Graft Replacement Research Articles

Lost in translation: the lack of agreement between surgeons and scientists regarding biomaterials research and innovation for treating bone defects.

With over 2 million grafts performed annually, bone ranks second only to blood in the frequency of transplants. This high demand is primarily driven by the persistent challenges posed by bone defects, particularly following trauma or surgical interventions such as tumour excision. The demand for effective and efficient treatments has increased exponentially in the twenty-first century. Limitations associated with autologous bone grafts drive exploration into replacements, including allografts, synthetic substitutes, and 3D-printed scaffolds. This research aimed to unravel disparities in the knowledge and evaluation of current and future bone defect treatments between surgeons and biomaterial scientists. A prospective cross-sectional survey, pre-registered with the OSF ( https://osf.io/y837m/?view_only=fab29e24df4f4adf897353ac70aa3361 ) and conducted online from October 2022 to March 2023, collected data on surgeons' views (n = 337) and scientists (n = 99) on bone defect treatments. Scientists were significantly more optimistic than surgeons regarding the future replacement of autologous bone grafts with synthetic or tissue-engineered substitutes (p < 0.001). Accordingly, scientists foresee a paradigm shift from autologous bone grafts to biomaterial and tissue-engineered solutions, reflecting their confidence in the ongoing advancements within this field. Furthermore, regulatory trepidations for 3D-printed bone scaffolds were acknowledged, with scientists emphasizing the need for a more significant focus on clinical relevance in preclinical studies and regulatory clarity. In a ranked categorical assessment, witnessing the technology in action was deemed most influential in adopting new bone regeneration methods by both scientists and surgeons. To conclude, this study was conducted through a web-based survey, highlighting a substantial translational gap. It underscores the immediate need ("call to action") for meaningful interdisciplinary collaboration between surgeons and scientists, often referred to as the need to "walk the talk". The findings underscore the critical importance of aligning clinical needs, research outcomes, and regulatory frameworks to improve the development and implementation of biomaterial-based bone graft substitutes that demonstrate efficacy and efficiency in bone defect treatment.

Complex Nasal Reconstruction: A Methodical Approach to the Three-Stage Paramedian Forehead Flap

AbstractComplex nasal reconstructions require adequate planning with an accurate estimation of the time necessary to perform each stage. Reconstructions of the entire nose, multiple subunits, or a substantial subunit typically require lining replacement and cartilage grafting. Securing the lining prior to a staged reconstruction is preferred, but options such as the Menick folded paramedian forehead flap (PMFF) allow for lining coverage at the time of the first stage. The free radial forearm flap and the PMFF remain the gold standard for the initial lining coverage. Cartilage grafting is fundamental to complex nasal reconstructions and can be secured in either the first or the second stage. Staged reconstructions require thorough patient education, patience from both the patient and the surgeon, and an understanding that final revisions may be necessary.

Improved Cardiac Rehabilitation Referral Rates following Coronary Artery Bypass Graft and Heart Valve Replacement in an Inner-City Veteran Population.

Cardiac rehabilitation (CR) is underutilized due to various barriers, despite its known benefits in decreasing 5-year mortality after cardiac surgery. The authors initiated a quality improvement project to identify barriers and enhance CR referral rates and participation. The team conducted a retrospective review of cardiac surgery patients from 2015 to 2022 at the Detroit Veterans Affairs. Phase 1 covered 2015-2017 (preintervention), phase 2 was the intervention period, and phase 3 covered 2018-2022 (postintervention). Appropriate CR referral was defined as within 6 months postevent. Referral rates and 1-year post-op hospitalization were assessed. Group 1 (2015-2017) had 54 male patients, 44% Black, 89% hypertensive, with a 22% CR referral rate. Group 2 (2018-2022) had 98 male patients, 64% Caucasian, mean age 73 years, with a 36% CR referral rate postintervention (P = 0.0018). One-year hospitalization decreased from 26% to 13% (P = 0.20). CR is still an underutilized tool. Provider education and complete funding of CR can improve referral rates and participation.

Transcatheter aortic valve replacement failure: surgical valve explantation after more than a decade.

