Midline Sternotomy Research Articles

Cyclosporine A-enhanced cardioplegia preserves mitochondrial basal respiration after ischemic arrest.

Mitochondrial permeability transition pore (mPTP) opening plays a crucial role in cell death during ischemia-reperfusion injury (IRI). Cyclosporine A (CsA) inhibits mPTP opening. This study aimed to investigate the effects of CsA treatment during cardioplegia on the mitochondrial function and cardiac IRI. Landrace pigs (52.9 ± 3.7 kg) were subjected to midline sternotomy, cardiopulmonary bypass at 34°C and 90 minutes of cardiac arrest. They received either a single shot of standard 4°C cold histidine-tryptophan-α-ketoglutarate (HTK)-Bretschneider solution (n = 11) or HTK-Bretschneider plus 1.2 mg/L CsA (histidine-tryptophan-α-ketoglutarate plus cyclosporine A (HTK/CsA); n = 11). During reperfusion global left-ventricular function was assessed and myocardial biopsies were harvested at baseline, during ischemia and 45 minutes following reperfusion. High-resolution respirometry and hydrogen peroxide production were measured. Immunohistochemical stainings for apoptosis-inducing factor and hypoxia-inducible factor-1α as well as a flow cytometry-based JC-1 mitochondrial membrane potential assay were performed. Hemodynamic parameters were comparable between both groups. The cytochrome C release (HTK: 930.3 ± 804.4 pg/mg, HTK/CsA: 699.7 ± 394.0 pg/mg, p = 0.457) as well as PGC1α content (HTK: 66.7%, HTK/CsA: 33.3%, p = 0.284) was lower in the HTK/CsA group. Respiratory measurements revealed that the oxygen flux under basal respiration was higher in the HTK/CsA group (8.2 ± 1.3 pmol·O2·s-1·mg-1·ww) than in the HTK group (3.8 ± 1.4 pmol·O2·s-1·mg-1·ww, p = 0.045). There were no significant differences regarding histological surrogates of apoptosis and necrosis. Supplementing cardioplegic solutions with CsA enhances the basal mitochondrial respiration thereby exerting a cardioprotective effect and diminishing IRI-induced damage. CsA seems to preserve mitochondrial function via non-ROS related pathways.

Mycotic aneurysms of pulmonary artery secondary to pulmonary valve endocarditis in a child

We present the case of a 7-year-old child with mycotic aneurysms of bilateral lower lobe pulmonary arteries secondary to pulmonary valve endocarditis. The child underwent pulmonary vegetectomy with ventricular septal defect closure and left lower lobe pulmonary lobectomy via midline sternotomy.

Bypassing the Ordinary: A Patient's Unique Journey to Reach His Destination

<h3>Introduction</h3> Advanced heart failure therapies include an armamentarium of mechanical circulatory support (MCS). We present a case for which an array of mechanical support systems were utilized to save a patient. <h3>Case Report</h3> A 71-year old male with HTN, HLD, and smoking history presented with expressive aphasia due to an embolic CVA. Initial workup revealed an ejection fraction <20% with severe global hypokinesis on TEE, and an occluded distal left main and multi-vessel disease by left heart catheterization. Patient underwent a noncomplicated quadruple bypass surgery. Post-operative day #3, he suffered a ventricular fibrillation cardiac arrest and was promptly taken to the OR for emergency IABP insertion followed by central cannulation for VA-ECMO. Post-operative day #4, his pressor requirements increased and a TEE revealed an EF of 5% despite IABP and VA-ECMO support. He was taken back again to the OR for axillary Impella 5.0 implantation and decannulation of VA-ECMO. Over the next couple weeks, he was weaned from pressors, but developed fevers of unknown origin. A CT head revealed a new frontal lobe hematoma in addition to a subacute CVA. He remained neurologically intact, though unable to wean from ventilation. A tracheostomy and PEG tube were inserted. The patient was highly functioning prior to his presentation and wanted everything done including LVAD implantation. A midline sternotomy approach was not suitable due to recent CABG and emergent central cannulation of ECMO; therefore, he underwent Heartmate 3 LVAD implantation via left thoracotomy approach with descending aorta outflow graft cannulation (see Figure 1) as destination therapy. He was discharged to acute rehab post-operative day# 55 and is now home, with tracheostomy and PEG discontinued, and able to walk with limited assistance. <h3>Summary</h3> In cases necessitating various MCS modalities, a left thoracotomy approach with descending aorta outflow graft cannulation for LVAD may be a viable alternative to midline sternotomy.

