Valve-sparing aortic root replacement (VSARR) has become an appealing choice for replacing an aneurysmal root when the patient’s anatomic characteristics are favorable, especially in patients with heritable thoracic aortic disease. It is a technically challenging procedure, and the learning curve is considerable. This approach’s chief advantages are that the patient’s own aortic valve apparatus is preserved, the repair (in expert hands) is durable, and it avoids the need for lifelong anticoagulation associated with the mechanical valves in the aortic root prostheses. In this report, we provide a step-by-step approach for aortic root replacement in patients with a tricuspid aortic valve suitable for VSARR. Operative Techniques in Thoracic and Cardiovasculary Surgery 28:80912022 Elsevier Inc. All rights reserved.
The current conventional open TAAA repairs are performed by select centers around the world with good outcomes. However, lesser experienced centers often encounter difficulties in replicating similar results of open TAAA surgeries. The modified branch-first open repair of TAAA has shown to be effective in minimizing visceral and renal complications by providing continuous visceral blood flow throughout the procedure. By debranching the visceral vessels first, we can perform this complex aortic procedure in a more controlled manner as compared to the traditional clamp and sew technique which requires speed, precision and experience. The entire repair can be performed on beating heart by deriving native blood flow via a closed circuit or a modification of the left heart bypass and continuously perfusing the abdominal viscera, thus avoiding cardiopulmonary bypass or deep hypothermic circulatory arrest which helps minimize bleeding and overall morbidity associated with extensive TAA surgeries. Adequate pre-operative planning is imperative to prevent spinal cord complications and intra-operative emergencies.
Abstract: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is an established method of short-term mechanical support for patients in cardiogenic shock, but can create left ventricular (LV) distension. This paper analyzes the physiologic basis of this phenomenon and treatment methods. This is a retrospective review of the existing literature on VA ECMO and LV distension. We undertook a PubMed review of all peer-reviewed papers focusing on VA ECMO, LV distension, and LV venting. We reviewed these papers and synthesized our findings. We also will discuss the various methods of LV venting and venting strategies we use at Columbia. LV distension is becoming an increasingly appreciated aspect of caring for patients on VA ECMO support. The literature demonstrates that the consequences of failing to anticipate, recognize, and treat LV distension are grave, and will worsen an already distended and hypocontractile LV. Myocardial recovery will be hindered, and LV thrombus formation more likely. Early recognition and aggressive management of LV distension is paramount in helping care for this critically ill patient population.
Submitted May 30, 2018. Accepted for publication Mar 07, 2019. doi: 10.21037/jtd.2019.03.29 View this article at: http://dx.doi.org/10.21037/jtd.2019.03.29
BACKGROUND Societal guidelines support concomitant management of atrial fibrillation (AF) in patients undergoing cardiac surgery. To assess real-world adoption and outcomes, this study evaluated Medicare beneficiaries with AF who underwent isolated coronary artery bypass grafting (CABG) with surgical ablation (SA) or left atrial appendage obliteration (LAAO) or both procedures in combination (SA D LAAO). METHODS The US Centers for Medicare & Medicaid Services inpatient claims database identified all patients with AF who underwent isolated CABG from 2018 to 2020. Diagnosis-related group and International Classification of Diseases- 10th revision procedure codes defined covariates for doubly robust risk adjustment. RESULTS A total of 19,524 patients with preoperative AF who underwent isolated CABG were stratified by SA D LAAO (3475 patients; 17.8%), LAAO only (4541 patients; 23.3%), or no AF treatment (11,508 patients; 58.9%). After doubly robust risk adjustment, longitudinal analysis highlighted that concomitant AF treatment with SA D LAAO (hazard ratio [HR], 0.74; P [ .049) or LAAO alone (HR, 0.75; P [ . 031) was associated with a significant reduction in readmission for stroke at 3 years compared with no AF treatment. Furthermore, SA D LAAO (HR, 0.86; P [ .016) but not LAAO alone (HR, 0.97; P [ .573) was associated with improved survival compared with no AF treatment. Finally, SA D LAAO was associated with a superior composite outcome of freedom from stroke or death at 3 years compared with LAAO alone (HR, 0.86;, P [ .033) or no AF treatment (HR, 0.81; P [ .001). CONCLUSIONS In Medicare beneficiaries with AF who underwent isolated CABG, concomitant AF treatment was associated with reduced 3-year readmission for stroke. SA D LAAO was associated with superior reduction in stroke or death at 3 years compared with LAAO alone or no AF treatment.
The Supplemental Tables can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2023.11.034] on http:// www.annalsthoracicsurgery.org.
