Total Circulatory Arrest Research Articles

Предикторы госпитальной летальности при экстренном хирургическом лечении острейшего расслоения аорты типа А по Стенфорду в условиях искусственного кровообращения: ретроспективное когортное исследование

INTRODUCTION: Acute Stanford type A aortic dissection is one of the most severe cardiovascular diseases with high in-hospital mortality. OBJECTIVE: To establish predictors of in-hospital mortality in the treatment of patients with acute Stanford type A aortic dissection under conditions of artificial circulation and to determine their threshold values. MATERIALS AND METHODS: Study design: retrospective, cohort, single-center. Inclusion criteria: surgical intervention with cardiopulmonary bypass, confirmed diagnosis of acute Stanford type A aortic dissection, age > 18 years. The study included 51 patients: 42 men and 9 women aged from 35 to 77 years, median 59 years [47; 65]. All patients (n = 51) were treated in 2022 and were divided into 2 groups depending on the outcome: group 1 (n = 27) included those who died in the intensive care unit within 30 days, group 2 (n = 24) included survived and discharged patients. The endpoint of trial was 30-day in-hospital mortality. RESULTS: Postoperative Sequential Organ Failure Assessment (SOFA) score > 7, Acute Physiology And Chronic Health Evaluation (APACHE) II score > 19, and Vasoactive-inotropic score (VIS) > 10, cardiopulmonary bypass time > 177 minutes, and total hypothermic circulatory arrest time > 30 minutes were associated with an increased risk of 30-day in-hospital mortality. CONCLUSIONS: Statistically significant predictors of hospital mortality in the treatment of patients with acute Stanford type A aortic dissection under cardiopulmonary bypass are the SOFA index, the APACHE II index and the VIS index after the end of surgery, as well as the time of cardiopulmonary bypass and the time of total hypothermic circulatory arrest.

Exploring Differences in Surgical Outcomes Depending on the Arterial Cannulation Strategy for Acute Type A Aortic Dissection: A Single-Center Study.

Type A aortic dissection (AD) and intramural hematoma (IMH) are critical medical conditions. Emergency surgery is typically performed under cardiopulmonary bypass immediately after diagnosis, which involves lowering the body temperature to induce total circulatory arrest. Selection of the arterial cannulation site is a critical consideration in cardiac surgery and becomes more challenging in patients with AD. This study explored the strengths and weaknesses of different cannulation methods by comparing each cannulation strategy and analyzing the reasons for patients' outcomes, especially mortality and cerebrovascular accidents (CVAs). This retrospective study reviewed the medical records of patients who underwent surgery for type A AD or IMH between 2008 and 2023, using the moderate hypothermic circulatory arrest approach at a single center. Among the 146 patients reviewed, 32 underwent antegrade cannulation via axillary, innominate artery, aortic, or transapical cannulation, while 114 underwent retrograde cannulation via the femoral artery. The analysis of surgical outcomes revealed a significant difference in the total surgical time, with 356 minutes for antegrade and 443 minutes for retrograde cannulation (p<0.001). The mean length of stay in the intensive care unit was significantly longer in the retrograde group (5±16 days) than in the antegrade group (3±5 days, p=0.013). Nevertheless, no significant difference was found between the groups in the 30-day mortality or postoperative CVA rates (p=0.2 and p=0.7, respectively). Surgeons should consider an appropriate cannulation strategy for each patient instead of adhering strictly to a specific approach in AD surgery.

Short- and long-term results of total arch replacement: Comparison between island and debranching techniques.

The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching)or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P=.001), had undergone more previous cardiac operations (54.5% vs 27.4%, P<.001), and had more connective tissue disorder (20.3% vs 4.6%, P<.001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10minutes, P<.001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37minutes, P<.001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P=.018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P=.486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P=.897). Ten-year survival was 80% (78% vs 80.9%, log-rank P=.356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P=.495). Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.

Atrial septal defect occluder device embolization: Experience of a tertiary care cardiac center.

