Repeat Sternotomy Research Articles

Transcatheter closure of the Gerbode type ventricular septal defect after redo mitral valve replacement

Gerbode defect is an uncommon ventricular septal defect (VSD) resulting in a left ventricle to right atrium shunt. Although typically congenital, acquired defects have been reported following infective endocarditis, cardiac surgery, trauma, or acute myocardial infarction. This condition causes left-to-right intracardiac shunt and potential hemodynamic instability. This complex anatomy poses therapeutic challenges, and optimal management is often unclear. We present a case of acquired Gerbode defect following a redo mitral valve replacement surgery in a 71-year-old man who developed severe dyspnea and pulmonary hypertension. Treatment was successfully performed with percutaneous transcatheter VSD closure using an Amplatzer device. This case highlights the importance of considering Gerbode defects in postoperative patients and demonstrates the efficacy of transcatheter closure in reducing symptoms and avoiding high-risk redo cardiac surgery. Transcatheter repair offers shorter recovery times, reduces pain, and avoids repeat sternotomy, making it a valuable and minimally invasive alternative for patients with acquired Gerbode defects. Keywords: Gerbode defect, left ventricle to right atrium shunt, redo mitral valve replacement, transcatheter closure

Angiographic evidence of an inadvertent cannulation of the marginal sinus following central line migration: illustrative case.

Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration. A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well. Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.

Towards Zero Phrenic Nerve Injury in Reoperative Pediatric Cardiac Surgery: The Value of Intraoperative Phrenic Nerve Stimulation.

Phrenic nerve injury is a devastating complication that results in significant morbidity and mortality. We developed a novel technique to localize the phrenic nerve and evaluate its success. Two groups of children underwent repeat sternotomy for a variety of indications. Group I (69 patients, nerve stimulator) and Group II (78 patients, no nerve stimulator). There was no significant difference in the mean age and weight between the two groups: (6.4 ± 6.5 years vs. 5.6 ± 6.4 years; p = 0.65) and (25.2 ± 24.1 vs. 22.6 ± 22.1; p = 0.69), respectively. The two groups were comparable in the following procedures: pulmonary conduit replacement, bidirectional cavopulmonary anastomosis, aortic arch repair, and Fontan, while Group I had more pulmonary arterial branch reconstruction (p = 0.009) and Group II had more heart transplant patients (p = 0.001). There was no phrenic nerve injury in Group I, while there were 13 patients who suffered phrenic nerve injury in Group II (p < 0.001). No early mortality in Group I, while five patients died prior to discharge in Group II. Eleven patients underwent diaphragm plication in Group II (p = 0.001). The mean number of hours on the ventilator was significantly higher in Group II (137.3 ± 324.9) compared to Group I (17 ± 66.9), p < 0.001. Group II had a significantly longer length of ICU and hospital stays compared to Group I (p = 0.007 and p = 0.006 respectively). Phrenic nerve injury in children continues to be associated with significant morbidities and increased length of stay. The use of intraoperative phrenic nerve stimulator can be an effective way to localize the phrenic nerve and avoid its injury.

Risk factors and early outcomes of repeat sternotomy in 1960 adults with congenital heart disease: A 30-year, single-center study

ObjectivePatients with congenital heart disease (CHD) increasingly live into adulthood, often requiring cardiac reoperation. We aimed to assess the outcomes of adults with CHD (ACHD) undergoing repeat sternotomy at our institution. MethodsReview of our institution's cardiac surgery database identified 1960 ACHD patients undergoing repeat median sternotomy from 1993 to 2023. The primary outcome was early mortality, and the secondary outcome was a composite end point of mortality and significant morbidity. Univariable and multivariable logistic regression models were used to determine factors independently associated with outcomes. ResultsOf the 1960 ACHDs patient undergoing repeat sternotomy, 1183 (60.3%) underwent a second, third (n = 506, 25.8%), fourth (n = 168, 8.5%), fifth (n = 70, 3.5%), and sixth sternotomy or greater (n = 33, 1.6%). CHD diagnoses were minor complexity (n = 145, 7.4%), moderate complexity (n = 1380, 70.4%), and major complexity (n = 435, 22.1%). Distribution of procedures included valve (n = 549, 28%), congenital (n = 625, 32%), aortic (n = 104, 5.3%), and major procedural combinations (n = 682, 34.7%). Overall early mortality was 3.1%. Factors independently associated with early mortality were older age at surgery, CHD of major complexity, preoperative renal failure, preoperative ejection fraction, urgent operation, and postoperative blood transfusion. In addition, sternotomy number and bypass time were independently associated with the composite outcome. ConclusionsDespite the increase in early mortality with sternotomy number, sternotomy number was not independently associated with early mortality but with increased morbidity. Improvement strategies should target factors leading to urgent operations, early referral, along with operative efficiency including bypass time and blood conservation.