High Oxygen is Likely to be Beneficial on Cardiac Contractility after Normothermic Regional Perfusion after Circulatory Death in a Porcine Model

<h3>Purpose</h3> The impact of high versus low oxygenation during normothermic regional perfusion (NRP) after anoxic circulatory death on donor heart contractility in a porcine model. <h3>Methods</h3> The animals were anaesthetized, pressure-volume catheters were placed in both ventricles and a pulmonary artery catheter was inserted percutaneously. Through a midline sternotomy, the heparinized animals were cannulated for extracorporeal circulation. Baseline data were obtained. Mechanical ventilation was withdrawn. After 15 minutes of warm ischemia, the aortic arch vessels and infrarenal aorta were clamped before NRP was commenced using a standard heart-lung machine. The animals were randomized to receive either FiO2 of 1.0 (HOX) or 0.21 (LOX) with a gradual increase to 0.40 during NRP. The NRP protocol includes early volume loading of the right ventricle and gradual wean over 35 minutes. Dobutamine and norepinephrine infusions were started during NRP for circulatory support. The animals were observed for 180 minutes after weaning from NRP. <h3>Results</h3> 15 of 19 animals were successfully weaned from NRP; 8/9 in the HOX and 7/10 in the LOX group, (p = 0.58). All weaned animals displayed acceptable cardiac function during the observation period and sustained a mean arterial pressure >60 mmHg with low filling pressures and cardiac index >2.5 L/min/m². The preload independent end-systolic pressure volume relationship as an index of contractility was preserved in both groups. The HOX RV contractility was higher than the LOX group (p=0.035); and not significantly in the LV (p=0.37) (Fig. 1). Biochemestry showed lower lactate levels in the HOX group. There was no difference in norepinephrine requirement between groups. <h3>Conclusion</h3> There were minimal haemodynamic and biochemical differences between the groups as all weaned animals demonstrated acceptable cardiac function. The high oxygenation group showed marginally better cardiac performance and lower lactate concentrations.

Improvement of Left but Not Right Ventricular Contractility after Circulatory Death and Normothermic Regional Perfusion in a Porcine Model

<h3>Purpose</h3> To investigate the impact of cerebral reperfusion on cardiac contractile function after normothermic regional perfusion (NRP) after anoxic circulatory death in a porcine model. <h3>Methods</h3> The animals were anaesthetized and biventricular pressure-volume catheters and a pulmonary artery catheter were inserted percutaneously. Through a midline sternotomy, the heparinised animals were cannulated for extracorporeal circulation. Baseline data were obtained before cessation of mechanical ventilation. Death was determined 5 minutes after mechanical asystole and after additional 3 minutes of warm ischemia NRP was started using a heart-lung machine. The animals were randomized before reperfusion to either clamping (CL) (n=8) or non-clamping (NCL) (n=8) of the aortic arch vessels; the infrarenal aorta was clamped in both groups. The NRP-protocol includes early volume loading of the right ventricle, infusion of dobutamine and norepinephrine and gradual wean over 30 minutes. The animals were observed for 180 minutes after weaning from NRP. <h3>Results</h3> All animals were successfully weaned from NRP. Both groups demonstrated an acceptable cardiac function after weaning with a mean arterial blood pressure above 75 mmHg and low filling pressures. The NCL group received significantly more norepinephrine (p=0.0484) than the CL group. The left ventricle End-systolic pressure-volume relationship as an index of contractility showed improvement in both groups after wean from NRP compared to baseline (p=0.0009). In the CL group, LV contractility showed a tendency to a better improvement compared to the NCL group (p=0.226) (Fig. 1). The RV showed preserved contractility in both groups. <h3>Conclusion</h3> LV contractility but not RV contractility improves after circulatory death and weaning from NRP. The improvement of the left ventricular contractility tends to be better when the aortic arch vessels are clamped compared to upper-body perfusion.