Transcatheter aortic valve replacement (TAVR) has become an established alternative to surgical aortic valve replacement for severe aortic stenosis. However, the long-term outcomes and need for surgical reintervention following TAVR remain uncertain. This case report describes a 76-year-old woman who underwent surgical explantation of a SAPIEN-XT valve more than a decade after initial TAVR implantation due to late valve failure. The patient presented with severe aortic insufficiency and heart failure symptoms. Surgical intervention involved concomitant ascending aortic replacement, tricuspid annuloplasty, and coronary artery bypass grafting. The TAVR valve was successfully explanted using careful blunt dissection to avoid annulus damage. Postoperative recovery was uneventful, with the patient discharged after 4 weeks. This case highlights the potential need for long-term surgical management of patients after TAVR, and emphasizes the importance of surgical preparedness as TAVR indications expand. It also provides valuable insights for surgeons encountering similar cases of late TAVR failure requiring explantation.

Mid-term results of a case series on branched xenopericardial roll graft replacement to treat aortic arch/arch graft infection.

We conducted this case series to evaluate the feasibility and mid-term outcomes of orthotopic aortic arch reconstruction using xenopericardial grafts to treat native aortic arch/arch graft infection. Between 2010 and 2023, adopting a multidisciplinary approach, we treated consecutive patients with aortic arch/arch graft infection by orthotopic branched xenopericardial roll graft replacement and tissue filling. The end-points of the study were the graft re-infection, graft-related complications such as pseudoaneurysm formation, thromboembolism, graft stenosis, graft calcification, and death. The subjects were 11 patients (8 men and 3 women) with a median age of 66 (51 to 79, [IQR] 59.0, 70.5) years. Of the 11 patients, 7 underwent preoperative mediastinal irrigation/negative-pressure wound treatment. The 30-day mortality was 0% (0/11 patients), and one patient died in hospital, after 8 months. Aorta-related death occurred in 18.2% (2/11 patients), with both cases developing local recurrence of fungal infection. The remaining 9 patients (81.8%) remained free of re-infection. The estimated 1-, 3-, 5-, and 7-year risk-adjusted survival rates were 91 ± 9%, 81 ± 12%, 58 ± 16%, and 58 ± 16%, respectively. The estimated 1-, 3-, 5-, and 7-year cumulative aorta-related mortality rates were 9 ± 9%, 19 ± 12%, 19 ± 12%, and 19 ± 12%, respectively. Graft-related complications included branch kinking in 1 patient and graft rupture in 1 patient. There were no cases of graft-related thromboembolism or graft calcification. The median follow-up period was 45 (8 to101, [IQR] 36.5, 70.9) months. The longest follow-up period until date of the currently surviving patients is 101 months. Although the xenopericardium appeared to be vulnerable to fungal infection, based on the favorable results obtained, we consider that branched xenopericardial roll graft replacement using a multidisciplinary, staged approach may serve as a useful treatment option for aortic arch/arch graft infection.

Leveraging in vivo animal models of tendon loading to inform tissue engineering approaches.

Tendon injuries disrupt successful transmission of force between muscle and bone, resulting in reduced mobility, increased pain, and significantly reduced quality of life for affected patients. There are currently no targeted treatments to improve tendon healing beyond conservative methods such as rest and physical therapy. Tissue engineering approaches hold great promise for designing instructive biomaterials that could improve tendon healing or for generating replacement graft tissue. More recently, engineered microphysiological systems to model tendon injuries have been used to identify therapeutic targets. Despite these advances, current tissue engineering efforts that aim to regenerate, replace, or model injured tendons have largely failed due in large part to a lack of understanding of how the mechanical environment of the tendon influences tissue homeostasis and how altered mechanical loading can promote or prevent disease progression. This review article draws inspiration from what is known about tendon loading from in vivo animal models and identifies key metrics that can be used to benchmark success in tissue engineering applications. Finally, we highlight important challenges and opportunities for the field of tendon tissue engineering that should be taken into consideration in designing engineered platforms to understand or improve tendon healing.