BACKGROUND Coronary artery aneurysms (CAAs), coronary arteriovenous malformations (CAVMs), and spontaneous coronary artery dissections (SCADs) are rare clinical entities, and much is unknown about their natural history, prognosis, and management. METHODS A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed in March 2023 to identify published papers related to CAAs, CAVMs, and SCADs. RESULTS CAAs are found in 0.3% to 12% of patients undergoing angiography and are often associated with coronary atherosclerosis. They are usually asymptomatic but can be complicated by thrombosis in up to 4.8% of patients and rarely by rupture (0.2%). CAAs can be managed medically, percutaneously with stents or coil embolization, and surgically. The most common surgical procedure is ligation of the aneurysm, followed by coronary artery bypass grafting. The incidence of CAVMs is 0.1% to 0.2% in patients undergoing angiography, and they are most likely associated with congenital abnormal development of the coronary vessels. The diagnosis of CAVMs is usually incidental. Surgical or percutaneous intervention is indicated for patients with large CAVMs, which carry a potential risk of myocardial infarction. SCADs represent 1% to 4% of all acute coronary syndromes and typically affect young women. SCADs are strongly correlated with pregnancy, suggesting the role of sex hormones in their pathogenesis. Conservative management of SCAD is preferred for stable patients without signs of ischemia as spontaneous resolution is frequently reported. Unstable patients should undergo revascularization either percutaneously or with coronary artery bypass grafting. CONCLUSIONS Further evidence regarding the management of these rare diseases is needed and can ideally be derived from multicenter collaborations.
The Supplemental Material can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2023.11.033] on http:// www.annalsthoracicsurgery.org.
Objective: Bicuspid aortic valve (BAV) represents 2 cusps oriented along a spectrum of equal (180/180) or unequal (150/210) leaflet surface area distribution along the aortic annular plane. We have taken the approach of respecting the native geometric orientation of the repaired BAV leaflets when creating the aortic neoroot during valve-sparing root reimplantation (VSRR) procedures. We investigated midterm outcomes with this 2-prong approach for VSRR in BAV syndrome. Methods: Of 72 patients in a prospectively maintained BAV repair database, 68 met inclusion criteria: 36 patients had 180/180 neoroot geometry, and 32 patients had 150/210 orientation. A multivariate ordinal logistic mixed effects model was performed to study parameters associated with recurrent AI greater than 2þ. Results: Preoperative parameters were similar between 180/180 and 150/210 groups, except for greater incidence of AI 4þ in the latter (50.0% [n ¼ 16] vs 8.3% [n ¼ 3]; P<.001). Postoperatively, stroke, renal failure, reoperation for bleeding, and pacemaker rates were 0 in the entire cohort. In-hospital/30-day mortality in the entire cohort was 1.5% (n ¼ 1). Multivariate ordinal logistic mixed effects model showed that preoperative AI greater than 3þ (odds ratio, 0.4; P ¼ .46) and geometric orientation of the aortic neoroot (odds ratio, 3.8; P ¼ .25) were not significantly associated with recurrence of AI greater than 2þ. Conclusions: Respecting BAV geometry for VSRR neoroot creation yields excellent midterm outcomes and may minimize conjoint cusp leaflet stress that may occur in ‘‘forcing’’ a 150/210 type I BAV into a 180/180 neoroot. (J Thorac Cardiovasc Surg 2020;160:47-57)
Copyright 2019 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2019.06.119
*Elektrokardiyografik değişiklikler, bilinen aterosklerotik veya revaskülarize edilmiş koroner damar bölgelerinin anatomisi ile birlikte değerlendirilmelidir. Hava embolisi çoğunlukla sağ koroner arteri etkiler ve genellikle ameliyathanede inferior derivasyonlarda ST değişiklikleri görülür. Bu durum çoğu zaman birkaç saat içinde kendiliğinden düzelir. Bununla birlikte postoperatif dönemde spesifik olmayan ST değişikliklerinin sık görüldüğü ve genellikle benign olduğu akılda tutulmalıdır. Perikardiyal değişiklikler ise genellikle diffüz konkav ST elevasyonları ile karakterizedir, sıklıkla perikardiyal frotman eşlik eder ve genellikle cerrahiden en az 12 saat sonra ortaya çıkar.
PULMONER HİPERTANSİYON VE SAĞ VENTRİKÜL FAİLURE:
*PVR’deki akut artışlar genellikle akut sol ventrikül disfonksiyonu, mitral kapak yetmezliği veya stenozu, volüm yüklenmesi, pulmoner ödem, atelektazi, hipoksi veya asidoz gibi nedenlerle gelişir. Pulmoner emboli de düşünülmelidir, ancak erken postoperatif dönemde nadir görülür.
*Sağ kalp yetmezliği geliştikçe sağ kalp boşlukları genişler, santral venöz basınç (CVP) artar, triküspit yetmezliği gelişebilir ve pulmoner arter basınçları ile sol kalp dolum basınçları yetersiz hale gelir.