Percutaneous device closure of atrial septal defect (ASD) has become an increasingly popular procedure as it offers several advantages. However, it is associated with infrequent, but life-threatening complications such as device embolization. To analyze the risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. A retrospective study was performed at a tertiary referral center for cardiac services. Pre-procedure, intra-procedure, and post-procedure data of patients whose ASD device embolized was collected retrospectively and analyzed for risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Results: Thirty devices were embolized, out of which 13 were retrieved percutaneously in the Catheter laboratory, whereas 17 patients underwent surgery. Fourteen patients had an unfavorable septal morphology for device closure. Ten devices were embolized in the catheter laboratory, five in the intensive care unit, and two in the ward. The devices were embolized to almost all chambers of the heart and great vessels. One patient had an inferior vena cava rim tear while attempting percutaneous retrieval. One patient required a short period of total circulatory arrest (TCA) for retrieval of the device from ascending aorta, while another required a lateral position for retrieval from descending aorta. One patient required re-exploration for bleeding, while another had an air embolism and succumbed. Once embolization occurs, the risks associated increase manifold. Most of the surgical extractions are uneventful; however, there could be certain complications that may need repair of valvular apparatus, the institution of TCA, or the need for the lateral position. Air embolization though very rare can occur which could be fatal.

Total Aortic Arch Replacement without Total Circulatory Arrest and Deep Hypothermia: A New Modification of Frozen Elephant Trunk Technique Using Left Axillar Artery for Arterial Cannulation

Total Aortic Arch Replacement without Total Circulatory Arrest and Deep Hypothermia: A New Modification of Frozen Elephant Trunk Technique Using Left Axillar Artery for Arterial Cannulation

Surgical treatment for patent ductus arteriosus in adult patients: a single center experience.

In contemporary practice, percutaneous closure of the patent ductus arteriosus (PDA) has become the procedure of choice. While the surgical ligation of ductus arteriosus ensures an immediate and definitive obliteration of the ductus, this therapeutic option is rarely used and reserved for situations when percutaneous solution is unsuitable. In this manuscript, we summarize the clinical and intraoperative findings of consecutive adult patients referred to our Institution in an interval of 10 years for surgical treatment of PDA. A total of five cases of surgical closure for PDA were performed in our Center. Four subjects were not suitable for percutaneous closure, and one was discovered intraoperatively, during surgery for another cardiac condition. In all patients, the closure of the PDA was carried out by means of a suture with reinforced patch threads, in a double layer. The intervention was performed in total cardiopulmonary bypass and mild or moderate hypothermia, through a transpulmonary approach. Total circulatory arrest was not required, in any of the cases. The occlusive balloon technique was applied to all patients. All patients survived the intervention and did not suffer perioperative complications. Postoperative follow-up at 36 months did not show repermeabilization of the arterial duct or aneurysmal dilation of the adjacent aorta. Moreover, all patients showed postoperative improvement in the performance of the left ventricle. In adult patients with PDA and contraindication to percutaneous closure or in those who require surgical sanction for other cardiac diseases, surgical closure of the duct is safe and associated with favorable clinical evolution.

Retained peripherally inserted central catheter guidewire with vegetation.