Transcatheter aortic valve replacement 23 years after heart transplant for aortic insufficiency

BackgroundClinicians continue to expand the availability of transcatheter aortic valve replacement (TAVR) for patients who historically would have been ineligible for surgical aortic valve replacement. Historically, reoperative aortic valve surgery after transplant was immensely complicated and high risk due to the repeat sternotomy approach, and the immunosuppression in transplant patients. As heart transplant patients continue to live longer, patients are beginning to develop novo aortic pathology of the transplanted organ. In these patients, TAVR may be a valuable rescue therapy for those with de-novo aortic valve disease.Case presentationHere, we present a single case of a 70-year-old man with a history of heart transplant 23 years prior complicated by severe sternal infection and subsequent removal of his sternum. Additionally, this patient had a recent history of kidney transplant due to renal cell carcinoma necessitating nephrectomy. He subsequently developed progressive symptomatic aortic insufficiency and underwent a successful TAVR to treat his new aortic disease.ConclusionsTo our knowledge, this represents only the second case report of TAVR for severe aortic insufficiency and one of the first reports of TAVR in a multiple organ recipient. TAVR may represent an important rescue therapy for post-transplant valve pathologies instead of high-risk reoperative surgical aortic valve replacement.

POSSIBLE CORONARY SYNDROME IN A CHILD WITH AORTIC ENDOCARDITIS DURING CARDIAC SURGERY.

Infective endocarditis (IE) in children it is serious condition and has a hospital mortality rate 10-20 % with medical treatment. Although, surgical management is the last chance for severely ill patients and has been associated with a mortality rate of 50 %. This is a case report of a child 10 years old with aortic IE who developed coronary syndrome intraoperatively. A 10-year-old boy with history of aortic valve repair 6 years ago was recently diagnosed with aortic endocarditis. He was transferred to the cardiac center for treatment. Clinically, he was unwell, pale and complaining of chest pain days before the surgery. He was admitted with electrocardiography changes, ST depression DI-II, V5 and V6.Echocardiogram revealed a mobile mass on the aortic valve which prolapsed into the left ventricle during diastole causing severe aortic regurgitation. Heparin anti-coagulation was instituted upon arrival. He received meropenem and teicoplanin for 5 days and was transfused before surgery. He underwent urgent aortic replacement due to the mobile mass on the aortic valve, unresolved EKG changes and increasing heart failure. Intraoperatively during repeat sternotomy and lysis of adhesions he developed worsening coronary syndrome (increase of previous ST depression DI-II and more III). Hypotension and bradycardia developed which did not responded to atropine. Pulseless electrical activity ensued, and open cardiac massage and paediatric advance life support was performed for 25 minutes before establishing cardiopulmonary by-pass (CPB). During CPB he developed increasing of metabolic acidosis, lactate and decreased of urine output less than 0.9 ml/kg/h. Aortic valve replacement with 19 mm mechanical valve was done during hypothermia 28 degrees. Following release of the cross-clamp no electrical activity occurred and was connected to the pacemaker VVI for 3 hours and worsening of lactic acidosis (lactate 17),urine output decreasing and creatinine increasing. Disconnection from CPB was done and the patient died. Surgery was performed in a resource restricted low- and middle-income country Figure 1.Mid esophageal AV Long Axis View (ME AV LAX) 110 degrees: significant size mass attached to right size of aortic valve, moving, creating severe insufficiency. Figure 2.Deep Transgastric Long Axis view (Deep TG LAX) 120 degrees, showed opening of aortic valve, thickened and dysplastic. Significant jet from aortic regurgitation with significant size vegetation and showed LV severe dilated with moderate to severe impairment.