*Potansiyel olarak ölümcül olabilen bu sürecin tersine çevrilmesine yönelik stratejiler, öncelikle geri döndürülebilir nedenlerin belirlenmesi ile başlar. Volüm durumu ve sol kalp fonksiyonu optimize edilmelidir. Sağ ventrikülün de kendine özgü bir Starling eğrisi vardır ve sağ ventrikül yetmezliğinde çoğu zaman sol kalp dolumunun yeterli olmasını sağlamak için daha fazla volüme ihtiyaç duyulur; ancak aşırı dilatasyon sağ ventrikül fonksiyonunu daha da kötüleştirebilir.
*Atelektatik akciğer bölgelerini açmak için pozitif end-ekspiratuvar basıncın (PEEP) dikkatli kullanımı ve hiperventilasyon, hipoksi ve hiperkapniye bağlı gelişen pulmoner vazokonstriksiyonun etkisini azaltabilir. Pulmoner vasküler direnci azaltmak amacıyla intravenöz vazodilatörlerin kullanımı, sıklıkla sistemik hipotansiyon ile sınırlıdır. İnotrop ajanlar (genellikle aynı zamanda vazodilatör etkisi de bulunan milrinon) yararlı olabilir.
AORT KAPAK REPLASMANI:
Aort Stenozu
Aort stenozu, hipertrofik ve uyumu azalmış (nonkompliant) bir sol ventrikülün gelişmesine neden olabilir. Bazı hastalarda stenotik kapağın replasmanı sonrasında, uzun süre anormal derecede yüksek afterload’a karşı çalışmaya adapte olmuş ventrikül postoperatif dönemde supranormal kardiyak debi ve kan basıncı düzeylerine kolaylıkla ulaşabilir. Bu nedenle yeni oluşturulmuş sütür hatlarının zarar görmesini önlemek amacıyla kan basıncının dikkatli kontrolü sıklıkla gereklidir.
Bazı hastalarda belirgin ventriküler hipertrofi dinamik sol ventrikül çıkış yolu obstrüksiyonuna yol açabilir. Bu durum en etkili şekilde volüm verilmesi, beta bloker kullanımı ve afterload artırılması ile tedavi edilir. Dinamik çıkış yolu obstrüksiyonu olmasa bile azalmış ventrikül uyumu (diyastolik disfonksiyon), hastanın hipovolemik hale gelmesi veya normal sinüs ritmini kaybetmesi durumunda ciddi hemodinamik bozulmaya yol açabilir. Bunun nedeni stroke volümün %30’una kadar olan kısmının atriyum ve ventrikül kontraksiyonları arasındaki senkronizasyona bağlı olmasıdır.
Bu nedenle ventriküler pacing tellerine ek olarak atriyal pacing tellerinin yerleştirilmesi, postoperatif dönemde hastada bradikardi veya kalp bloğu gelişmesi durumunda önemli avantajlar sağlayabilir.
Aort Yetmezliği
Aort yetmezliği olan hastalarda sol ventrikül genellikle belirgin hipertrofi olmaksızın dilate durumdadır ve postoperatif dönemde sıklıkla yetersiz kontraktil fonksiyon gösterir. Bu hastalarda volüm durumunun, afterload’un, inotropinin ve ritmin optimize edilmesi çoğu zaman zorlayıcı olabilir.
MİTRAL KAPAK REPLASMANI:
Mitral Yetmezlik
Yetersiz (inkompetan) bir mitral kapağın onarımı veya replasmanı sonrasında artan afterload ve buna bağlı gelişen duvar gerilimi artışı, altta yatan sol ventrikül disfonksiyonunun ortaya çıkmasına neden olabilir. Cerrahi sonrasında görülen afterload uyumsuzluğunu (afterload mismatch) azaltmak amacıyla sıklıkla inotropik destek ve sistemik vazodilatasyon gerekebilir. Nadiren sol ventrikül disfonksiyonu, cerrahi sırasında yerleştirilen sütürlerin sirkumfleks koroner arteri istemeden zedelemesi veya akımını bozması sonucunda gelişebilir.
Mitral Stenoz
Mitral yetmezliği olan hastaların aksine, mitral stenozlu hastalarda sol ventrikül fonksiyonu genellikle korunmuştur. Bununla birlikte mevcut pulmoner hipertansiyonun alevlenmesi postoperatif dönemde sık görülür. Bu nedenle postoperatif yönetim stratejileri çoğunlukla sağ ventrikül fonksiyonunun optimize edilmesine ve pulmoner vasküler direncin (PVR) azaltılmasına odaklanır.
