Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Distress Syndrome: An Italian Society for Cardiac Surgery Report

An increased need of extracorporeal membrane oxygenation (ECMO) support is going to become evident as treatment of SARS-CoV-2 respiratory distress syndrome. This is the first report of the Italian Society for Cardiac Surgery (SICCH) on preliminary experience with COVID-19 patients receiving ECMO support. Data from 12 Italian hospitals participating in SICCH were retrospectively analyzed. Between March 1 and September 15, 2020, a veno-venous (VV) ECMO system was installed in 67 patients (94%) and a veno-arterio-venous ECMO in four (6%). Five patients required VA ECMO after initial weaning from VV ECMO. Thirty (42.2%) patients were weaned from ECMO, while 39 (54.9%) died on ECMO, and six (8.5%) died after ECMO removal. Overall hospital survival was 36.6% (n = 26). Main causes of death were multiple organ failure (n = 14, 31.1%) and sepsis (n = 11, 24.4%). On multivariable analysis, predictors of death while on ECMO support were older age (p = 0.048), elevated pre-ECMO C-reactive protein level (p = 0.048), higher positive end-expiratory pressure on ventilator (p = 0.036) and lower lung compliance (p = 0.032). If the conservative treatment is not effective, ECMO support might be considered as life-saving rescue therapy for COVID-19 refractory respiratory failure. However warm caution and thoughtful approaches for timely detection and treatment should be taken for such a delicate patients population.

Diagnosing left ventricular aneurysm from pseudo-aneurysm: a case report and a review in literature

Rupture of the free wall of the left ventricle (LV) is a catastrophic complication occurring in 4% of patients after myocardial infarction (MI) and in 23% of those who die of MI. Rarely the rupture is contained by an adherent pericardium creating a pseudo-aneurysm. This clinical finding calls for emergency surgery. If no ruptures are detectable and myocardium wall integrity is confirmed, we are in the presence of a true aneurysm, which can be treated by means of elective surgery. Differentiation between these two pathologies remains difficult. We report the case of a patient with a true aneurysm, initially diagnosed as pseudo-aneurysm at our institution; we have reviewed the literature on this difficult diagnosis and outlined characteristic findings of each clinical entity.

Unexpected limited chronic dissection of the ascending aorta

We report a rare case of a limited chronic dissection of the ascending aorta that was accidentally discovered at operation performed for severe aortic stenosis and moderate to severe dilatation of the ascending aorta. Preoperative investigations such as transoesophageal echocardiography and cardiac catheterization missed the diagnosis of dissection. Intraoperative findings included a 3.5 cm eccentric bulge of the ascending aorta and a 5 mm circular shaped intimal tear comunicating with a limited hematoma or small dissection of the media layer. (The rarety of the report is that the chronic dissection is limited to a small area (approximatively 3.5 x 2.5 cm) of the ascending aorta).

Off pump treatment of aortic arch rupture: extraanatomic hybrid reconstruction

We present a possible alternative technique to treat the rupture of aortic arch aneurysms on beating heart without necessity of cardiopulmonary bypass (CPB), hypothermic circulatory arrest and cerebral protection, using a bifurcated vascular prosthesis to revascularize the subclavian and carotid arteries and an endovascular prosthesis to repair the aortic arch. We report the case of a 78-year-old woman successfully treated with this technique. Since in our institution endovascular prostheses are placed by the interventional cardiologists, the operation was done in cooperation between cardiac surgeons and interventional cardiologists.

Is total arterial myocardial revascularization with composite grafts a safe and useful procedure in the elderly?

OBJECTIVE

The aim of the study was to evaluate the mid-term results of total arterial myocardial revascularization (TAMR) with composite grafts in patients older than 70 years when compared to standard CABG technique, since the usefulness of TAMR in the elderly has not been demonstrated yet.

METHODS

A prospective randomized study was designed with the following end-points: post-operative complications, death, recurrence of angina, graft occlusion, any cardiac event and reinterventions. One hundred and eighty-eight patients older than 70 years were enrolled and assigned to Group 1(G1)=94 pts, for total arterial revascularization or Group 2(G2)=94 pts, for standard CABG (LITA on LAD plus additional saphenous veins). The groups were comparable in terms of pre-operative characteristics and Euroscore (mean: G1=8.4 vs. G2=8.2).