Comparing Deprivation vs Vulnerability Index Performance Using Medicare Beneficiary Surgical Outcomes

Health care researchers, professionals, payers, and policymakers are increasingly relying on publicly available composite indices of area-level socioeconomic deprivation to address health equity. Implications of index selection, however, are not well understood. To compare the performance of 2 frequently used deprivation indices using policy-relevant outcomes among Medicare beneficiaries undergoing 3 common surgical procedures. This cross-sectional study examined outcomes among Medicare beneficiaries (65 to 99 years old) undergoing 1 of 3 common surgical procedures (hip replacement, knee replacement, or coronary artery bypass grafting) between 2016 and 2019. Index discriminative performance was compared for beneficiaries residing in tracts with high- and low-deprivation levels (deciles) according to each index. Analyses were conducted between December 2022 and August 2023. Tract-level deprivation was operationalized using 2020 releases of the area deprivation index (ADI) and the social vulnerability index (SVI). Binary outcomes were unplanned surgery, 30-day readmissions, and 30-day mortality. Multivariable logistic regression models, stratified by each index, accounted for beneficiary and hospital characteristics. A total of 2 433 603 Medicare beneficiaries (mean [SD] age, 73.8 [6.1] years; 1 412 968 female beneficiaries [58.1%]; 24 165 Asian [1.0%], 158 582 Black [6.5%], and 2 182 052 White [89.7%]) were included in analyses. According to both indices, beneficiaries residing in high-deprivation tracts had significantly greater adjusted odds of all outcomes for all procedures when compared with beneficiaries living in low-deprivation tracts. However, compared to ADI, SVI resulted in higher adjusted odds ratios (adjusted odds ratios, 1.17-1.31 for SVI vs 1.09-1.23 for ADI), significantly larger outcome rate differences (outcome rate difference, 0.07%-5.17% for SVI vs outcome rate difference, 0.05%-2.44% for ADI; 95% CIs excluded 0), and greater effect sizes (Cohen d, 0.076-0.546 for SVI vs 0.044-0.304 for ADI) for beneficiaries residing in high- vs low-deprivation tracts. In this cross-sectional study of Medicare beneficiaries, SVI had significantly better discriminative performance-stratifying surgical outcomes over a wider range-than ADI for identifying and distinguishing between high- and low-deprivation tracts, as indexed by outcomes for common surgical procedures. Index selection requires careful consideration of index differences, index performance, and contextual factors surrounding use, especially when informing resource allocation and health care payment adjustment models to address health equity.

A penetrating aortic ulcer rapidly evolving into aortic dissection in a patient presenting with respiratory tract infection to the emergency department: an acute aortic syndrome case report

BackgroundPenetrating aortic ulcers (PAU) are life-threatening conditions which derive from severely advanced atherosclerotic lesions of the aorta. The clinical course is unpredictable; thus clinical vigilance should be maintained. It is very challenging to separate PAU from co-existing AAS as predisposing factors and findings overlap.Case presentationCase of 58-year-old gentleman, who presented for atypical chest pain in the setting of respiratory tract infection. Computed Tomographic angiography (CTA) of the chest showed a large PAU and intramural hematoma which rapidly progressed into an acute aortic dissection in the emergency department. Close follow up with cardiac point of care ultrasound one hour later detected an intimal flap which was not initially present on CTA. Patient underwent surgical aortic graft replacement and had an uneventful in-hospital stay.DiscussionThis case underlines the importance of broadening differential diagnoses in atypical presentations in patients with risk factors. Prompt intervention and careful management are imperative to optimize patient outcomes and prevent complications of aortic lesions. Cardiac point of care ultrasound can help in detecting progression of dynamic atherosclerotic diseases such as acute aortic syndrome.

Machine learning-based prediction of new onset of atrial fibrillation after mitral valve surgery

Abstract Background New-onset postoperative atrial fibrillation (nPOAF) is a common complication after cardiac surgery (30–50%), being associated with unfavorable long-term outcomes. Using the Society of Thoracic Surgeons National Adult Cardiac Database, we used machine learning (ML) to predict nPOAF and related 30-day outcomes following mitral valve (MV) surgery. A total of 27,856 MV operations were performed at 910 centers between 7/1/2017 and 6/30/2020 on patients without AF or a prior permanent pacemaker. The primary endpoint was nPOAF postoperatively. ML techniques utilized included penalized logistic regression, gradient boosting, decision trees, and random forests. Results The overall incidence of nPOAF was 35.4% and that of new pacemaker insertion was 5.6%. Patients who developed nPOAF were older (67 ± 10 vs 60 ± 13 years), had more mitral valve stenosis (14.1% vs 11.7%), and hypertension (72.1% vs 63.3%). They underwent more mitral valve replacement (39.1% vs 32.7%) and coronary artery bypass grafting (23.9% vs 16%). For predicting nPOAF, ML methods offer sensitivity, specificity and precision superior to logistic regression. The accuracy rate was identical with penalized and non-penalized logistic regression (0.672). Conclusions Predicting nPOAF and its short-term sequelae following MV surgery remains highly challenging. Machine learning methods offer a moderate degree of improvement in predicting nPOAF even in large national-level studies, in the absence of multi-modal data, such as real-time wearables data, electrocardiograms, heart rhythm monitoring, or cardiac imaging.