Expanding perigraft seroma after ascending aorta replacement

BackgroundPerigraft seroma is a persistent and sterile fluid confined within a fibrous pseudomembrane surrounding a graft that develops after graft replacement. Development of perigraft seroma is an uncommon complication that occurs after the surgical repair of the thoracic aorta using woven polyester grafts. mechanism underlying perigraft seroma formation remains unclear.Case presentationHerein, we describe the case of 77-year-old man who underwent repeat sternotomy for the treatment of large perigraft seroma 1 year after ascending aorta replacement for acute type A dissection. After removing a cloudy yellow fluid, we covered the prosthetic graft with fibrin glue and wrapped it with a new graft. Bacterial culture and laboratory examination of the fluid confirmed the final diagnosis of perigraft seroma, and there was no evidence of recurrence. The area in which fluid accumulated around the graft shrunk 1 year after surgery.ConclusionsThe cause of a expanding perigraft after repair of the thoracic aorta remains unknown. Physicians should be aware that chronic expanding mediastinal seroma with Dacron grafts is one of the rare postoperative complications of thoracic aortic surgery. Applying fibrin glue to the graft surface might effectively prevent the recurrence of perigraft seroma.

Early Concerning Outcomes for the Edwards Inspiris Resilia Bioprosthesis in the Pulmonary Position

BackgroundThe Inspiris Resilia (Edwards Lifesciences LLC) bioprosthesis has gained widespread use in the aortic position; however no robust data are available about its use in the pulmonary position. MethodsWe reviewed our outcomes for the Inspiris Resilia in the pulmonary position between August 2019 and October 2021. ResultsTwenty-seven patients (15 female patients [56%]; mean age, 22.26 ± 14.99 years) were included. The most common original pathology was tetralogy of Fallot (13 patients, 48%). Five patients (18.5%) had prior transcatheter interventions. The mean right ventricular end-diastolic volume index was 164.25 ± 45.1 mL/m2. Sternotomy or repeat sternotomy was the most common approach (21 patients, 77.8%). The standard technique for pulmonary valve replacement was used in 22 patients (81.5%), whereas the prosthesis was implanted as a conduit in the remaining 5 (18.5%). Trivial to mild prosthetic regurgitation was present in 6 patients (22.2%) at the time of discharge. There was no early mortality. Follow-up was complete in all patients (mean, 16 ± 8 months), with no late mortality or late reoperations. New prosthetic regurgitation developed in 13 patients (48%), all of whom underwent replacement with the standard surgical technique. No regurgitation occurred in the conduit cases. This progressed to moderate regurgitation in 6 patients (22%) and severe in 3 (11%). Three patients (11%) underwent transcatheter valve-in-valve after their surgical pulmonary valve replacement. ConclusionsThe early data regarding the Inspiris Resilia bioprosthesis use in the pulmonary position is concerning. The prosthesis design may not be suitable for low-pressure circulation, or modification of its implantation technique may be needed.

Deep sternal wound infection and pectoralis major muscle flap reconstruction: A single-center 20-year retrospective study.