Staged repair of truncus arteriosus with double aortic arch, tracheoesophageal fistula, and choanal atresia via a multi-disciplinary approach: a case report

The previously unreported case of a child with an exceedingly rare amalgamation of complex defects, including truncus arteriosus (TA), double aortic arch (DAA), tracheoesophageal fistula, and choanal atresia is presented. First, on day-of-life (DOL) 2, with a joint effort involving Pediatric Cardiac Surgery, General Surgery, and Otolaryngology, division of tracheoesophageal fistula and repair of esophageal atresia, along with choanal atresia repair, was carried out. Via a right thoracotomy, the tracheoesophageal fistula, located medial to the azygous vein, was skeletonized and ligated. The proximal esophagus was then mobilized up to the thoracic inlet as it coursed through the vascular ring. This enabled esophageal anastomosis with preservation of both aortas. Next, on DOL 11, the child underwent TA repair. Following a standard midline sternotomy and cooling to moderate hypothermia, the left aortic arch was divided and oversewn. The aorta was then transected anteriorly, and the main pulmonary artery (MPA) exiting the posterior aorta was harvested as a single button. The aortic defect from the pulmonary artery button was repaired with autologous pericardium. Next, through a right ventriculotomy, the previously seen conoventricular septal defect was identified and closed. Finally, a 10-mm pulmonary homograft was anastomosed to the pulmonary artery bifurcation to complete the repair. The patient was discharged on DOL 78 and was noted to be doing well at 1-year follow-up. This case validates the feasibility of fistula repair complicated by DAA through a right thoracotomy, the durability of staged, complete repair of TA and DAA, and the advantages of a holistic, team-based approach that optimizes timing of all repairs based upon a careful consideration of the exponential, rather than additive, effects of multi-organ disease on post-cardiac surgery outcomes in neonates.

RARE AND DEMANDING: PARATHYROID ADENOMA LOCALIZATION, SURGERY AND OUTCOME.

Objectives: To assess the methods of preoperative parathyroid adenoma localization and to compare it with operative findings. Patients and methods: Between June 2017 and June 2019, we had operated 8 cases of parathyroid adenomas. Three patients were males and 5 patients were females. Age ranged from 26 year old to 72 year old with average of 42 year old. Seven cases were sporadic while one case was part of MEN2a. All patients had ultrasonography for preoperative localization, all had CT scan and 4 patients had Sestamibi scan. In all patients, intraoperative measurements of parathyroid hormone was done before and 10 minutes after surgical excision. Results: Ultrasonography was successful in localizing only one case with certainty. CT scan located the adenoma in another 2 patients. In 4 patients who performed Sestamibi scan, the adenomas were located precisely in all of them including one case of ectopic parathyroid adenoma behind the sternum. In one patient, all the modalities failed in localization which was achieved easily intraoperatively. Single adenoma was found in 6 patients and two adenomas in two patients. The adenomas were located in the neck in 7 patients and in the anterior mediastinum in one patient .Surgical removal was done through neck incision in 7 cases while midline sternotomy in one case. All the patients had resolution of symptoms within the follow up period. Conclusion: Sestamibi scan is the best investigation in preoperative localization of parathyroid adenoma. Ultrasonography and CT scan can aid in the diagnosis with less sensitivity. Intraoperative localization is possible even in cases of negative investigations.