Type a aortic dissection after aortic wrapping performed 26 years ago: a case report

BackgroundAortic wrapping (AW) has been performed as a less invasive alternative to aortoplasty. However, AW can also cause long-term aortic complications. In this report, we present a rare case of a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction after AW.Case presentationA female patient had undergone urgent aortic valve replacement with a 19-mm mechanical valve to treat infective endocarditis and AW to treat an enlarged ascending aorta 26 years prior. At the age of 71 years, the patient was diagnosed with a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction. We performed graft replacement of the ascending aorta, including complete resection of the wrap. The patient was discharged on postoperative day 10, and there have been no cardiovascular events during her ongoing follow up.ConclusionsAW in younger patients can lead to late aortic complications. Careful consideration should be paid when performing AW in young patients, and patients who have previously undergone AW require strict life-long follow-up.

Stroke after heart valve surgery: a single center institution report

IntroductionStroke is a potentially debilitating complication of heart valve replacement surgery, with rates ranging from 1 to 10%. Despite advancements in surgical techniques, the incidence of postoperative stroke remains a significant concern, impacting patient outcomes and healthcare resources. This study aims to investigate the incidence, risk factors, and outcomes of in-hospital adverse neurologic events, particularly stroke, following valve replacement. The analysis focuses on identifying patient characteristics and procedural factors associated with increased stroke risk.MethodsThis retrospective study involves a review of 417 consecutive patients who underwent SVR between January 2004 and December 2022. The study cohort was extracted from a prospectively recorded cardiac intensive care unit database. Preoperative and perioperative data were collected, and subjects with specific exclusion criteria were omitted from the analysis. The analysis includes demographic information, preoperative risk factors, and perioperative variables.ResultsThe study identified a 4.3% incidence of postoperative stroke among SVR patients. Risk factors associated with increased stroke susceptibility included prolonged cardiopulmonary bypass time, aortic cross-clamp duration exceeding 90 min, prior stroke history, diabetes mellitus, and mitral valve annulus calcification. Patients undergoing combined procedures, such as aortic valve replacement with mitral valve replacement or coronary artery bypass grafting with AVR and MVR, (OR = 10.74, CI:2.65–43.44, p-value = < 0.001) and (OR = 11.66, CI:1.02–132.70, p-value = 0.048) respectively, exhibited elevated risks. Internal carotid artery stenosis (< 75%) and requiring prolonged inotropic support were also associated with increased stroke risk(OR = 3.04, CI:1.13–8.12, P-value = 0.026). The occurrence of stroke correlated with extended intensive care unit stay (OR = 1.12, CI: 1.04–1.20, P-value = 0.002) and heightened in-hospital mortality.ConclusionIn conclusion, our study identifies key risk factors and underscores the importance of proactive measures to reduce postoperative stroke incidence in surgical valve replacement patients.

A posterior pericardial chest tube is associated with reduced incidence of postoperative atrial fibrillation after cardiac surgery: A propensity score–matched study