BackgroundOne of the most drastic complications of median sternal incision is deep sternal wound infection (DSWI), as it can lead to prolonged hospitalization, increased expected costs, re-entry into the ICU and even reoperation. Since the pectoralis major muscle flap (PMMF) technique was proposed in the 1980s, it has been widely used for sternal reconstruction after debridement. Although numerous studies on DSWI have been conducted over the years, the literature on DSWI in Chinese population remains limited. The purpose of this study was to investigate the clinical characteristics of DSWI in patients and the clinical effect of the PMMF at our institution.MethodsThis study retrospectively analyzed all 14,250 consecutive patients who underwent cardiac surgery in the Department of Cardiothoracic Surgery of Drum Tower Hospital from 2001 to 2020. Ultimately, 134 patients were diagnosed with DSWI.,31 of whom had recently undergone radical debridement and transposition of the PMMF in the cardiothoracic surgery or burns and plastic surgery departments because of DSWIs, while the remaining patients had undergone conservative treatment or other methods of dressing debridement.ResultsIn total, 9,824 patients were enrolled in the study between 2001 and 2020, of whom 134 met the DSWI criteria and 9690 served as controls. Body mass index (OR = 1.08; P = 0.02; 95% CI, 1.01∼1.16) and repeat sternotomy (OR = 5.93; P < 0.01; 95% CI, 2.88∼12.25) were important risk factors for DSWI. Of the 134 patients with DSWI, 31 underwent the PMMF technique, and the remaining 103 served as controls. There were significant differences in coronary artery bypass grafting (CABG) (P < 0.01), valve replacement (P = 0.04) and repeat sternotomy (P < 0.01) between the case group and the control group. The postoperative extubation time (P < 0.001), ICU time (P < 0.001), total hospitalization time (P < 0.001) and postoperative hospitalization time (P < 0.001) in the PMMF group were significantly lower than those in the control group. The results of multivariate regression analysis showed that PMMF surgery was an important protective factor for the postoperative survival of DSWI patients (OR = 0.12; P = 0.04; 95% CI, 0.01∼0.90).ConclusionsStaphylococcus aureus was the most common bacteria causing DSWI, which was associated with BMI and reoperation, and can be validly treated with PMMF.

477 Utility Of CTA Parameters For TAVR In LVAD Patients

Introduction: Left ventricular assist devices (LVADs) have become destination therapy for many patients with heart failure reaching end-stage. These patients are living longer due to advances in device design as well as medical therapy. Approximately 1/3 of these patients will develop severe aortic insufficiency (AI). Repeat sternotomy for surgical valve replacement is risky and suboptimal in some situations as transplant may become necessary and would require open heart surgery. Transcatheter aortic valve replacement (TAVR) has been used in these situations; however, it can be difficult due to a lack of aortic valve calcification, primarily aortic insufficiency, and active suction from the LVAD.

Surgical management of diastolic heart failure after septal myectomy for obstructive hypertrophic cardiomyopathy.

ObjectiveSome patients with obstructive hypertrophic cardiomyopathy may remain limited after surgical relief of the subaortic obstruction. In this report, we describe experience in surgical management of patients with advanced diastolic heart failure symptoms after adequate transaortic septal myectomy for obstructive hypertrophic cardiomyopathy.MethodsWe identified adult patients who presented with heart failure symptoms after previous transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and underwent repeat sternotomy for transapical myectomy to enlarge a small left ventricular cavity. Functional recovery after hospital dismissal was assessed through a questionnaire-based survey.ResultsSix patients with previous septal myectomy presented with New York Heart Association functional class III symptoms. Preoperative transthoracic Doppler echocardiography confirmed adequate relief of subaortic outflow tract obstruction with only trivial or mild mitral valve regurgitation; left atrial volume index was increased at 46 mL/m2 (range, 44-47 mL/m2). Following transapical myectomy, the left ventricular diameter was enlarged from 23 mm (range, 21-27 mm) to 29 mm (range, 27-31 mm) at end-systole and from 40 mm (range, 38-42 mm) to 43 mm (range, 42-50 mm) at end-diastole. All the patients were alive after a median follow-up of 0.6 years (range, 0.4-3.5 years), and 5 patients responded to a postoperative survey and indicated improvement in their heart condition compared with functional status before the repeat myectomy.ConclusionsPatients with diastolic heart failure after septal myectomy for obstructive hypertrophic cardiomyopathy may present with systolic cavity obliteration due to excessive myocardial hypertrophy. Repeat transapical myectomy can enlarge the left ventricular chamber and augment the diastolic volume, which results in improved physical capacity and patient-perceived functional status.