RESULTS

No differences between the groups were observed in terms of mean number of grafted vessels (G1=2.1 vs. G2=2.3), mean aortic cross-clamping time (G1=34+/-8 vs. G2=33+/-6min), mechanical ventilation time (G1=23+/-4 vs. G2=22+/-4hr), ICU stay (G1=40+/-10 vs. G2=39+/-9hr), post-operative complications and hospital mortality (G1=5.3% vs. G2=4.2%). At a mean follow-up of 12+/-4 months, cumulative incidence of angina recurrence was 2.1% in G1 vs. 11% in G2 (P=0.021). Angiographic evaluation showed 98.2% arterial patency in G1 vs. 86% saphenous vein graft patency in G2 (P<0.001). Multivariate analysis identified conventional CABG surgery as independent predictor of angina recurrence, graft occlusion and late cardiac events.

CONCLUSIONS

Total arterial revascularization with composite grafts proved to be a safe and effective procedure also in the elderly. Composite arterial grafts provided superior clinical outcome with a lower rate of angina recurrence, graft occlusion and late cardiac events when compared to conventional CABG strategy.

Safety and usefulness of composite grafts for total arterial myocardial revascularization: a prospective randomized evaluation

OBJECTIVES

To evaluate the results of total arterial revascularization with composite grafts compared with the results of conventional coronary surgery, we enrolled 200 consecutive patient undergoing myocardial revascularization.

METHODS

Patients were randomly assigned to 2 groups of 100 patients each: group 1 underwent total arterial revascularization, and group 2 received left internal thoracic artery on left anterior descending artery grafts plus additional saphenous vein grafts. The groups were comparable in terms of continuous and discrete variables and preoperative risk factors.

RESULTS

There were no differences between group 1 and group 2 in terms of the number of grafted vessels (mean, 2.8 vs 2.9, respectively), crossclamping time (mean, 38 +/- 7 vs 40 +/- 6 min, respectively), intensive care unit stay (mean, 25 +/- 8 vs 24 +/- 7 hours, respectively), and hospital mortality (1% in both groups) nor were there any differences in postoperative complications. At the mean follow-up of 12 +/- 4 months, patients receiving total arterial revascularization (group 1) showed a better outcome in terms of angina recurrence (group 1 vs group 2: 2 vs 13 patients, P =.007), need of percutaneous transluminal coronary angioplasty reintervention (group 1 vs group 2: 0 vs 8 patients, P =.0012), and actuarial freedom from cardiac events (group 1 vs group 2: 96% vs 67%, P =.006). Angiography carried out in 72% in group 1 and in 68% in group 2 demonstrated a patency rate of 99% of saphenous vein grafts in group 1 and 89% of saphenous grafts in group 2.

CONCLUSIONS

Total myocardial revascularization with composite arterial grafts provided superior clinical results and improved patient outcome, even in the short term to midterm. Arterial conduit-related benefits were clearly evident with respect to recurrence of angina and a higher graft patency rate.

Prospective evaluation of a new sternal closure method with thermoreactive clips

OBJECTIVES

The role of the sternal closure techniques on the incidence of sternal dehiscence and wound infection are well defined among a high number of other variables involved. In the various series, the incidence of wound complication in cardiac surgery varies from 2 to 8%. The aim of our study is to evaluate the role of thermal-dependent shape-memory Nitillium clips in reducing the incidence of sternal dehiscence following sternotomy.

METHODS

We perspectively randomized 1000 consecutive patients requiring cardiac surgery to evaluate the incidence of sternal wound complications (SWC), sternal dehiscence and/or other related complications. We compared Group I (500 patients), in which sternal closure was achieved with standard sternal wires, with Group II (500 patients), in which sternal approximation was carried out by means of thermoreactive Nitillium clips. The two randomized groups were comparable in terms of age, gender, Euroscore and risk factors for sternal/wound complications.

RESULTS

In our study the overall incidence of SWC was 4.7%. The incidence of SWC was considerably higher in Group I (6.8%) when compared to Group II (2.6%) (P=0.003). Mechanical sternal dehiscence without infection occurred in 14 patients in Group I and in one patient in Group II (P=0.002). Despite sternotomy wound infection occurred similarly in both groups (15 patients in Group I vs. 12 patients in Group II), sternal revision was performed only in patients of Group I (Group I: 9/15 vs. Group II: 0/12; P=0.001).

CONCLUSION

Thermal shape-memory Nitillium clips provided superior results in sternal osteosynthesis following midline sternotomy, due to a considerable reduction of sternal dehiscence and related complications. The clinical benefit of Nitillium clips was demonstrated even in patients with several risk factors for SWC.

Intraoperative microwave ablation in patients undergoing valvular surgery: midterm results

AIM OF THE STUDY

To assess the safety and efficacy of intraoperative microwave ablation to restore sinus rhythm and systolic atrial function in patients undergoing valvular surgery.