ObjectivePostoperative atrial fibrillation (POAF) is a common complication after cardiac surgery that is associated with other adverse outcomes. Recent studies have shown that drainage of pericardial effusion by a posterior pericardial incision reduces the incidence of POAF. An alternative approach is a chest tube placed posteriorly in the pericardium. We evaluated whether the use of a posterior pericardial drain was associated with reduced risk of POAF in patients undergoing coronary artery bypass graft (CABG) and/or aortic valve replacement (AVR). MethodsThis observational study included 2535 patients who underwent CABG (n = 1997), AVR (n = 293), or combined CABG and AVR (n = 245) in Iceland from 2002 to 2020. From our study population, 553 (22%) received a 20-Fr posterior pericardial chest tube in addition to standard mediastinal and left pleural drains. The incidence of POAF in patients with and without a posterior pericardial drain was compared before and after 1:1 propensity score matching. ResultsOf 2535 patients, 1100 were included in the matched cohort. The incidence of POAF was lower in patients receiving posterior pericardial chest tube drainage compared with the control group, both before (34% vs 43%, P < .001) and after (33% vs 43%, P = .002) matching. In a multivariable analysis, posterior pericardial chest tube drainage was independently associated with a reduced risk for POAF (adjusted odds ratio 0.67; 95% confidence interval, 0.52-0.88; P = .003). ConclusionsThis observational study suggested that posterior pericardial chest tube drainage is associated with a significant reduction of POAF after routine CABG and/or AVR procedures. The results are hypothesis-generating and must be confirmed in prospective randomized trials.

Decellularized aortic homografts versus mechanical composite grafts for aortic root replacement.

Mechanical composite valve grafts (MCVGs) are the first-line therapy for aortic root replacement in young adults. Decellularized aortic homografts (DAH) present a promising novel alternative due to their lower thrombogenicity. We aimed to compare both treatment options regarding survival and valve-related adverse events. This study was designed as a single-centre retrospective cohort study including patients who underwent root replacement with MCVG or DAH between 2000 and 2022. Urgent or emergent procedures were excluded. The study cohort included 289 patients (MCVG n = 216, DAH n = 73) with a mean age of 48.5 ± 12 years (MCVG 49 ± 12 years vs DAH 47 ± 11 years; P = 0.23) and a median EuroScore II of 1.7% (1.2, 2.6). The 30-day mortality was 1% (n = 3). Cumulative survival at 3 years was 99% for DAH and 94% for MCVG, respectively (P = 0.15). Mean follow-up was 98.9 ± 72.7 months. Bleeding events (n = 14, 6.5%) and thromboembolism (n = 14, 6.5%) were only observed in the MCVG group (P = 0.19 and 0.09, respectively). Four cases (5%) of moderate structural valve deterioration occurred, all in the DAH group (P ≤ 0.001). The cumulative incidence of a composite end point of valve-related adverse events was significantly higher in the MCVG group (P = 0.0295). Aortic root replacement with MCVGs and decellularized aortic homografts showed low mortality in an elective setting. Patients in the homograft cohort demonstrated significantly higher freedom from valve-related adverse events. DAH present a promising treatment option for young patients requiring root replacement; however, data on long-term durability are needed.

Dynamic Eye Closure Restoration in Facial Palsy with Neurotized Platysma Muscle Graft in Rats.

One of the most devastating deficits of facial paralysis is eyelid dysfunction, which is controlled by the orbicularis oculi muscle (OOM), as it leads to loss of the protective mechanism of the eye. This study used a rat model to assess the functional outcomes of neurotized platysma muscle grafts (PMGs) for OOM replacement. Forty male Sprague-Dawley rats with iatrogenic right eyelid dysfunction were divided into five groups: one control group and four groups utilizing PMG with different sources of nerve innervation. Eyelid function recovery was assessed at 2, 4, 6, and 8 weeks. The PMGs were harvested for pathological examination at the end of the study. All rats except those in the control group and one from the group using ipsilateral frontal and upper zygomatic frontal nerve branches directly neurotized to the PMG (nerve-to-muscle) recovered eyelid closure function within 8 weeks of the study period. The mean recovery time was 3.87 ± 1.28 weeks. A total of 87.5% of rats that had the contralateral zygomatic branch as the donor nerve regained the consensual corneal reflex (p-value < 0.001). Replacement of neurotized PMG for OOM function is successful in a rat model. Using the upper zygomatic branch as the donor nerve, it was possible to restore the consensual corneal reflex. This method shows promise for further human studies.

Mechanical Properties, Drug Release, Biocompatibility, and Antibacterial Activities of Modified Emulsified Gelatin Microsphere Loaded with Gentamicin Composite Calcium Phosphate Bone Cement In Vitro.