Reoperative Mitral Valve Surgery Through Port Access

Minimally invasive mitral valve surgery (MIMVS) has become the standard approach for mitral valve pathology in many centres. The anterolateral mini thoracotomy access is beneficial in reoperative surgery by avoiding repeat sternotomy associated risks. The aim of this study is to analyse the safety of this technique. All patients undergoing reoperative MIMVS between 2008 and 2019 were studied retrospectively. Primary endpoint was 30-day major complications and mortality; secondary outcome was long term survival, reoperation rate and rate of more than moderate recurrent regurgitation. 146 Patients underwent reoperative MIMVS with a mean age of 68 ± 8 years. The composite outcome of 30-day major complication and mortality was 29.5%. 30-Day mortality was 6.2% and stroke rate 3.4%. Survival for the whole cohort was 89.7 ± 2.5% at 1-year, 71.6 ± 4.3% at 5 year and 50.9 ± 5.9% at 8-year follow up. Cox regression analysis revealed reduced left ventricular function (HR 2.8; 95%CI 1.5 - 5.0), GFR < 60 (HR 2.1; 95%CI 1.2 - 3.7) and active endocarditis (HR 6.4; 95%CI 2.7 - 15.4) as variables associated with reduced long-term survival. The cumulative incidence of re-operation after mitral valve replacement was 11.3 ± 3.2% at 5-year and for repair 16.2 ± 7.5% at 5-year. The cumulative incidence of more than moderate recurrent regurgitation after mitral valve repair was 25.4 ± 9.0% at 3-year. Minimally invasive access in reoperative mitral valve surgery in the current study showed similar 30-day mortality and stroke rate compared to repeat sternotomy results reported in literature.

Reoperative Aortic Arch Surgery under Mild Systemic Hypothermia: Two-Center Experience.

Background The aim of the study was to assess the indications, surgical strategies, and outcomes after reoperative aortic arch surgery performed generally under mild hypothermia. Methods Ninety consecutive patients (60 males, mean age, 55 ± 16 years) underwent open reoperative aortic arch surgery after previous cardiac aortic surgery. The indications included chronic-progressive arch aneurysm (55.5%), chronic aortic dissection (17.8%), contained arch rupture (16.7%), and graft infection (10%). The reoperation was performed through a repeat sternotomy (96%) or clamshell thoracotomy (4%) using antegrade cerebral perfusion under mild systemic hypothermia (28.9 ± 2.5°C) in all except three patients. Results The surgery comprised hemiarch or total arch replacement in 41 (46%) and 49 (54%) patients, respectively. The distal extension included classic or frozen elephant trunk technique, each in 12 patients, and total descending aorta replacement in 4 patients. Operative mortality was 6 (6.7%) among all patients, with age identified as the only independent predictor of operative mortality ( p = 0.05). Permanent and transient neurologic deficits occurred in 1% and 9% of the patients, respectively. Estimated survival at 8 years was 59 ± 8% with advanced heart failure predictive for late mortality ( p = 0.014). Freedom from second reoperation or intervention on the aorta was 78 ± 6% at 8 years, with most of these events occurring downstream in patients with chronic degenerative aneurysms. Conclusion Aortic arch reoperations performed using antegrade cerebral perfusion under mild systemic hypothermia offer favorable operative outcomes with an exceptionally low rate of neurologic morbidity without any difference between hemiarch and complex arch procedures.

Heart Mate II Deactivation Using a Left Atrial Appendage Occluder in the Outflow Cannula

Introduction Reverse cardiac remodeling may occur in some LVAD recipients. Although considered the standard therapy, surgical device explantation with repeat sternotomy might be undesirable or very high risk. On the other hand, there are few data reporting minimally invasive percutaneous LVAD deactivation. We describe a case of a man with LVAD malfunction due to driveline fracture and LV function recovery who had a Heart Mate II deactivated with a percutaneous technique using a left atrial appendage occluder (LAAO) positioned inside the outflow cannula. Case Report A 48 yo male patient with previous diagnosis of dilated cardiomyopathy and HMII implanted in 2017 as bridge to transplant was admitted due to device malfunction and alarm triggering after coughing crisis. On admission, the pump was off probably due to driveline fracture, although the patient was asymptomatic and hemodynamically stable. An echocardiogram showed cardiac remodeling and ejection fraction improved from 29% to 69%. The heart team proposed to keep the pump off and to perform a minimally invasive outflow cannula occlusion. A cardiac CT was performed and according to the measured land zone, the LAAO device Lambre (Lifetech Scientific Corp., Shenzhen, China)1824 mm was selected. Through a 5F sheath in the left common femoral artery, a pig-tail catheter was used to obtain an aortography. Through an 8F sheath in the right femoral artery, a 5F pig-tail catheter was placed inside the outflow cannula, then an Amplatz Super-Stiff (Boston Scientific, Marbourough, MA, US) 0.035’’inch wire was advanced to the distal aspect of the graft. Using an over-the-wire technique, a 9F Lambre delivery sheath was positioned, and the Lambre 1824 mm device was released, occluding the outflow cannula from the anastomosis. A new aortography showed decreased flow to the graft. After the procedure, the patient was maintained on anticoagulation and persisted asymptomatic. Echocardiogram one week later showed no flow in the outflow graft. LV ejection fraction remained 60%. He is now in hospital discharge planning. Summary To the best of our knowledge this the first report of LVAD deactivation with the fully recapturable Lambre LAAO device. We propose that the use of a LAA occlude to obstruct HM II outflow cannula is feasible and safe.