Tracheoinnominate fistula due to high-riding innominate artery: A rare but potentially life-threatening complication following long-term tracheostomy

Tracheoinnominate fistula (TIF) is a rare but potentially life-threatening complication after tracheostomy. TIF was mostly observed within 7–21 days after tracheostomy but can present even years after tracheostomy. The risk factors for TIF are high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, excessive neck movement (hyperextension), radiotherapy, prolonged intubation, and high-riding innominate artery (HRIA). HRIA is also a rare anatomical variation of the innominate artery (IA) whereas IA bifurcates above the sternoclavicular joint. We report a rare case of TIF in a patient with HRIA, who presented with airway bleeding 2 months after percutaneous tracheostomy (PT) and was successfully managed with aggressive resuscitation and midline sternotomy. Knowledge of anatomical variation of the aortic arch and its major branches is essential for the physician who is routinely performing or managing tracheostomy. All the health-care workers involved in the management of tracheostomy should bear this complication in mind while dealing with any airway bleed. We recommend the routine use of bedside neck ultrasonography before all PTs to locate any aberrant vessel within the vicinity of tracheostoma to prevent this complication.

WOUND INFECTIONS AFTER TOTAL MEDIAN STERNOTOMY – RISK FACTORS, MICROBIOLOGICAL ANALYSIS, PROPHYLAXIS AND TREATMENT METHODS

Introduction. Median sternotomy represents a standard surgical access in cardiac surgery, despite the growing popularity of minimally invasive access. Posternotomy infections are a serious complication and are directly related to patients' survival in the short and long term. Despite prevention, their expression is still significant - from 0.5% to 6.8%, and associated hospital mortality rates range from 7% to 35%. Aims. Analysis of frequency, risk factors, microbiological agents, prevention options and surgical techniques for deep wound infections after open heart surgery for a 17 - year period. Materials and methods. For the period from October 2002 to June 2019, 146 (1.42% of 10,307 operated) patients were treated at the Cardiac Surgery Clinic at the University Hospital “St. Georgi "diagnosed with deep sternal infection. The study is a retrospective using data from medical records and hospital records. The Center of Disease Control (CDC) criteria were used to define deep sternal infections. Results. The sex ratio is 2.04: 1 – men: women. The average age for both sexes is 65.4 years. The average stay of patients in the intensive care unit was 5 days (from 0 to 46 days), and the average total hospital stay was 15.6 days (from 5 to 55 days). Early postoperative mortality was 13,7%. The most common risk factors were diabetes mellitus, obesity and emergency surgery. Conclusion. Cardiac surgery with total midline sternotomy is associated with a risk of developing mediastinitis. Despite the advances in cardiac surgery and the use of mini-invasive techniques, the rate of development of deep wound infections remains relatively high.

Surgical Repair of a Transannular Rupture During Transfemoral Transcatheter Aortic Valve Replacement.

Annular rupture is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR). Mortality rates are high if immediate intervention, most often necessitating surgical repair, is not performed. Herein, we describe an 87-year-old man who, after deployment of TAVR, experienced acute decompensation and required urgent conversion to a midline sternotomy to repair an aortic annular rupture. This case demonstrates an example of a rare but severe complication of TAVR. This report provides an in-depth description of the surgical approach to repair an aortic annular rupture and demonstrates the utility of performing minimally invasive procedures inside a hybrid operating room.

