Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting.

The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.

Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database.

OBJECTIVES: To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore 'real-world' practice. DESIGN: Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants' demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. SETTING: 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. PARTICIPANTS: 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. RESULTS: In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60-75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. CONCLUSIONS: Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Clinically significant incidental findings during preoperative computed tomography of patients undergoing cardiac surgery.

With the development of minimally invasive cardiac surgery, chest and abdominal computed tomography (CT) scans are becoming an integral part of preoperative assessment and planning. Therefore, the number of incidental findings (IFs) detected with CT is rising. We aimed to investigate the frequency of clinically significant IFs on chest and abdominal CT scans performed during the preoperative assessment of patients undergoing adult cardiac surgery in a 2-year period. In a cohort of 401 patients (mean age 67.4 ± 12.3, female gender 28.9%, median logistic EuroSCORE 5.8 [0.9, 90.5]) who underwent chest or abdominal CT imaging during the study period, we identified 75 patients (18.7%) with clinically significant IFs who needed a further treatment or work-up to confirm the diagnosis or postoperative follow-up. Our data indicate that clinically significant IFs in patients referred for cardiac surgery are frequent. It is important to identify clinically significant Ifs, as a clear postoperative follow-up plan should be made.

Dramatic resolution of an immediate postoperative distortion of the circumflex artery during mitral valve surgery.

Injury or distortion of the circumflex coronary artery can occur during mitral valve surgery, due to its proximity to the mitral valve annulus. We present the case of a 72-year-old male patient with symptomatic mitral regurgitation, who underwent minimally invasive mitral valve surgery. The initial reparative gesture was complicated by intraoperative infarct due to a distortion of the circumflex artery (CX) caused by the rigidity of the ring used; the mainstay of the treatment was the removal of the previous device implanted in favor of a flexible one with restitutio ad integrum of the CX patency.

Mitral valve annulus and circumflex artery: In vivo study of anatomical zones.

OBJECTIVE: To provide, with the use of preoperative coronary computed tomography angiography, an in vivo anatomical characterization of the relationship between the circumflex artery and mitral valve annulus to identify different risk classes and to increase the surgical awareness of those anatomical relations. METHODS: Ninety-five (mean age: 64.2 ± 11.7) consecutive patients, initially referred for elective minimally invasive mitral valve surgery, underwent preoperative coronary computed tomography angiography. The distance between the circumflex artery and mitral annulus was assessed using 6 points designed on the posterior mitral annulus, starting from the anterolateral to the posteromedial commissure; this design created an ideal 5-zone system. High-risk anatomy was defined as a distance less than 3 mm between the circumflex artery and the mitral valve annulus. RESULTS: The shortest distance between the circumflex artery and mitral valve annulus was observed at the area between the anterolateral commissure and the midpoint of P1 scallop, so-called zone 1 (5.49 ± 3.13 mm), whereas the longest distance occurred at zone 5 (12.03 ± 4.93). Twenty-four patients (25%) were identified with high-risk anatomy (mean distance 1.94 ± 0.8 mm). Left dominant and co-dominant hearts demonstrated a shorter circumflex artery-mitral valve annulus distance at all the zones. At multinomial logistic regression, the pattern of coronary dominance and the size of the circumflex artery were independent factors for high-risk anatomy. CONCLUSIONS: Coronary computed tomography angiography is a useful investigation to identify patients at risk of circumflex artery flow disturbance; for high-risk anatomy, this knowledge may enhance a safer operative technique.

Early failure of a bioprosthetic aortic valve due to thrombus formation while on rivaroxaban.

There is increasing evidence that bioprosthetic valve thrombosis (BPVT) is more common than previously thought. However, there are very few cases describing the occurrence of BPVT on therapeutic anticoagulation, and no previous cases are available stating the occurrence of BPVT on direct oral anticoagulant therapy. We describe the case of surgically managed aortic BPVT that was diagnosed while the patient was on rivaroxaban.

Management of refractory bleeding post-cardiopulmonary bypass in an acute heparin-induced thrombocytopenia type II renal failure patient who underwent urgent cardiac surgery with bivalirudin (Angiox®) anticoagulation.