Bone defects are commonly addressed with bone graft substitutes; however, surgical procedures, particularly for open and complex fractures, may pose a risk of infection. As such, a course of antibiotics combined with a drug carrier is often administered to mitigate potential exacerbations. This study involved the preparation and modification of emulsified (Em) crosslinking-gelatin (gel) microspheres (m-Em) to reduce their toxicity. The antibiotic gentamicin was impregnated into gel microspheres (m-EmG), which were incorporated into calcium phosphate bone cement (CPC). The study investigated the effects of m-EmG@CPC on antibacterial activity, mechanical properties, biocompatibility, and proliferation and mineralization of mouse progenitor osteoblasts (D1 cells). The average size of the gel microspheres ranged from 22.5 to 16.1 μm, with no significant difference between the groups (p > 0.05). Most of the oil content within the microspheres was transferred through modification, resulting in reduced cytotoxicity. Furthermore, antibiotic-impregnated m-EmG did not compromise the intrinsic properties of the microspheres and exhibited remarkably antibacterial effects. After combining with CPC (m-EmG@CPC), the microspheres did not significantly hinder the CPC reaction and produced the main product, hydroxyapatite (HA). However, the compressive strength of the largest microsphere content of 0.5 wt.% m-EmG in CPC decreased significantly from 59.8 MPa of CPC alone to 38.7 MPa of 0.5m-EmG@CPC (p < 0.05). The 0.5m-EmG@CPC composite was effective against Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) in drug release and antibacterial tests. Compared with m-EmG alone, the 0.5m-EmG@CPC composite showed no toxicity to mouse fibroblast cells (L929). Additionally, the proliferation and mineralization of mouse osteoblastic osteoprogenitor cells (D1 cells) did not have a negative impact on the 0.5m-EmG@CPC composite over time in culture compared with CPC alone. Results suggest that the newly developed antibacterial 0.5m-EmG@CPC composite bone cement did not negatively affect the performance of osteoprogenitor cells and could be a new option for bone graft replacement in surgeries.

Establishing a bone bank within a hospital setting in India: early insights from a tertiary care center in Northern India-a review article.

When addressing bone defects resulting from trauma, infection, or tumors, the use of allogenic bone is often necessary. While autografts are considered the standard, they have limitations and can lead to donor site morbidity. Consequently, there has been exploration into the feasibility of utilizing allogenic bone and bone graft replacements. Allogenic bone transplants are acquired from donors following rigorous procurement, sterile processing, and donor screening procedures. To ensure the safe storage and effective utilization of allograft material, a bone banking system is employed. Establishing and managing an orthopedic bone bank, entails navigating complex legal and medical organizational aspects. This paper examines the establishment and operation of bone banks in India, drawing upon our first-hand experience in managing one at a tertiary care center in Northern India.Level of evidence: Level IV.

Reoperative approach after extra-anatomic ascending-to-descending aortic bypass graft

BackgroundExtra-anatomic ascending-to-descending aortic bypass grafts have historically been utilized as a safe and effective solution for repairs of complex coarctation of the aorta. However, reports on reoperation in these patients remain rare. We present a case of an aortic valve replacement and coronary artery bypass grafting in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.Case presentationThe patient is a 59-year-old male with a complex aortic history, including repair of aortic coarctation with an ascending-to-descending aortic bypass graft 13 years prior, was admitted to the hospital for shortness of breath and chest pain that had developed over the past year. On further workup, he was found to have severe bileaflet aortic valve stenosis, non-ST elevation myocardial infarction, and moderate coronary artery disease. He underwent surgical aortic valve replacement and coronary artery bypass grafting. Given his unique anatomy, cardiopulmonary bypass approach involved separate cannulation of the right axillary and left common femoral arteries with cross-clamp of both the aorta and the extra-anatomic graft. Using this approach, the redo operation was successfully performed.ConclusionsReports on reoperation after ascending-to-descending aortic bypass grafting are rare. We describe our approach to cardiopulmonary bypass and reoperation in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.

Y-shaped graft replacement of an isolated innominate artery aneurysm via the transmanubrial approach.

We report the rare case of an obese woman with a 32-mm isolated innominate artery aneurysm. Due to the deep location of the aneurysm within the thoracic inlet, we selected a transmanubrial osteomuscular sparing approach to obtain a clear field of vision. During the aneurysmectomy and reconstruction with a Y-shaped graft, we performed a temporary bypass using a contralateral leg of the graft to the right common carotid artery. Through these techniques, we successfully achieved complete resection and reconstruction of the aneurysm without the need for cardiopulmonary bypass.