Introduction of an Analgesia Prescription Guideline Can Reduce Unused Opioids After Cardiac Surgery: A Before and After Cohort Study

The authors aimed to assess whether the introduction of a tailored Analgesia Prescription Guideline would decrease the amount of unused opioid following discharge from cardiac surgery. Prospective, observational, before and after study. Quaternary care university hospital. A total of 191 participants who underwent cardiac surgery requiring midline sternotomy and cardiopulmonary bypass. There were 99 participants in the before cohort (prior to introduction of the Analgesia Prescription Guideline), and 92 participants in the after cohort (after introduction of the Analgesia Prescription Guideline). Using prospectively collected observational data on participant opioid consumption in the before cohort, a tailored Analgesia Prescription Guideline was developed. This guideline then was introduced to all opioid-prescribing providers in the cardiothoracic surgery department. Prospective data then were collected in the after cohort of participants. Opioid prescription practices and opioid consumption between the two groups then were compared. Opioid prescriptions were given to 62/99 participants (63%) in the before cohort, and 48/92 (52%) in the after cohort (rate difference 0.1, CI 95% -0.26, 0.046). In the before cohort, the mean (± standard deviation) number of opioid tablets prescribed, used, and leftover was 26 (±10), 11 (±10), and 15 (±12), respectively. In the after cohort, the mean number of opioid tablets prescribed, used, and leftover was 18 (mean difference -8, CI 95% -12, -5), 10 (mean difference -1, CI 95% -5, 3), and 8 (mean difference -7, CI 95% -11, -3), respectively. There were 110/191 (58%) participants using no opioids following discharge, and 10/191 (5%) still using opioids two weeks after discharge. There were no differences between groups with regard to demographics, opioid-related side effects, pain scores, satisfaction, opioid storage. and disposal practices. The development and implementation of a tailored Analgesia Prescription Guideline decreased the amount of opioids prescribed after cardiac surgery and resulted in lower numbers of unused leftover opioid tablets in the community. Patient comfort and satisfaction scores remained high.

The impact of incisional negative pressure wound therapy on the wound healing process after midline sternotomy.

Previous studies have reported that the use of incisional negative pressure wound therapy (INPWT) might reduce the incidence of wound infections, although its mechanism remains unknown. We designed a prospective study to explore the effects of INPWT on different stages of the wound healing process. After meeting the inclusion criteria, 108 patients were enrolled. Based on exclusion criteria four patients were excluded and 104 patients were randomised into two groups. INPWT was applied after primary closure of the midline sternotomy in the study group (n = 52), while conventional wound dressing was applied in the control group (n = 52). We documented the incidence of deep sternal wound infections and analysed the pre‐ and postoperative inflammatory biomarkers and scar size in both groups. No wound infections were observed in the study group compared with six cases (11.1%) in the control group, (P = .026). No significant differences were observed in the inflammatory biomarkers between the groups. Scar size was significantly smaller in the study group. We concluded that INPWT has less effect on the inflammatory phase and appears to have more effect on the proliferation phase through pronounced scar formation.