METHODS

Forty-one patients with atrial fibrillation (AF) underwent operations. The mean age was 61 years (range, 45- 76 years). AF was permanent in 30 patients and paroxysmal in 11. Associated cardiac procedures were mitral valve repair in 10 patients, mitral valve replacement in 12, and mitro-aortic valve replacement in 19. The microwave procedure (FLEX, AFx inc.) was performed to create an endocardial bilateral encircling isolation of the ostia of the pulmonary veins.

RESULTS

There was no hospital mortality or morbidity. The mean follow-up period was 14.2 months. At follow-up, sinus rhythm was found in 34 patients (82.9%). Echocardiography results at follow-up showed no major or minor left atrial thrombosis and only a mild impairment of the systolic left atrial function.

CONCLUSION

Intraoperative microwave ablation is a safe and effective treatment to restore sinus rhythm and a mildly impaired left atrial function in patients with AF undergoing cardiac surgery.

Pulmonary valve lipoma presenting as syncope

We report a case of a pulmonary valve lipoma presenting as syncope in a 28-year-old woman. Surgical excision of the mass was performed in urgency and the patient was discharged uneventfully.

[A reduction in the invasiveness during surgical revascularization: the harvesting of the great saphenous vein by a video endoscopic technic]

BACKGROUND

The authors report their preliminary experience of endoscopic saphenous vein harvesting as part of a program devoted to reducing the invasivity of surgical myocardial revascularization. This method allows us to minimize the cutaneous incisions in the inferior limbs necessary to harvest the saphenous vein, thus reducing the incidence of complications.

METHODS

The study includes 41 patients who underwent endoscopic saphenous vein harvesting from October 1998 to September 1999 and, as a control group, 20 patients with similar characteristics operated on with the traditional technique during the same period. The variables considered were: the time necessary to harvest the saphenous vein, the incidence of complications, and the postoperative mobilization.

RESULTS

All the endoscopically harvested grafts were adequate for the scheduled procedure. The only complication occurred in a patient operated on with the traditional technique. The time of harvesting and the day of mobilization were similar in the two groups. The reduction of surgical trauma allowed a fast deambulation recovery and better esthetic results.

CONCLUSIONS

When complete arterial revascularization is not feasible, the endoscopic harvesting of the required saphenous vein segment allows for a significant reduction in the invasivity of the procedure.

Completion pneumonectomy: experience with 47 cases

From 1982 through March 1994, fourty-seven patients underwent completion pneumonectomy for a reappearing lung cancer, lung metastases, late complications, benign lung diseases, and early complication of bronchial or pulmonary artery sleeve resections. Intraoperative bleeding was higher than in standard pneumonectomy; there was one intraoperative mortality (2.3%). Operative mortality was 14.9% overall but was 3.6% in completion pneumonectomy for lung cancer, 20% for late complications and benign disease, and 57% for the treatment of early complications of sleeve resections. Three and five-year survival in patients with lung cancer who survived the operation was 43.8% and 28.7% according to the Kaplan-Meier method; no significant difference in long-term survival was present between patients with a second primary lung cancer or recurrence. Completion pneumonectomy is indicated in reappearing lung cancer and should be considered in benign disease when a less invasive procedure is not available. Completion pneumonectomy for the treatment of early complications of bronchial or pulmonary artery sleeve resections has a very high mortality but no alternative is available.

Chylothorax after pleuro-pulmonary surgery: a rare but unavoidable complication

The incidence of chylothorax after pleuro-pulmonary operations as well as its treatment is reported. Of 1744 operations performed postoperative chylothorax developed in 13 (0.74%). It resulted in two cases from the transection of the thoracic duct, in six from the transection of the so-called minor lymph channels, which drain lymph from mediastinal nodes straight into the thoracic duct or drain lung segments into the thoracic duct via the pulmonary ligament; the transection of these channels occurred during mediastinal lymphadenectomy or during the section of the pulmonary ligament. In 5 patients the site of leakage was not determined as reoperation was not required. Conservative treatment with low-fat diet and medium-chain triglycerides and/or total parenteral nutrition was attempted in all but one patient but was successful only in 5 cases whose mean losses were 292 ml/day. Seven patients were reoperated after a mean of 11 days; their mean losses were 930 ml/day. One patient was reoperated on the third postoperative day without attempting conservative treatment; his mean loss was 850 ml/day. Lymphadenectomy seems to be an important risk factor for postoperative chylothorax. Chyle leakage around 500 ml/day or higher that tends to decrease below 500 ml/day after a few days of dietary manipulation usually stops within 10-20 days, while leakage over 500 ml/day that does not tend to decrease below 500 ml/day seldom if ever stops without surgery, so that a more aggressive attitude is justified.