Sir, Central venous cannulation is often a necessity for patients in intensive care units or in patients with difficult peripheral access. Loss of the guidewire is a serious and potentially life-threatening complication with reports of fatalities in up to 20% of cases, when the complete guide wire is lost.[1] A 2-year 3-month-old female child presented to our institute with chief complaints of poor weight gain, abdominal discomfort, and decrease in appetite. Chest X-ray of the patient showed a radio-dense wire extending into inferior vena cava (IVC) and right atrium [Figure 1]. Patient had a history of hospital admission at the age of 8 months for jaundice. Peripherally inserted central catheter (PICC) was inserted at that hospital in right femoral vein due to difficult peripheral venous cannulation. PICC line was kept for 12 days and later it was removed. Later on, patient presented to our institute with above mentioned complaints. Computerised tomography (CT) scan showed evidence of a linear radio-dense wire extending from infrarenal IVC into the right ventricle. Its tip was seen in the superior vena cava suggestive of foreign material [Figure 1b]. Transthoracic echocardiography showed a hyperechoic mobile structure of size 20 × 10 mm (possibly a vegetation) in the right atrium having attachment to the superior vena cava and IVC with to-and-fro movement across tricuspid valve and near total occlusion of IVC by hyperechoic structure till mid abdomen level [Video 1]. Moderate to severe tricuspid regurgitation (TR) was seen on transthoracic echocardiography. Surgical removal of PICC guidewire was planned. Complete blood count, serum electrolytes, coagulation profile, liver, and kidney function tests were done preoperatively. Preoperative electrocardiogram showed sinus tachycardia and nonspecific ST-T wave changes. The open surgical repair was planned under hypothermic cardiopulmonary bypassFigure 1: (a) Chest X-.Ray PA view showing a radio dense wire extending into inferior vena cava and right atrium. (b) Computerised tomography scan showing evidence of a linear Ra: Right atrium dense wire extending from infrarenal IVC, extending into right ventricle and the tip is seen in superior vena cava suggesting foreign material. (c) Guidewire with vegetation. (d) Right atrium opened with blocked IVC. IVC: Inferior vena cava {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_0bc3rv32"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Patient was induced with general anaesthesia and endotracheal intubation carried out after injecting fentanyl 5 mg/kg, midazolam 0.1 mg/kg, and vecuronium 0.1 mg/kg. Five lead electrocardiogram, invasive arterial blood pressure, central venous pressure, temperature, end tidal carbon dioxide, pulse oximetry, and urine output were monitored intraoperatively. Cardiopulmonary bypass (CPB) was established after cannulating ascending aorta and right atrium. Total circulatory arrest was initiated. Right atrium was opened and removal of guidewire with vegetation from right atrial wall and tricuspid valve leaflet were done [Figure 1c and 1d]. Tricuspid valve was checked for tricuspid regurgitation and anteroseptal commissuroplasty was done. Post repair, moderate to severe tricuspid regurgitation was present. CPB was instituted again, and tricuspid valve was repaired. After complete rewarming, patient was weaned off CPB uneventfully. 180 ml of packed red blood cells was transfused intraoperatively. Total duration of surgery was four hours. Patient was shifted to paediatric intensive care unit and was extubated on second postoperative day. Complications pertaining to the retained guide wire include complete loss of wire, injury to the vessel from the wire, fracture of the wire, and bleeding.[1–5] Patients undergoing foreign body removal pose a challenge for the anaesthesiologist as there can be risk of arrhythmia, bleeding causing haemodynamic instability, prolonged aortic cross clamp time, and postbypass myocardial dysfunction. Percutaneous retrieval was not possible in this case due to the extent of guide wire with associated vegetation and risk of its embolisation. Therefore, decision was made for surgical plan to remove guide wire under cardiopulmonary bypass. This case highlights the importance of formulating a plan for the anaesthetic management of patients undergoing guidewire removal and preparedness for postoperative management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients.

The presence of right heart thrombi in transit (RHTiT) in the setting of acute pulmonary embolism (PE) is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high- or intermediate-high-risk PE with coexisting RHTiT. A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute PE with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography and laboratory tests. Eligibility criteria for surgical treatment were acute PE with RHTiT, right ventricular overload on imaging studies and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end point was hospital all-cause mortality; secondary end points were perioperative complications and long-term mortality. The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was 1 death in the long-term follow-up, not related to PE. Surgical treatment of patients with acute PE and coexisting RHTiT can provide favourable results.

Bentall through a right mini-thoracotomy

Objective: The minimally invasive right thoracotomy approach is being increasingly used for aortic valve surgeries. It has several benefits in terms of decreased blood loss and length of hospital stay as compared to conventional sternotomy technique. Selected patients requiring aortic root and ascending aorta surgery can be operated on using a similar approach. In this case series, we share the outcomes of Bentall surgery done through right mini-thoracotomy. Methods: This was a single-center retrospective study of five patients who underwent elective right mini-thoracotomy modified Bentall Procedure. Instruments routinely used in minimally invasive cardiac surgery were used. The outcomes that were evaluated include cross-clamp times, cardiopulmonary bypass (CPB) times, time to extubation, total length of intensive care unit (ICU) and hospital stay, re-exploration rates, and inhospital and 30-day mortality. Results: The mean CPB times and cross-clamp times were 128 and 96 min, respectively. The total circulatory arrest was used in two patients with a mean time of 12 min. The mean time to extubation was 7 h. The mean ICU stay and the total length of hospital stay were 1.5 and 5 days, respectively. No patient required re-exploration for bleeding. We did not have any inhospital or 30-day mortality. Conclusion: The right mini-thoracotomy modified Bentall procedure is reproducible and safe in selected patients with annuloaortic ectasia.