NÖROVASKÜLER DURUM:
*Kanama riski nedeniyle inme ile başvuran kardiyak cerrahi hastaları intravenöz trombolitik tedavi için uygun adaylar değildir. Bununla birlikte, embolik damar oklüzyonu bulunan seçilmiş hastalarda, olaydan sonraki 6–8 saat içinde uygulanması durumunda endovasküler tedavi faydalı olabilir. Posterior dolaşım oklüzyonlarında bu süre 24 saate kadar uzayabilir
Left ventricular distention (LVD) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is increasingly recognized but seldom reported in the literature. The current study defined LVD as not present (LVD−); subclinical (LVD+, evidence of pulmonary edema on chest radiograph AND pulmonary artery diastolic blood pressure greater than 25 mm Hg within the first 2 hours of intensive care unit admission); or clinical (LVD++, need for decompression of the left ventricle immediately following VA-ECMO initiation). Among 226 VA-ECMO device runs, 121 had sufficient data to define LVD retrospectively. Nine patients (7%) developed LVD++ requiring immediate decompression, and 27 patients (22%) met the definition of LVD+. Survival to discharge was similar among groups (LVD++: 44%, LVD+: 41%, LVD−: 44%). However, myocardial recovery appeared inversely related to the degree of LVD (LVD++: 11%, LVD+: 26%, LVD−: 40%). When death or transition to device was considered as a composite outcome, event-free survival was diminished in LVD++ and LVD+ patients compared with LVD−. Multivariable analysis identified cannulation of VA-ECMO during extracorporeal cardiopulmonary resuscitation (ECPR) as a risk factor for decompression (odds ratio [OR]: 3.64, confidence interval [CI]: 1.21–10.98; p = 0.022). Using a novel definition of LVD, the severity LVD was inversely related to the likelihood of myocardial recovery. Survival did not differ between groups. Extracorporeal cardiopulmonary resuscitation was associated with need for mechanical intervention. ASAIO Journal 2017; 63:257–265.
Objectives: We investigated the frequency of prosthesispatient mismatch (PPM) after mechanical mitral valve replacement (MVR), its effect on postoperative systolic pulmonary arterial pressure (PAP), and the relationship of indexed effective orifice area (EOA) with systolic PAP and hemodynamic variables of the prosthetic valve. Study design: The study included 100 patients (27 men, 73 women; mean age 51±11 years) with a normally functioning mechanical mitral valve prosthesis. Prosthetic mitral EOA, indexed EOA, and net atrioventricular compliance (Cn) were estimated by Doppler echocardiography. Prosthesis-patient mismatch was defined as an indexed EOA ≤1.2 cm2/m2 and Cn ≤4 ml/mmHg, and pulmonary hypertension (PHT) was defined as systolic PAP ≥40 mmHg. Results: The frequencies of PPM and postoperative persistent PHT were 33% and 31%, respectively. Postoperative persistent PHT was seen in 79% and 8% in patients with and without PPM, respectively (p<0.001). The frequency of low Cn was significantly higher in patients with PPM (60% vs. 31%; p<0.001). Postoperative systolic PAP was significantly higher in patients with PPM (42.0±6.6 mmHg vs. 29.9±6.0 mmHg, p<0.0001) and in 41 patients having a low Cn compared to 59 patients having a high Cn (37.2±8.8 mmHg vs. 31.6±7.4 mmHg, p<0.001). Postoperative systolic PAP was significantly correlated with indexed EOA (r=-0.535, p<0.001) and Cn (r=-0.422, p<0.001), whereas prosthetic valve size was not correlated with systolic PAP (r=0.022, p=0.829) and indexed EOA (r=0.008, p=0.93). In multivariate regression analysis, indexed EOA, age, mean transprosthetic gradient, and Cn were independent factors affecting systolic PAP. Conclusion: Prosthesis-patient mismatch after MVR is associated with persistent PHT. Use of a prosthetic valve that is compatible to the body surface area may significantly reduce the incidence of PPM, and thus the frequency of persistent PHT.
Türk Kardiyol Dern Arş – Arch Turk Soc Cardiol 2009;37(8):523-530
The use of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) to support patients with acute heart failure has been associated with ventricular distension and pulmonary edema, the mechanism of which is not fully understood. This study examined the impact of VA ECMO on left ventricular (LV) Starling curves to elaborate a framework for anticipating and treating LV distension. A previously developed and validated model of the cardiovascular system was used to generate pressure–volume (PV) loops and Starling curves while holding mean arterial pressure (mABP) constant at a range of values either by adjusting systemic resistance or by adding VA ECMO support. It was found that under all conditions of similar mAPB, the Starling curve was unchanged; therefore, the degree of LV distension is obligated by the mAPB (irrespective of whether controlled pharmacologically with or without ECMO support and independent of heart rate), LV contractility, and target stroke volume. The Starling relationship provides a conceptual framework for understanding the risk and treatment of LV distension during VA ECMO support. ASAIO Journal 2017; XX:00–00.