CARDIAC POSTEROLATERAL WALL PSEUDOANEURYSM RUPTURE PRESENTING IN THE AMBULATORY SETTING: A SURGICAL SUCCESS

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Myocardial wall rupture(MWR) describes a rare traumatic myocardial injury causing a distinct fissure in cardiac musculature [1]. MWR generally presents as a subacute mechanical complication of acute myocardial infarction(AMI), with 90% of cases presenting within two weeks of AMI [2]. Left anterior descending artery most frequently precipitates this complication, causing anterolateral MWR [3]. The presented case demonstrates successful surgical repair in a patient with outpatient pseudoaneurysm rupture and cardiogenic shock secondary to occult posterolateral infarction. CASE PRESENTATION: A 58-year old without previous cardiac history presented to the hospital after an outpatient syncopal episode with altered mental status, weakness, and back pain. The patient exhibited profound hypotension of 62/44mmHg with tachycardia, 140bpm. Physical examination showed a pale, lethargic male with venous congestion of the head, profound jugular venous distension, muffled heart sounds, impalpable pulses, and cool distal extremities. Integument showed diffuse skin mottling and progressive cephalic cyanosis. Initial troponin level was .09ng/nL. Electrocardiogram showed ST-elevations in leads I and aVl and t-wave inversion in V2-V3, concerning for posterolateral STEMI. A CT-angiography study was performed for concern of aortic dissection which revealed a ruptured 3.0cm left posterolateral pseudoaneurysm with contrast invasion into the pericardial space(Figure 1). Hemopericardium with cardiac tamponade was appreciated on echocardiogram. Given the findings of posterolateral MWR of the left ventricle, cardiogenic shock, and cardiac tamponade, the patient underwent emergent cardiac surgery via midline sternotomy and controlled release of the pericardial tamponade. Cardiac excision was performed to a depth of 3.5cm to remove the pseudoaneurysm and a sutured bovine patch repair resulted in hemostatic repair(Figure 2). Postoperative cardiac catheterization displayed complete proximal circumflex artery occlusion(Figure 3). The patient was stabilized and safely discharged on postoperative day 7 and without mortality at 1-month. DISCUSSION: MWR remains a rare entity occurring in approximately 1.7% of AMI cases [3]. While echocardiogram remains standard for initial identification of MWR, this case demonstrates the utility of CT-angiography to delineate rupture from mimicking pathologies like arterial dissection. MWR previously represented a universally fatal process, but increasing early surgical intervention has improved mortality risk even in the outpatient setting at the time of presentation. This case demonstrates a favorable outcome through a time-sensitive, surgical repair with pseudoaneurysm resection. CONCLUSIONS: While MWR still carries significant mortality risk, increasing rates of early surgical intervention have demonstrated reduced mortality risk and cardiac surgery should be considered when appropriate. Reference #1: Daya SK, Tan D, Tolerico PH, Gowda RM, Khan IA. Survival of an octogenarian after rupture of the left ventricular free wall caused by myocardial infarction. Texas Hear Inst J. 2004;31(2):178-180. http://www.ncbi.nlm.nih.gov/pubmed/15212133. Accessed April 7, 2020. Reference #2: Marchandot B, Crimizade U, El GS, Morel O. Giant ventricular pseudoaneurysm following inferior myocardial infarction: insights from multimodal imaging approach. Eur Heart J. 2018;2:1–3 Reference #3: Honda S, Asaumi Y, Yamane T, et al. Trends in the clinical and pathological characteristics of cardiac rupture in patients with acute myocardial infarction over 35 years. J Am Heart Assoc. 2014;3(5). doi:10.1161/JAHA.114.000984 DISCLOSURES: No relevant relationships by Edward Bergeron, source=Web Response No relevant relationships by Connor Kerndt, source=Web Response No relevant relationships by Abhay Kommana, source=Web Response No relevant relationships by Peter Morkos, source=Web Response

Bilateral ultrasound-guided thoracic erector spinae plane blocks using a programmed intermittent bolus improve opioid-sparing postoperative analgesia in pediatric patients after open cardiac surgery: a randomized, double-blind, placebo-controlled trial

BackgroundPostoperative pain after pediatric cardiac surgery is usually treated with intravenous opioids. Recently, the focus has been on postoperative regional analgesia with the introduction of ultrasound-guided erector spinae plane blocks...

Robotic coronary artery surgery: Outcomes and pitfalls.

Coronary artery bypass grafting is one of the most commonly performed surgical procedures in cardiovascular surgery with a steadily evolving minimally invasive approach. Conventional coronary artery bypass grafting (CABG) is performed traditionally via midline sternotomy. Exciting advancements in technology and engineering over the last two decades have resulted in the transition from conventional to minimally invasive CABG including robotically assisted surgery. The minimally invasive techniques are continuously striving to promote coronary revascularization into the arena of minimally invasive surgery. Examination of 10 previously completed studies with relevant follow-up periods enables an insightful vision into the outcomes and pitfalls surrounding robot-assisted CABG (RACAB) as explored in this review. Studies indicate that RACAB is associated with decreased postoperative complications such as major adverse cardiac or cerebrovascular events without compromise in survival rates. Despite this, certain drawbacks such as incurring costs and technical complexity of the procedure cannot be dismissed. There exist patient-related benefits from minimally invasive techniques such as decreased certain postoperative complications. Furthermore, with experience and a specialized stepwise program, it is possible to perform the entire procedure from the console. However, certain pitfalls involving increased expenses, steep learning curve and the lack of proper haptic feedback currently withhold the worldwide expansion of RACAB and limit it to specialized institutions only.