Minimally invasive redo aortic valve replacement with a sutureless valve implant.

Reoperations for a dysfunctional mechanical aortic valve prosthesis are usually performed with a repeat sternotomy. Reopening the chest may be associated with a heart structure tear, bleeding, excessive transfusion, and a possible unfavorable outcome. Experience performing a redo aortic valve replacement with a minimally invasive approach and avoiding lysis of the pericardial adhesions is growing. We describe a redo aortic valve replacement procedure performed because of subvalvular pannus formation in a patient with a mechanical prosthesis. A partial J-shaped hemisternotomy at the 3rd intercostal space was performed; the ascending aorta was exposed and the valve was replaced with a sutureless bioprosthesis. The video tutorial shows the surgical approach, cardiopulmonary bypass solutions, and sutureless valve deployment.

Re-exploration Early after Cardiac Surgery in Adults: The Importance of Bleeding-Related Complications.

Re-explorations soon after cardiac surgery are mostly related to bleeding or unclear hemodynamic situations possibly related to heart compression resulting from pericardial hematoma. This condition has a significant impact on mortality, morbidity, and costs. The aim of this study was to analyze indications and outcomes of re-exploration for bleeding or pericardial tamponade early after cardiac surgery in adults. The clinical data of 4790 consecutive adult patients who underwent cardiac surgery in our institution from January 2011 to May 2016 were retrospectively analyzed. We identified 331 re-explorations performed in 231 patients. Sixty-seven of these patients had >1 re- exploration. In most cases (88%), repeat sternotomy was performed. Most procedures (57%) were performed within the first 48 hours. In two-thirds of re-explorations, active bleeding or pericardial hematoma was verified. In the remaining cases, neither bleeding nor significant pericardial hematoma leading to tamponade was found. Among the cases with active bleeding causes, the most bleeding sites were found to be at the coronary anastomosis and the epicardial exposure harvesting site, as well as from the side branches of bypass grafts and intercostal arteries. The incidence of re-exploration after cardiac surgery in adults was low (4.8%). In about two-thirds of the cases, active bleeding or significant pericardial hematoma was found. The most common bleeding causes were the easiest to treat.

Percutaneous cardioplegic arrest before repeat sternotomy in patients with retrosternal aortic aneurysm

ObjectiveRedo sternotomy in patients with arterial cardiac structures adherent to the sternum carries a risk of catastrophic bleeding. In some of those cases, particularly if they have undergone multiple previous operations, deep hypothermic circulatory arrest alone may not provide sufficient time for a controlled dissection. MethodsWe present a series of 6 cases at risk for exsanguination during sternal re-entry successfully reoperated using percutaneous cardioplegic cardiac arrest induced before completed sternal re-entry to avoid or minimize the hypothermic circulatory arrest time. ResultsAll patients survived their complex operations. ConclusionsPercutaneous cardioplegic arrest allows safer repeat sternotomy in patients with arterial cardiac structures adherent to the sternum.

