Indications and outcomes of second aortic procedures after acute type A dissection repair

OBJECTIVES

Aortic arch or aortic root replacement is not performed in all cases of acute type A aortic dissection (ATAD), and a second aortic procedure will become necessary over time for some patients. Indications and outcomes, of second aortic procedures have not been studied extensively.

METHODS

Characteristics and in-hospital outcomes of all patients undergoing surgical repair for type A acute aortic dissection were analysed and patients needing second aortic procedure during follow-up were identified. The latter group was divided in 2 subgroups: on-pump includes patients operated on using cardiopulmonary bypass and off-pump without cardiopulmonary bypass.

RESULTS

A total of 638 patients underwent surgery for ATAD; 8% required a second aortic procedure. The most frequent indication for the second aortic procedure was dehiscence of suture lines (44%), followed by arch dilatation (24%). In-hospital mortality was 12%. Isolated ascending aorta replacement at the first surgery was associated with higher incidence of second aortic procedure (P = 0.006). Most patients in the on-pump group underwent a proximal reoperation (75%), with a mortality rate of 14.2%. In-hospital mortality of patients in the off-pump group was 7.7%. Long-term survival analysis showed no difference between groups (P = 0,526), Off-pump patients have greater likelihood of a second intervention during follow-up (P  = 0.004).

CONCLUSIONS

Extended aortic root surgery and customized aortic arch repair in ATAD could be reasonable to reduce the incidence and mortality of high-risk second aortic procedures.

Influence of minimal invasive extracorporeal circuits on dialysis dependent patients undergoing cardiac surgery

INTRODUCTION

Cardiac surgery in patients on chronic renal dialysis is associated with significant morbidity and mortality. Minimally invasive extracorporeal circuits (MiECC) have shown a positive impact on patient outcome in different high-risk populations. This retrospective study compares the outcome of these high-risk patients undergoing heart surgery either with a MiECC or a conventional extracorporeal circulation (CECC).

METHODS

This is a single-center experience including 131 consecutive dialysis dependent patients undergoing cardiac surgery between January 2006 and December 2016. A propensity score matching was employed leaving 30 matched cases in each group.

RESULTS

After propensity score matching the 30-day mortality was significantly lower in the MiECC group (n = 3 (10%) vs n = 10 (33%) in the CECC group, p = .028). Further, intraoperative transfused units of packed red blood cells were lower in the MiECC group (1.4 ± 1.8 units vs 2.8 ± 1.7, p < .001).

CONCLUSIONS

There are evident advantages to using MiECC in dialysis dependent patients, especially regarding mortality. These findings necessitate additional research in MiECC usage in high-risk populations.

Midterm outcomes of minimally invasive mitral valve surgery in a heterogeneous valve pathology cohort: respect or resect?

Background

Minimally invasive mitral valve surgery (MIV) through a right lateral thoracotomy has become the standard of care at specialized centers and might soon will be the only acceptable surgical treatment option in the future era of interventional procedures. The aim of our study was to analyze the outcomes of our MIV-specialized, single-center, mixed valve pathology cohort with regard to morbidity, mortality and midterm outcomes comparing two different repair techniques (respect versus resect).

Methods

Baseline and operative variables, postoperative outcomes and follow-up information about survival, valve competence and freedom from reoperation were retrospectively collected and analyzed. The repair cohort was divided into three groups (resection, neo-chordae and both) and compared for outcomes.

Results

Between July 22^nd 2013 and May 31^st 2022 a total of 278 consecutive patients underwent MIV. Out of those, we identified 165 eligible patients for the three repair groups: 82 patients (29.5%) had "resection", 66 "neo-chordae" (23.7%) and 17 "both" (6.1%). All preoperative variables were comparable between the groups. The predominant valve pathology of the entire cohort was degenerative disease with 20.5% Barlow's, 20.5% bi-leaflet and 32.4% double segment pathology. Bypass time was 164±47, cross-clamp time 106±36 minutes. All valves planned for repair (85.6%) were successfully repaired except for 13 resulting in a repair rate of 94.5%. Only 1 patient (0.4%) had to be converted to clamshell and 2 (0.7%) needed rethoracotomy for bleeding. Mean intensive care unit (ICU) stay was 1.8 days and hospital stay 10.6±1.3 days. In-hospital mortality was 1.1% and the incidence of stroke (1.8%). All in-hospital outcomes were comparable between the groups. Follow up was complete in 86.2% (n=237) for a mean of 3.7±0.8, up to 9 years. Five-year survival was 92.6% (P=0.5) and freedom from re-intervention 96.5% (P=0.1). All but 10 patients had mitral regurgitation less than grade 2 (95.8%, P=0.2) and all but two had less than New York Heart Association (NYHA) II (99.2%, P=0.1).

Conclusions

Despite a heterogeneous cohort with mixed valve pathologies, there is a high reconstruction rate, low short- and midterm morbidity, mortality and need for re-intervention with comparable outcomes of the resect and respect technique in a specialized MIV center.