Minimally invasive surgical and transcatheter interventions for aortic valve incompetence: current concepts and future perspectives.

We are currently witnessing rapid evolution in minimally invasive surgical (MI-AVS) and transcatheter (TAVR) techniques and innovations for the treatment of aortic valve disease. Current TAVR technology approved for the treatment of aortic valve stenosis do not consistently perform favorably in non-calcified aortic valve regurgitation (AR). Surgical aortic valve repair (AVr) by conventional midline sternotomy is generally accepted as the contemporary "gold standard" intervention, while prosthetic aortic valve replacement and the well-known Ross procedure as a biological alternative to AVr, are reserved for patients who are at risk of early repair failure. AVr offers potential benefits over prosthetic replacement in younger patients with contraindications to long term anticoagulation and life-expectancies greater than the expected structural prosthetic valve degeneration. Even though excellent AVr outcomes are achieved in high-volume expert centers, it is generally regarded to be technically challenging, have significant learning curves and is subsequently infrequently performed by inexperienced surgeons. However, MI-AVS is now the routine approach for isolated aortic valve surgery in various cardiac centers and reports that describe minimally invasive AVr outcomes are progressively emerging. This article outlines the current role and future perspectives of contemporary AR repair techniques by MI-AVS and describes the ongoing evolution of exciting TAVR technology designed specifically for the treatment of non-calcified AR.

Case report: cardiac herniation following robotic-assisted thymectomy

BackgroundThe first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal surgical complication may occur following any operation in which a pericardial incision or resection is performed. The majority of literature on cardiac herniation involves case reports after intrapericardial pneumonectomy. Currently, there are no reports of cardiac herniation after thymectomy with pericardial resection.Case presentationA 44-year-old Asian female with symptomatic myasthenia gravis was referred for thymectomy. Originally thought to have Bell’s Palsy, her symptoms began with right eyelid drooping and facial weakness. Over time, she developed difficulty holding her head up, upper extremity weakness, difficulty chewing and dysarthria. These symptoms worsened with activity. She was found to have positive acetylcholine receptor binding antibody on her myasthenia gravis panel. A preoperative CT scan demonstrated a 3.5 cm × 2 cm anterior mediastinal mass along the right heart border and phrenic nerve. A complete thymectomy, via right-sided robotic-assisted approach was performed en bloc with a portion of the right phrenic nerve and a 4 cm × 4 cm portion of pericardium overlying the right atrium and superior right ventricle. Upon undocking of the robot and closure of the port sites, the patient became acutely hypotensive (lowest recorded blood pressure 43/31 mmHg). The camera was reinserted and demonstrated partial cardiac herniation through the anterior pericardial defect toward the right chest. An emergent midline sternotomy was performed and the heart was manually reduced. The patient’s hemodynamics stabilized. A vented Gore-Tex 6 cm × 6 cm patch was sewn along the pericardial edges with interrupted 4–0 prolene to close the pericardial defect.ConclusionThis potentially fatal complication, although rare, should always be considered whenever there is hemodynamic instability entry or resection of the pericardium during surgery. We now routinely sew in a pericardial patch using our robotic surgical system for any defect over 3 cm × 3 cm that extends from the mid- to inferior portions of the heart.

The Evolution of Mitral Valve Surgery: the Future in the Hand of Robots.