Abernethy Malformation: Possible Diagnosis for Patients with Congenital Heart Disease and Persistent Cyanosis.

Infant, nine months of age, female, diagnosed with congenital heart disease, with signs of heart failure associated with cyanosis and difficulty in gaining weight. Cardiomegaly with prevalence of pulmonary vascular network. Ectopic atrial rhythm with right ventricular overload and left anterosuperior divisional block. Single atrium with absent interatrial septum, atrioventricular connection with a single valve and two orifices, with increased pulmonary pressure and high Qp/Qs. Absence of portal vein and intrahepatic segment of the inferior vena cava. Infrahepatic portion continuing with the azygos system at the level of the thoracic cavity, presence of mesenteric-caval communication associated with signs suggestive of hepatic peribiliary fibrosis. Abernethy malformation is a rare condition and represents an extrahepatic portosystemic shunt that develops between the mesenteric-portal vasculature and the systemic veins. It may be associated with cardiac malformations and advance with pulmonary hypertension and even the need for liver transplantation. Persistent cyanosis after corrective surgery led to a deeper investigation and correct diagnosis of this malformation. Sternotomy with 68 minutes of cardiopulmonary bypass and nine minutes of total circulatory arrest. In the postoperative period, persistence of cyanosis was evident, even though there were no immediate complications. Patient was discharged on the 10th postoperative day. An abdominal computed tomography angiography confirmed the diagnosis of Abernethy type I malformation, and the patient was transferred for liver transplantation after congenital heart disease treatment.

Modification of pulmonary endarterectomy to prevent neurologic adverse events.

Neurologic adverse events (NAEs) are a major complication after pulmonary endarterectomy (PEA) performed under periods of deep hypothermic circulatory arrest (HCA) for chronic thromboembolic pulmonary hypertension. We modified the PEA strategy to prevent NAEs and evaluated the effectiveness of these modifications. We reviewed the surgical outcomes of 87 patients divided into the following three groups based on the surgical strategy used: group S (n = 49), periods of deep HCA with alpha-stat strategy; group M1 (n = 19), deep HCA with modifications of slower cooling and rewarming rates and the pH-stat strategy for cooling: and group M2 (n = 13), multiple short periods of moderate HCA. PEA provided significant improvement of pulmonary hemodynamics in each group. Sixteen (29%) of the 49 group S patients suffered NAEs, associated with total circulatory arrest time (cutoff, 57min) and Jamieson type I disease. The Group M1 and M2 patients did not suffer NAEs, although the group M1 patients had prolonged cardiopulmonary bypass (CPB) and more frequent respiratory failure. NAEs were common after PEA performed under periods of deep HCA. The modified surgical strategy could decrease the risk of NAEs but increase the risk of respiratory failure. Multiple short periods of moderate HCA may be useful for patients at risk of NAEs.

Completely detached mechanical aortic valve prosthesis stuck to the aortic arch in a patient with Behçet’s disease

BackgroundAlthough detachment of the implanted valve prosthesis was a well-known complication in patients with Behçet’s disease, complete detachment of an aortic bileaflet valve prosthesis has never been reported.Case presentationAn 18-year-old boy with Behçet’s disease (HLA-A26 positive) who had previously undergone aortic valve replacement with an 18-mm ATS-Advanced Performance (ATS-AP) valve (ATS Medical, Inc., Minneapolis, MN) at the age of 12 years, presented sudden-onset general fatigue and was emergently transferred to the regional hospital. Chest X-ray showed displacement of the implanted mechanical valve. An echocardiogram revealed mobile valve prosthesis and severe aortic regurgitation. Just before leaving for our hospital for surgical treatment, a completely detached valve prosthesis was floating in the ascending aorta. On arrival, the valve prosthesis was stuck to the transverse arch. Emergent removal of the previous mechanical valve from the aortic arch and redo aortic valve replacement with a 24-mm ATS-AP valve were performed under total circulatory arrest. Infectious endocarditis was denied by histopathological examination. The patient was back to the intensive care unit with extracorporeal membrane oxygenation support, which was successfully decannulated 5 days later.ConclusionsThis was the first report of a patient with Behçet’s disease who encountered a complete detachment of implanted aortic valve prosthesis. The patient could be rescued by emergent surgery.