997 Ascending Aorta Pseudoaneurysm 40 Years Following Surgical Atrial Septal Defect Repair

Abstract Background Ascending aorta pseudoaneurysm is a rare postoperative complication of cardiac surgery. It is often attributed to infection and dehiscence at sites of aortotomy, cannulation, cross-clamp placement, and proximal coronary anastomoses. Mortality risk is 29-46% and this requires prompt surgical intervention. Case summary A 48-year-old woman who underwent atrial septal defect repair at 8 years of age, presented with chest pain radiating to the right shoulder and dyspnoea. Cardiac-gated CT angiography demonstrated a 21mm pseudoaneurysm arising anteriorly from the proximal ascending aorta, 6mm above the right coronary artery ostium, likely the site of previous cardioplegia cannula. There was active blood flow from the aorta into the pseudoaneurysm sac. It was heavily calcified, apart from a thinned irregular wall inferiorly, from which rupture was imminent. She underwent emergency surgery. Using femoro-femoral cardiopulmonary bypass, the chest was safely re-entered. Under mild hypothermia and distal ascending aorta cross-clamping, the pseudoaneurysm was resected and aorta repaired using a Gelweave patch. The patient recovered uneventfully and was discharged home after one week. Discussion Accurate imaging, primarily via cardiac-gated CT angiography, is crucial for diagnosis and surgical planning in patients presenting with aortic pseudoaneurysm, particularly those close to the aortic valve and coronary arteries. Operative strategy, including need for deep hypothermic circulatory arrest and/or graft replacement of aorta, depends on pseudoaneurysm anatomy. It is recommended that preventative measures are taken during the primary operation, inserting the cardioplegia cannula tip through full-thickness purse-strings and/or addition of separate oversewing sutures after decannulation. Alternative techniques of pseudoaneurysm repair are also discussed.

Partial cardiopulmonary bypass through left thoracotomy for coarctation repair in children

BackgroundA left thoracotomy approach is anatomically appropriate for childhood aortic coarctation; however, the pediatric femoral arteriovenous diameters are too small for cardiopulmonary bypass cannulation. We aimed to determine the safety of a partial cardiopulmonary bypass through the main pulmonary artery and the descending aorta in pediatric aortic coarctation repair.MethodsWe retrospectively reviewed 10 patients who underwent coarctation repair under partial main pulmonary artery-to-descending aorta cardiopulmonary bypass with a left thoracotomy as the CPB group. During the same period, 16 cases of simple coarctation of the aorta repair, with end-to-end anastomosis through a left thoracotomy without partial CPB assistance, were included as the non-CPB group to evaluate the impact of partial CPB.ResultsThe median age and weight at surgery of the CPB group were 3.1 years (range, 9 days to 17.9 years) and 14.0 (range, 2.8–40.7) kg, respectively. Indications for the partial cardiopulmonary bypass with overlap were as follows: age > 1 year (n = 7), mild aortic coarctation (n = 3), and predicted ischemic time > 30 min (n = 5). Coarctation repair using autologous tissue was performed in seven cases and graft replacement in three. The mean partial cardiopulmonary bypass time, descending aortic clamp time, and cardiopulmonary bypass flow rate were 73 ± 37 min, 57 ± 27 min, and 1.6 ± 0.2 L/min/m2, respectively. Urine output during descending aortic clamping was observed in most cases in the CPB group (mean: 9.1 ± 7.9 mL/kg/h), and the total intraoperative urine output was 3.2 ± 2.7 mL/kg/h and 1.2 ± 1.5 mL/kg/h in the CPB and non-CPB group, respectively (p = 0.020). The median ventilation time was 1 day (range, 0–15), and the intensive care unit stay duration was 4 days (range, 1–16) with no surgical deaths. No major complications, including paraplegia or recurrent coarctation, occurred postoperatively during a median observation period of 8.1 (range, 3.4–17.5) years in the CPB group. In contrast, reoperation with recurrent coarctation was observed in 2 cases in the non-CPB group (p = 0.37).ConclusionsPartial cardiopulmonary bypass through the main pulmonary artery and descending aorta via a left thoracotomy is a safe and useful option for aortic coarctation repair in children.