABF was performed successfully in 20 of 22 patients. The age of the patients ranged from 49 to 75 years, with 11 male and 11 female subjects. LABF required a median duration of 267 minutes (range, 199 to 365 minutes) to complete. Median aortic cross-clamp time was 89.5 minutes (range, 64 to 14 minutes) with an aortic anastomotic time of 37 minutes (range, 30 to 56 minutes). Blood loss averaged 0.69 +/- 0.081 L. Median intensive care stay was 1 day, and hospital stay was 4 days. The median duration of postoperative intravenous narcotics via patient-controlled analgesia pump was 2 days. No patients received epidural analgesia. Nearly all patients began a liquid diet 1 day and a solid diet 4 days after surgery. Complications occurred early in our experience and included one death secondary to mesenteric infarction possibly caused by excessive visceral traction. There was one pelvic abscess, one ureteral injury, and two limb occlusions necessitating thrombectomy and revision. The last six patients had uneventful operative procedures and recoveries. Of the two LABF failures, one patient required open conversion because of inadequate aortic exposure and the other required a short upper midline incision to complete the aortic anastomosis. Compared with conventional open aortobifemoral bypasses performed concomitantly during this period, selected LABF patients required fewer narcotics, experienced less bowel dysfunction, and were discharged home sooner. Aortobifemoral bypass can be performed through a minimally invasive laparoscopic approach. Although technically demanding with a steep learning curve, experience should reduce the significant complication rate. Compared with a conventional open aortobifemoral bypass, advantages include less pain, minimal postoperative bowel dysfunction, and a shorter hospital stay.

Total Laparoscopic Aortobifemoral Bypass

Aim To assess the feasibility of aortobifemoral bypass by a laparoscopic approach. Material and methods During November 2002 through July 2003 a total of 21 patients with aorto-iliac occlusive disease underwent total laparoscopic aortobifemoral bypass surgery. Results The median operative time was 240 (range 150–420) min with a median aortic cross-clamp time of 60 (30–120) min. Operating time was reduced with experience. The median blood loss was 500 (100–2500) ml. One conversion to open surgery for acute dilation of the small bowel was necessary. Post-operative complications occurred in five patients (coagulation problems, disseminated intravascular coagulation secondary to thrombosis of the left limb, cerebro-vascular accident, dyspnoea, lymph leak) and there was no peri-operative death. Median hospital stay was 7 (5–30) days. Conclusion Aorto-bifemoral bypass using a total laparoscopic approach can be performed safely. As all new techniques, a learning curve is observed. This new technique should be evaluated in a larger randomised trial to assess its clinical value in comparison to conventional surgery.

Hand-assisted laparoscopic aorto-aortic bypass: initial experience in a porcine model.

Videoscopic surgical techniques have been developed to reduce morbidity of open aortic reconstructions. The advantage of hand-assisted laparoscopic surgery (HALS) technique is the introduction of the surgeon's hand into the peritoneal cavity. The aims of this study were to assess the feasibility and to examine the learning curve, limitations, and pitfalls of the HALS technique to perform aortic reconstruction in a porcine model for training purposes. HALS aorto-aortic 8 mm polytetrafluoroethylene (PTFE) interposition grafts were placed in 12 pigs. Proficiency was judged by measuring operative time points, satisfactory completion of the operation, and the need to convert to open procedure. The strength of the relationship between order number in which a procedure was performed and the various surgical time point measures was described with the Spearman rank correlation. HALS aortic grafting was successful in the last 8 pigs. The first 2 pigs required conversion to open repair, and the graft of the third and fourth animals occluded early. Median operative time was 115 minutes (range: 75 to 205), median intestinal retraction time was 28 minutes (range: 10 to 40), median aortoiliac dissection time was 30 minutes (range: 20 to 60), and median aortic cross-clamp time was 48 minutes (range: 35 to 82). The Spearman rank correlations and p values between the order of the procedure and the intestinal retraction time, aortoiliac dissection time, clamping time, and total operative time were -0.62 (0.06), -0.47 (0.17), -0.69 (0.03), and -0.83 (0.03), respectively. HALS facilitates intestinal retraction and completion of laparoscopic aortoiliac dissection. It offers adequate exposure in pigs for aortic grafting and allows open sutured aortic anastomosis. The learning curve for HALS aortic surgery in a porcine model is short and within reach of surgeons with standard laparoscopic surgery skills, since no laparoscopic suturing is required. Training on this porcine model may be an efficient and safe way to introduce surgeons to HALS for aortoiliac reconstruction.