Propensity Matched Outcomes of Minimally Invasive Mitral Surgery: Does a Heart-Team Approach Eliminate Female Gender as an Independent Risk Factor?

BACKGROUND

There is increasing evidence that female gender is an independent risk factor for cardiac surgery. Minimally invasive mitral surgery (MIV) has proven to have excellent long-term results, but little is known about gender-dependent outcomes. The aim of our study was to analyze our heart team's decision-based MIV-specialized cohort.

METHODS

In-hospital and follow-up data were retrospectively collected. The cohort was divided into gender groups and propensity-matched groups.

RESULTS

Between 22 July 2013 and 31 December 2022, 302 consecutive patients underwent MIV. Before matching, the total cohort showed that women were older, had a higher EuroSCORE II, were more symptomatic, and had more complex valve pathology and tricuspid regurgitation resulting in more valve replacements and tricuspid repairs. Intensive and hospital stays were longer. In-hospital deaths (n = 3, all women) were comparable, with more atrial fibrillation in women. The median follow-up time was 3.44 (0.008-8.9) years. The ejection fraction, NYHA, and recurrent regurgitation were low and comparable and atrial fibrillation more frequent in women. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.9 and p = 0.2). Propensity matching compared 101 well-balanced pairs; women still had fewer resections and more atrial fibrillation. During the follow-up, women had a better ejection fraction. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.3 and p = 0.3).

CONCLUSIONS

Despite women being older and sicker, with more complex valve pathology and subsequent replacement, early and mid-term mortality and the need for reoperation were low and comparable before and after propensity matching, which might be the result of the MIV setting combined with our patient-tailored decision-making. We believe that a multidisciplinary heart team approach is crucial to optimize patient outcomes in MIV, and it might also reduce the widely reported increased surgical risk in female patients. Further studies are needed to prove our findings.

The impact of age and sex on in-hospital outcomes in acute type A aortic dissection surgery

Background

Older age and female sex are thought to be risk factors for adverse outcomes after repair of acute type A aortic dissection (AAAD). The aim of this study is to analyze age- and sex-related outcomes in patients undergoing AAAD repair.

Methods

Retrospective analysis of patients undergoing emergency AAAD repair. Patients were divided in Group A, patients aged ≥75 years and Group B <75. Intraoperative and postoperative data were compared between groups before and after propensity score matching. Sex differences were analyzed by age group.

Results

Between January 2006 and December 2018, 638 patients underwent emergency AAAD repair. Group A included 143 patients (22.4%), Group B 495 (77.6%). More patients in Group A presented with circulatory collapse (Penn C 26.6% vs. 9.7%, P=0.001) while Group B presented with circulatory collapse-branch malperfusion (Penn BC 29.3% vs. 15.4% P=0.001). After propensity score matching, Group B patients received more complex aortic root (33.6% vs. 23.2%, P=0.019) and concomitant bypass surgery (12.3% vs. 6.3%, P=0.042). There was no significant difference in in-hospital mortality between age groups (18% vs. 12% P=0.12). In Group B, in-hospital mortality was significantly higher in females (22.2% vs. 8.2%, P=0.028). Differences in mortality disappeared after the age of 75 (18.3% vs. 19.4% P=0.87).

Conclusions

Morbidity and mortality are comparable between patients under and over 75 years after AAAD repair. Female patients <75 had higher in-hospital mortality than their male counterparts.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Concomitant Coronary Artery Bypass in Patients with Acute Type A Aortic Dissection

Coronary Artery Bypass Grafting (CABG) is sometimes necessary in acute Type A Aortic Dissection (AAAD) repair. The aim of this study is to analyze the incidence, indications and influence in-hospital outcomes of AAAD repair requiring concomitant CABG in a high-volume single-center experience. Retrospective study of all consecutive AAAD patients. Those who underwent concomitant CABG were identified. Preoperative, intraoperative, postoperative and follow-up data were collected and analyzed. Between January 1, 2010 and December 31, 2016, 382 patients underwent emergency surgery for AAAD. Forty-one (10.7%) underwent concomitant CABG. In this group, mean age was 64 ± 14 years, 32 were male (78%). Indication for CABG was coronary dissection in 28 patients (68.3%), post-cardiopulmonary bypass (CPB) right heart failure in 7 (17.1%), post CPB left heart failure in (7.3%) and native coronary pathology in 3 (7.3%). In 33 (80.5%) one graft was needed, in 7 (17%) two were performed and in 1 patient (2.4%) 3 were necessary. The right coronary artery (RCA) was the only revascularized vessel in 26 cases (63.4%), the left coronary artery (LCA) alone in 11 (26.8%), and both coronary systems in 4 (9.8%). In-hospital mortality was 51.2% (N = 21); eight (19.5%) patients had postoperative myocardial infarction (MI) and 11 (26.8%) had a major neurological event. Multivariable logistic regression identified concomitant CABG as a predictor of in-hospital mortality (Odds Ratio (OR) = 3.8115, 95% CI= 0.514-2.138, p = 0.001). In our study, concomitant CABG was performed in 10.7% of AAAD repair surgery and it was associated with high in-hospital mortality.