Can regional cerebral oxygen saturation monitoring during circulatory arrest time predict postoperative neurological dysfunction in patients undergoing surgical pulmonary thromboendarterectomy? Useful index for short- and long-term outcomes.

A hypothermic circulatory arrest is usually used to correct thoracic aorta pathologies. The emergency treatment of acute type A aortic dissection and elective repair of aortic arch pathologies are the most common indications for using hypothermic circulatory arrest. A hypothermic circulatory arrest can also be used for surgical pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension. Intervals with total circulatory arrest offer a clear surgical field for thrombus and emboli removal from the pulmonary artery branches. The price to pay for intermittent circulatory arrest during pulmonary thromboendarterectomy is postoperative neurological dysfunction due to brain hypothermia and hypoperfusion. A noninvasive method for cerebral monitoring during cardiac surgery is real-time regional cerebral oxygen saturation (rSO2 ). Liu et al. report that continuous monitoring of rSO2 during surgical pulmonary thromboendarterectomy may reduce the long cerebral hypoperfusion time and prevent postoperative neurological dysfunction.

Protective effect of Tulbaghia violacea extract on cardiac damage: deep circulatory arrest rat model

Objectives: Total circulatory arrest (TCA) technique is a method used in cardiac surgery accompanied by cardiopulmonary bypass (CPB). It has been shown that Tulbaghia violacea extract increases antioxidant capacity, regulates blood pressure, decreases lipid peroxide, and reduces atherosclerosis. In this experimental study, we aimed to investigate the effect of T. violacea extract administration on serum oxidative stress parameters (Total antioxidant status [TAS], total oxidant status [TOS] and oxidative stress index [OSI] and deoxyribonucleic acid [DNA] damage level with 8-Hydroxy-2-Deoxyguanosine [8-OHdG]) and histopathological changes in the heart and other organs in rats with deep circulatory arrest model. Methods: In this study, 48 Wistar Albino adult rats, 24 female and 24 male, obtained from Harran University Experimental Animals Research Center were used. The average weight of female rats was 250-300 g, and the average weight of male rats was 450-500 g. These rats were randomly divided into four groups. 6 male and 6 female rats were used in each group (Group 1 = Sham, Group 2 = Injury, Group 3 = Treatment and Injury, Group 4 = Treatment). Results: As a result of this experimental study, the changes in the biochemical 8-OHdG, TOS, OSI and TAS levels of the groups were found to be statistically significant (p &amp;lt; 0.001). In the subgroup analyzes of the data, 8-OHdG level, which is an oxidative DNA damage marker in Group 2 was higher than the Group 1, Group 3 and Group 4 and there was a statistically significant difference (p &amp;lt; 0.001, p = 0.027 and p &amp;lt; 0.001; respectively). The TOS level of the injury group was higher than Group 1, Group 3 and Group 4 and there was a statistically significant difference (p &amp;lt; 0.001, p = 0.003 and p &amp;lt; 0.001; respectively). Conclusions: As a result of our study, we revealed that T. violacea extract has a protective effect on organ and tissue damage in the TCA model.