ObjectiveTo examine the current literature behind the evolution of mitral valve surgery techniques and their impact on patient outcomes.MethodsAn electronic literature search among major databases was performed (PubMed, Embase, Scopus, Cochrane, and Google scholar). All the relevant articles were screened and identified to be included in this narrative review. The main outcomes were postoperative morbidity, length of in-hospital stay, and long-term mortality.ResultsMinimally invasive and robot-assisted approach to mitral valve repair and replacements has shown great potential in improving surgical outcomes when compared against traditional midline sternotomy. Selected patients can benefit from percutaneous mitral valve surgery; however, more evidence is required to ascertain its long-term outcomes.ConclusionCurrent evidence suggests that robotic and minimal invasive mitral valve surgeries are increasing in practice with satisfactory perioperative and mortality rates. However, long-term data is yet to be published to support current practice.

Indications and Results of Repair of the Rhumatismal Valve in Children in Senegal concerning 63 Cases

In Africa, acute rheumatic fever is endemic. Cardiac involvement is one of the most common complications in the form of valvular heart disease representing all damages to the heart valves. It is in this perspective that we realized this study whose general objective was to evaluate the results of mitral repair surgery in children in Senegal and the specific objective was to state the indications for mitral repair surgery and assess the results in terms of morbidity and mortality. This is a retrospective and analytical monocentric study, in the thoracic and cardiovascular surgery department of FANN National University Hospital Center in Dakar. It took place over a period of 30 months. All the patients who underwent mitral surgery, aged less than 18 years were included. The total number of patients was 63, including 39 girls and 24 boys, a sex ratio of 0.62. The average age at the time of the surgery was 12 years old [5 - 17]. The functional symptomatology was dominated by the dyspnea found in all the patients. Cardiac ultrasound was diagnosed with mitral regurgitation in all patients. For all surgical procedures, the approach was a vertical midline sternotomy. The mitral valve was approached by left atriotomy in 40 patients (63.5%) and by transseptal way in 23 patients. All patients had undergone mitral valve repair associated or not with either aortic valve repair in 9 patients (14.2%), aortic valve replacement in 3 patients (4.8%), or one tricuspid valve repair in 31 patients (49%). The average duration of intubation was 6 hours [2 - 52]. The average length of stay in intensive care was 2 days. Postoperative complications have been observed. Surgery was performed in 10 patients with 3 mitral valve replacements, 2 aortic valve replacements, a double mitral and an aortic valve replacement associated with a tricuspid repair and in 4 cases a perfection of their mitral repair. Early and late surgical mortality was zero. The average follow-up time for our patients was 9 months [1 - 26]. During their follow-up, the evolution was favorable in 89% of patients who no longer had any functional symptoms.

Surgical delay of anterior chest wall prior to open coronary arterial bypass grafting surgery may decrease postoperative sternal complications

Open coronary arterial bypass grafting (CABG) procedures are inherently risky in regards to the healing capacity of the subsequent sternal wound. Patients often have underlying risk factors for poor healing and the procedure itself often reduces vascularity to the anterior chest with internal mammary artery (IMA) dissection. Currently unrelated is the surgical delay procedure. It is a well-established technique for augmenting vascularity and ultimatelytissue survival. It involves partial disruption of the blood supply to a flap for a period of time prior to fully elevating the flap (usually between 3 and 21 days). Recently, endoscopic robotic IMA dissection has become possible as a part of totally endoscopic CABGs for left-sided vessel disease. We are proposing a new technique, using surgical delay for patients who require open sternotomies for CABGS to reduce the rate of postoperative sternal wound complications. To delay the CABG, the majority of a robotic internal IMA dissectionwould be performed prior to an open CABG via a midline sternotomy. We hypothesize that this may decrease sternal wound complication rates. Potential pitfalls include consequences of disrupting the normal anatomic location of the IMAs and causing inflammation before the open CABG. Animal models will be the next step, as they will evaluate the feasibility of the delay as well as help to determine the optimal timing for the procedure.