Do all roads lead to Rome? Treatment of malposition pacemaker lead in the left ventricle

Malpositioning of a pacemaker lead in the left ventricle is a rare device-related complication, which can lead to serious complications. Herein, we describe the case of a malpositioned lead, which entered the left ventricle via a direct transcutaneous puncture of the left common carotid artery.

Outcomes of patients operated for acute type A aortic dissection requiring preoperative cardiopulmonary resuscitation

BACKGROUND AND AIM

Acute type A aortic dissection (AAAD) is a life-threatening condition. The emergency operation usually results in 20% perioperative mortality. If preoperative cardiopulmonary resuscitation (CPR) is necessary, there is an increase in the rate of mortality. The aim of the present study was to report the outcomes of AAAD surgery in patients requiring preoperative CPR in a high-volume center.

METHODS

A retrospective analysis of preoperative, intraoperative, postoperative, and follow-up data in patients requiring preoperative CPR in the setting of AAAD surgery was performed.

RESULTS

Between January 2006 and December 2018, 637 patients underwent emergency surgery for AAAD. In total, 26 (4%) patients received CPR; the mean age was 63 ± 13 years; and 18 were male (69%). The reason for CPR was acute tamponade (N = 14, 54%), pulseless electrical activity (N = 5, 19%), asystole or ventricular fibrillation (N = 7, 27%), and four (15%) patients were not operated due to prolonged CPR and severe initial neurological impairment. There was no intraoperative mortality. The in-hospital mortality rate was 50% (N = 11), due to severe cerebral damage confirmed by computed tomography, and six patients (55%) were older than 70 years. The median follow-up was 35 months (7-149), which was 100% complete; two patients had permanent hemiplegia, one had anterior spinal syndrome, and other two died during the follow-up. The overall survival rate was 41% (n = 9).

CONCLUSION

Surgery outcomes were still reasonable in AAAD patients requiring preoperative CPR in a high-volume center.

Aortic valve replacement with or without myocardial revascularization in octogenarians. Can minimally invasive extracorporeal circuits improve the outcome?

OBJECTIVE

The positive impact of minimally invasive extracorporeal circuits (MiECC) on patient outcome is expected to be most evident in patients with limited physiologic reserves. Nevertheless, most studies have limited their use to low-risk patients undergoing myocardial revascularization. As such, there is little evidence to their benefit outside this patient population. We, therefore, set out to explore their potential benefit in octogenarians undergoing aortic valve replacement (AVR) with or without concomitant myocardial revascularization.

METHODS

Based on the type of the utilized ECC, we performed a retrospective propensity score-matched comparison among all octogenarians (n = 218) who received a primary AVR with or without concomitant coronary artery bypass grafting in our institution between 2003 and 2010.

RESULTS

A MiECC was utilized in 32% of the patients. The propensity score matching yielded 52 matched pairs. The 30-day postoperative mortality (2% vs. 10%; p=0.2), the incidence of low cardiac output (0% vs. 6%; p=0.2) and the Intensive Care Unit (ICU) stay (2.5 ± 2.6 vs. 3.8 ± 4.7 days; p=0.06) were all in favour of the MiECC group, but failed to reach statistical significance while the 90-day postoperative mortality did (2% vs. 16%; p=0.02).

CONCLUSION

MiECCs have a positive influence on the outcome of octogenarians undergoing AVR with or without concomitant coronary artery bypass grafting. Their use should, therefore, be extended beyond isolated coronary artery bypass graft (CABG) surgery.

Late prosthetic graft infection after frozen elephant trunk presenting by haemoptysis and positive ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography

In cardiothoracic surgery, prosthetic graft infection represents a diagnostic and therapeutic challenge. Although clinical assessment, imaging techniques and microbiological investigations are helpful, late graft infection can be difficult to identify using classical diagnostic tools. An aggressive surgical approach involving removal and replacement of all prosthetic materials is technically demanding but remains the best strategy to eradicate infection. Herein, we report a case of a late aortic graft infection, after frozen elephant trunk implantation with atypical presentation, diagnosed with (18)F-fluorodeoxyglucose-positron emission tomography and treated successfully through a radical surgical strategy. This case emphasizes the emerging diagnostic role of positron emission tomography and encourages the adoption of an aggressive surgical approach.

Left ventricular pseudoaneurysm following transfemoral aortic valve implantation

In spite of being a less-invasive technique, transcatheter aortic valve implantation (TAVI) remains associated with potential serious complications. Left ventricular pseudoaneurysm (LVP) is a known, serious complication of transapical TAVI. However, this complication has not been described after the trans-femoral approach. We describe a case of LVP after transfemoral TAVI, emphasizing the importance of an immediate diagnosis of this potential life-threatening complication.

Repair of quadricuspid aortic valve by bicuspidization: a novel technique

Quadricuspid aortic valve (QAV) is a rare congenital lesion, generally manifesting with valve regurgitation. Standard treatment involves valve replacement, though anecdotal cases of successful repair by means of valve tricuspidization have been reported. Here, the successful application of a repair technique previously unreported in the setting of QAV is described.