Retrospective analysis of 147 cases of reoperations in congenital heart disease

To analyse the clinical data of reoperations in congenital heart disease and discuss the management strategy of reoperation for congenital heart disease. Methods: We retrospectively studied the clinical data for patients underwent reoperation in congenital heart disease in Cardiovascular Surgery, Second Xiangya Hospital, Central South University from January 2007 to December 2015. Demographic and operative details, in-hospital mortality and major postoperative complications were analysed. Results: A total of 8 647 congenital heart disease surgery procedures were performed, including 147 (1.7%) reoperations. Among the patients, residual septal defect repair (30 cases, 20.4%), planed staged operation (28 cases, 19.0%), and Fontan procedure (20 cases, 13.6%) were the most common kinds of reoperation. In addition, 140 (95%) operations were through repeat sternotomies, 144 (98%) patients underwent operation with cardiopulmonary bypass, and 100 (68%) with cardiac arrest. Cardiopulmonary bypass and aortic cross clamp were maintained for 21-447 (135.5±87.8) minutes and 0-202 (49.9±49.7) minutes. There were 10 in-hospital deaths with a total mortality of 6.8%. The major complications included low cardiac output syndrome (24 cases, 16.3%), renal dysfunction (7 cases, 4.8%), respiratory insufficiency (14 cases, 9.5%), unplanned reoperations for drainage of haemorrhagic cardiac tamponade (4 cases), and delayed sternal closure (2 cases). Conclusion: Repeat sternotomy is the main way of reoperation, but it is not a major risk for operative mortality and morbidity. Improving the management of complex malformation, standardizing the follow-up, choosing the right timing of surgery, and reducing surgical complications will help reduce the risk of reoperation.

Does Type of Mechanical Circulatory Support as Bridge to Heart Transplant Affect Outcomes?

Purpose Bridge to transplant (BTT) with left ventricular assist device (LVAD) is associated with repeat sternotomy, risk of adverse events, and allosensitization. Consequently intra-aortic balloon pump (IABPs) have been increasingly used as BTT despite a paucity of data comparing the two strategies. We aim to compare pre- and post- heart transplant (HTx) outcomes in patients supported by LVAD and IABP as BTT. Methods This retrospective cohort study included all patients BTT by LVAD (n=115) and IABP (n=32) at a single medical center between 7/2010 and 4/2018. Results Twenty-three (20%) patients bridged with LVAD and 3 (9%) bridged with IABP died on the waiting list (p=0.03), whereas 83 (72%) LVAD patients and 23 (72%) IABP patients underwent HTx after 373 (median, IQR 184;743) and 18 (12;31) days of support, respectively. Six (19%) patients with IABP crossed over to LVAD. Patients BTT with LVAD had higher weight (86.3 +/- 20.5 vs 77.7 +/- 16.5, p=0.05) and albumin (3.7 +/- 1.5 vs 2.9 +/- 0.5, p Conclusion BTT with IABP compared to LVAD was associated with longer post-HTx hospital stay, lower rejection score, similar renal function, and similar short-term survival. Additional studies are needed to compare these two strategies with respect to patient outcomes as well as overall cost effectiveness.

Left Ventricular Pseudoaneurysm Caused by a Left Ventricular Venting Catheter via the Right Superior Pulmonary Vein during Thoracic Aortic Surgery: A Case Report

A left ventricular (LV) pseudoaneurysm is one of the complications of acute myocardial infarction. It is also reported after chest trauma, cardiac surgery, and endocarditis. We report a rare case of an LV pseudoaneurysm induced by an LV venting catheter through the right superior pulmonary vein during thoracic aortic surgery. A 77-year-old man was referred for surgical repair of a distal aortic arch aneurysm. He underwent total aortic arch reconstruction with the frozen elephant trunk technique. The early postoperative period was uneventful. Postoperative contrast computed tomography and transthoracic echocardiography (TTE) revealed a pseudoaneurysm with a narrow neck at the apex of the LV that had sub-clinically progressed. Because of the risk of spontaneous rupture, an urgent aneurysmectomy was performed via a repeat sternotomy. Under cardioplegic arrest, the pseudoaneurysm was opened and the small orifice, which communicated with the LV, was confirmed. No myocardial ischemic changes were observed around the orifice. The pseudoaneurysm was thought to be induced by endocardial laceration by the tip of the venting catheter. The pseudoaneurysm was closed by linear repair reinforced with felt strips. The patient recovered well and was discharged 18 days after the second surgery. TTE showed no recurrence of LV aneurysm at the last follow-up.