Acute heparin-induced thrombocytopenia (HIT) patients present a myriad of anticoagulation management challenges, in clinical settings where unfractionated heparin (UFH) is the traditional drug of choice. UFH use in cardiac surgery is a known entity that has been subject to rigorous research. Research has, thus, led to its unparalleled use and the development of well-established protocols for cardiac surgery. In comparison to UFH, bivalirudin use for acute HIT patients requiring urgent cardiac surgery with cardiopulmonary bypass (CPB) is still in its infancy. We describe the tailored post-CPB management of refractory bleeding in a 65-year-old infective endocarditis, acute HIT patient with renal failure who underwent urgent aortic valve replacement and mitral valve repair with bivalirudin anticoagulation. A management approach that entailed a combination of continuous venovenous haemofiltration (CVVH), 4-Factor prothrombin complex concentrate (PCC) (Beriplex), recombinant factor VIIa (rFactor VIIa) and desmopressin (DDAVP) were consecutively used post-operatively in theatre. Based on this case study experience, two modifications to institutional protocols are recommended. The first is the use of CVVH in theatre to eliminate bivalirudin in renal failure patients or in patients where bivalirudin elimination is prolonged. Secondly, a 'rescue therapy/intervention' algorithm for the swift identification of refractory bleeding post-CPB is also recommended. Rescue therapy agents, such as a 4-Factor PCCs and rFactor VIIa, should be incorporated into the protocol after a robust evidence-based search and agreement with the haematologist. The aim of these recommendations is to reduce the risk of bleeding associated with bivalirudin use for inexperienced institutions and experienced institutions alike, until larger randomized, controlled studies provide more in-depth knowledge to expand our clinical practice.

Infective endocarditis in a parachute-like asymmetrical mitral valve.

A 21-year-old woman was admitted to our unit with suspected infective endocarditis. Transthoracic and transoesophageal echocardiogram demonstrated vegetation in a parachute-like asymmetrical mitral valve with severe mitral regurgitation. She was completely asymptomatic before this presentation. Though there was no evidence of mitral stenosis, this deformity is associated with transvalvular turbulence, which would account for the increased likelihood of infective endocarditis. She underwent a prosthetic mitral valve replacement with a 21 mm ATS mechanical valve.

Right atrial thrombus masquerading as intracardiac cyst: a case report.

Intracardiac cystic lesions are rare. Hydatid disease, blood cysts and bronchogenic cysts in various chambers of the heart have been reported. Right atrial thrombus presenting as a cystic lesion on echocardiogram has not been reported. We describe a patient with mitral regurgitation in atrial fibrillation with a right atrial cyst, which was found to be a cavitating thrombus.

Microwave surgical ablation for atrial fibrillation during off-pump coronary artery surgery using total arterial-Y-grafts: an early experience.

This study demonstrates the efficacy and eligibility of concomitant epicardial microwave AF (MWAF) ablation during off-pump arterial revascularisation using the left internal mammary to radial 'Y' graft (OPCABy) in patients with permanent and paroxysmal atrial fibrillation. From June 2004 to December 2005, sixteen consecutive patients were offered MWAF ablation and OPCABy. AF was permanent in 11 cases and paroxysmal in five. The MWAF ablation protocol exploited the use of either the Flex 4 or Flex 10 probe (Afx- Guidant, Santa Clara, CA). Spontaneous cardioversion was used to demonstrate conduction block. Data were collected prospectively. Patients were followed-up in outpatient clinic at 6 weeks, 3 months and 6 months after discharge. Sinus rhythm was seen in 75%, 67% and 71% of patients at conclusion of surgery, and 3 and 6 months postoperatively. Cardioversion to sinus rhythm was seen in 67% of patients with permanent AF and 80% of patients with paroxysmal AF. Spontaneous cardioversion at operation occurred in 12 patients, all of whom were in sinus rhythm at six months. The use of MWAF ablation during concomitant OPCABy surgery is an effective therapy in the short- to medium-term. Spontaneous return to sinus rhythm is a reliable intraoperative indicator of long-term success.

Wire perforation of Flex 10 microwave device during thoracoscopic atrial fibrillation ablation.

OBJECTIVES: Rapid advances in technology are increasing the repertoire of techniques available for the surgical treatment of atrial fibrillation (AF). These techniques utilize new devices which are normally safe. However, potential problems can arise with a new device as is illustrated in this report. METHODS: A 58-year-old man underwent a thoracosopic AF ablation utilizing the Flex 10 probe (Guidant, Afix, Fremont, CA). RESULTS: We experienced an important device failure following thoracoscopic microwave AF ablation that has not been reported to date. CONCLUSIONS: Although new devices seem to be safe, potential problems often emerge with time, and clinicians pioneering these technologies have an obligation to report these experiences to the wider surgical community.

Intraoperative confirmation of ulnar collateral blood flow during radial artery harvesting using the "squirt test".

Hand ischemia is a major concern after radial artery harvesting for coronary revascularization. Although a number of preoperative tests have been described to assess the adequacy of ulnar collateral blood flow, many of them are subjective and unreliable. In addition, the presence of arterial connections between the radial and ulnar systems in the elbow and forearm and variability in forearm angiology imply that assessment of alternative blood supply to the hand can only be made once collateral branches of the radial artery have been divided. We describe a technique for intraoperative assessment of ulnar collateral blood flow after mobilization and division of collateral branches of the radial artery.