Functional Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

<h3>Purpose</h3> The aim of the present study was to investigate the long-term outcomes of pulmonary thromboembolis (PEA) in patients with Chronic thromboembolic pulmonary hypertension (CTEPH), with a particular focus on identifying an effect on the improvement of functional class and right ventricular pressure. <h3>Methods</h3> Twenty-six patients underwent PEA surgery between May 2012 to April 2021. The median age was 60 ± 13.48 years, and there were more women (61.5%) than men. 9 patients (34.6%) were diagnosed with deep vein thrombosis (DVT), and 5 patients (19.2%) had cancer history. The mean ACC time for PEA was 96.88 ± 33.97 min and the mean total circulatory arrest time was 25.52 ± 10.66 minutes. Jamieson classification I was 22 patients (84.6%), II was 2 patients (7.6%), and III was 2 patients (7.6%). <h3>Results</h3> After PEA surgery, most patients (88.5%) were weaned from inotropics without extracorporeal membrane oxygenation (ECMO) support during the first few days. After surgery, 96.2% of the patients remained free of continuous renal replacement therapy. The 5-year survival rate was 95.5%, and the 5-year freedom rates of cardiac death was 100%. Our study suggests that after PEA surgery, mortality rate was low and there was marked improvement in NYHA class and health status (p<0.001, Figure) not only significantly lowered RVSP and TR grade (p<0.001, left Table). Cox univariate regression analysis demonstrated that male sex, CKD (grade III-IV), and MPA involvement were independent predictors of non-improvement after PEA surgery, according to RVSP reduction. MPA involvement remained significant predictors of non-improvement after PEA surgery in multivariate Cox regression (right Table). <h3>Conclusion</h3> Despite the increased perioperative risk and mortality, PEA could be a best choice of treatment to patients with elevated RVSP but clear indication for surgery. Furthermore, significant RV pressure reduction and improved functional outcomes can be achieved in especially non-MPA involved patients.

Bentall surgery and total arch repair with debranching of supra-aortic vessels: a case report

BackgroundThe surgical approach to pathologies of the Ascending Thoracic Aorta (ATA) that compromise aortic root and the aortic arch is currently one of the most complex interventions in the spectrum of cardiac surgery, where circulatory arrest with cerebral perfusion plays an important role for Success postoperative and patient survival.Case presentationWe present the case of a 57-year-old patient with the only history of arterial hypertension and an ATA Aneurysm that compromised segment of the aortic root up to segment 2 of the aortic arch. A successful Bentall surgery was performed, debranching supra-aortic vessels with Total Circulatory Arrest with Deep Hypothermic Cerebral Perfusion-Antegrade Bilateral.ConclusionsWith the advent of new anesthetic and neuroprotection techniques, perioperative imaging protocols, advanced hemodynamic monitoring, and invaluable advances in perfusion and Extracorporeal Circulation with circulatory arrest, they have made this surgical challenge a valuable tool for today’s cardiovascular surgeon.

Initiating a Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Endarterectomy Program Based on a Single Center Experience in Lebanon.

In 2018, the American University of Beirut Medical Center established the first multidisciplinary Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Endarterectomy program in Lebanon. The study describes the challenges faced in establishing the program and in improving patient referral, evaluation, and perioperative care. The program establishment including the preparation phase, clinical evaluation, and team education is discussed. The implementation of the flow of patients referred to the program was established. Education regarding diagnosis and referral were provided to physicians in the community. The initial experience is described in a retrospective analysis of 4 consecutive patients who were diagnosed with CTEPH and underwent PEA. Four patients were diagnosed with CTEPH had PEA performed. The mean age of patients was 64 years. The average CPB and total circulatory arrest times were 244 and 23.9minutes per side, respectively. No mortalities were encountered perio-operatively. All patients reported significant improvement in functional capacity from NYHA III and IV to a NYHA class of I with an average PASP decrease of 59.5 ± 19.7 mmHg and mPAP drop by 30.2 ± 16.3 mmHg. The launch of the first CTEPH and PEA program in Lebanon, with a clear framework, coupled with good surgical outcomes is very encouraging. The program offers a curative solution for CTEPH patients in the region. A clear referral process and an increase in disease and treatment awareness in the community are crucial to the future success of the program, offering a definitive treatment, and avoiding delays to surgery.

Fontan procedure with extracardiac conduit in pediatrics and children: Short-term results

IntroductionThe concept of Fontan circulation was first clinically introduced in 1971. Technical modifications have been advocated with the concept of total cavopulmonary connection, introduced in the late 80s. Recently, an extracardiac conduit to divert inferior vena cava flow to the pulmonary arteries has been advocated, and it affords excellent palliation for patients with various forms of the anatomic or functional single ventricle.Patients and methodsFrom September 2019 to August 2021, 12 patients (five males and seven females) with a mean age of 10.7 (6–15) years underwent a Fontan procedure with extracardiac conduit at the National Heart Institute. The mean weight was 34.75 (18–60) kg. The underlying diagnoses included tricuspid atresia (n = 2), double-inlet left ventricle (n = 3), transposition of great arteries (n = 1), and double-outlet right ventricle (n = 6). All patients were in sinus rhythm.ResultsThere was one operative mortality. The type of conduit used was Gortex in 11 patients (91.7%) and Dacron in one patient (8.3%). The mean conduit size was 20 mm (16–26 mm). The mean cardiopulmonary bypass time was 127 (90–200) min. Aortic cross-clamping time was 25 min in two patients who needed total circulatory arrest. The mean duration of chest tube drainage was 31.8 days (15–130 days). All patients had sinus rhythm before the operation remained sinus. The mean ejection fraction was 65% (55–71%). The arterial oxygen saturation increased from a preoperative mean level of 64.2% (55–70%) to 90% (85–93%). There were nine patients (75%) who had fenestrations. The mean postoperative hospital stay was 36.7 (15–150) days, ICU stay was 6.5 (3–8) days, and mechanical ventilation time was 13.7 (4–27) h. There were three patients (25%) who needed reoperation, one who needed reintervention with chylous pleural effusion (8.3%), protein-losing enteropathy (8.3%), and infection. All patients had New York Heart Association (NYHA) functional class ≤II.ConclusionThe extracardiac conduit is an easy way to perform the Fontan procedure, as it provides an excellent early result, maintenance of sinus rhythm, and preservation of ventricular function.

Surgical results of chronic thromboembolic pulmonary endarterectomy in our recently developed program.

Background In this case series, we aimed to present our diagnostic workup, surgical management, and results of the patients who underwent pulmonary endarterectomy. Methods In this case series, a total of 26 patients (8 males, 18 females; median age: 58 years; range, 34 to 67 years) who were evaluated by a multidisciplinary team and were diagnosed with chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy in our clinic between November 2015 and December 2019 were included. Pulmonary endarterectomy procedure was performed in all cases under cardiopulmonary bypass and total circulatory arrest. The results of the procedures were analyzed retrospectively. Results Perioperative complications were observed in seven patients (26.9%) and in-hospital mortality rate caused by perioperative complications was 15.38%. At one-year of postoperative follow-up, the mean systolic pulmonary artery pressure decreased from 78±22 mmHg to 41±20 mmHg, pulmonary vascular resistance decreased from 698±10 dyn·s·cm-5 to 235±10 dyn·s·cm-5, 6-min walk distance increased from 345±10 m to 460±10 m and, arterial oxygen saturation increased from 85±3.5% to 95±4%. New York Heart Association functional class improvement from Class III-IV to Class I-II was observed in most patients, and one-year mortality rate was 19.23%. Conclusion We suggest that patients diagnosed chronic thromboembolic pulmonary hypertension should be referred to cardiac surgery centers for pulmonary thromboendarterectomy, early before irreversible arteriopathy occurs.

Preoperative hematological parameters are inadequate for predicting mortality in Stanford Type A aortic dissection repair

Background: Mortality in acute Type A aortic dissection is still high and unpredictable. We aimed to investigate the validity of preoperative hematological markers and possible risk factors in predicting in-hospital mortality in patients operated with deep hypothermic circulatory arrest method. Methods: 78 consecutive patients who were admitted to the emergency service and operated on were retrospectively analyzed. Risk factors for in-hospital death were investigated to develop a predictive model. Results: There was no difference between patients in terms of the were demographic data of the patients. In the mortality group, only preoperative creatinine levels were found to be higher (p &lt; 0.05). Factors affecting mortality were found as total circulatory arrest (TCA) and cross-clamp (X-clamp) times when intraoperative data were examined (p &lt; 0.05). ROC analysis was performed to determine the power to predict mortality and to determine the cut-off point. In ROC analysis to predict mortality, X-Clamp time &gt; 71 minutes, 68.2% sensitivity and 66.1% specificity, TCA &gt; 44.5 minutes, 72.7% sensitivity and 73.2% specificity were found. In the mortality group, these values were found to be significantly higher than those who were discharged. Conclusion: In the surgical treatment of Type A aortic dissection under deep hypothermia, hematologic biomarkers may be insufficient in estimating the risk for mortality. Keywords: Acute; aortic dissection; biomarker; mortality