Safety Time and Optimal Temperature of Unilateral Antegrade Cerebral Perfusion in Acute Type A Aortic Dissection: A Single-Center 15-Year Experience.

Background: The optimal level of hypothermia and safe time of unilateral antegrade cerebral perfusion (uACP) in acute type A aortic dissection (ATAAD) repair remain controversial. Objectives: To analyze the association of uACP time and circulatory arrest temperature with surgical outcomes of ATAAD. Methods: We retrospectively analyzed 263 patients who had undergone ATAAD repair between 2006 and 2020 using uACP. The patients were stratified by three chronologically equivalent periods (period 1, 2006 to 2010; period 2, 2011 to 2015; period 3, 2016 to 2020) to demonstrate the decade-long evolution of surgical strategy and outcomes. Results: The mean age of the patients was 59.4 ± 12.5 years, and 68.8% were male. The hospital mortality rates were 15.1%, 12.9%, and 11.0% from period 1 to 3 (p = 0.740). The median circulatory arrest temperatures were 20, 23, and 25 °C (p < 0.001), respectively, and the median uACP times were 72, 59, and 41 minutes (p < 0.001). The incidence rates of postoperative permanent neurologic deficits were 13.2%, 10.9%, and 18.3% (p = 0.312), and those of transient neurologic deficits were 9.4%, 10.9%, and 11.9% (p = 0.936), respectively. Multivariate logistic regression analysis showed that uACP time ≥ 60 minutes was an independent predictor of hospital mortality rather than postoperative stroke. ROC curve analysis estimated an optimal cutoff value of 52 minutes of uACP time when the circulatory arrest temperature was ≥ 25 °C to predict hospital mortality (area under the curve: 0.72). Conclusions: Unilateral antegrade cerebral perfusion time was associated with hospital mortality after ATAAD surgery. A safe threshold of 50 to 60 minutes of uACP should be considered.

Post-extubation use of high-flow nasal oxygenation induces upper airway leak and intrathoracic sepsis after successful Bentall procedure: A case report.

RATIONALE: In recent few years, high-flow nasal oxygenation (HFNO) has been widely used for management of acute hypoxemic respiratory failure and during postextubation periods, including after endotracheal intubation general anesthesia (ETGA). However, HFNO generates positive pressure in the injured airway following removal of endotracheal tube may cause airway leaks. This is the first case report of severe airway leak syndrome following postextubation use of HFNO in surgical patients. PATIENT CONCERNS: This case report describes a 75-year-old female with critical aortic stenosis who underwent an emergency Bentall procedure. HFNO (flow rate of 45 L/min) was applied after weaning from mechanical ventilation and removal of the endotracheal tube. DIAGNOSES: At 6 hours after HFNO application, subcutaneous emphysema in the neck bilaterally and face was noted, and the emphysema extended into the supraclavicular regions. INTERVENTIONS: The HFNO cannula was removed soon after and the patient was re-intubated with an endotracheal tube the following day due to progressive respiratory insufficiency. Unfortunately, the patient general condition deteriorated, as the subcutaneous air collections progressed into deep tissue infections of the neck, mediastinal abscesses, and left-sided empyema. Patient received surgical interventions repeatedly to drain the mediastinal abscess and empiric antimicrobial therapy was given. OUTCOMES: The patient passed away about 2 months later due to uncontrollable sepsis. LESSONS: Air leaks in the upper airway can occur during the use of post-extubation HFNO use, and the resulting subcutaneous emphysema can progress to severe intrathoracic infections in surgical patients who have a sternotomy wound. Therefore, HFNO-induced subcutaneous emphysema should be treated more aggressively in open thoracic or sternotomy surgeries to prevent the development of intrathoracic sepsis.

Aortic root remodeling after surgical repair of acute type A aortic dissection using different anastomosis techniques.

Background: After surgical repair of acute type A aortic dissection (aTAAD), remodeling of the residual aortic segments is the key outcome parameter associated with late reoperation or aorta-related adverse events. In this study, we analyzed the surgical outcomes of aTAAD using either a telescopic or continuous anastomosis technique, focusing on their impact on aortic root remodeling during the longitudinal follow-up. Methods: Between 2012 and 2018, 112 surgical repairs of aTAAD with ascending aorta replacement and without aortic arch or aortic root replacement were performed. The medical records were reviewed retrospectively, and early and late outcomes were compared between the telescopic and continuous anastomosis techniques. The generalized estimating equation method was used to analyze the effects of different anastomosis techniques on serial aortic root remodeling. Results: The telescopic anastomosis technique was used in 46 cases (41.1%), and the conventional continuous anastomosis technique was used in 66 cases (58.9%). There were no differences in in-hospital mortality or the incidence of major complications between the groups. The telescopic anastomosis group demonstrated stable postoperative regression of the aortic root diameter during follow-up. In contrast, the continuous anastomosis group showed a progressive dilatation of the aortic root. There was a trend toward better aortic root adverse event-free survival rates in the telescopic anastomosis group (P = .081). Conclusions: The telescopic anastomosis technique is a safe alternative to the continuous anastomosis technique in the surgical repair of aTAAD, with comparable early results. In addition, telescopic anastomosis was associated with beneficial aortic root remodeling in the medium term compared with continuous anastomosis.

Outcomes of acute type A aortic dissection operations performed by early-career cardiovascular surgeons.

Objective: Surgical outcomes of acute type A aortic dissection have been recognized to be associated with the surgical volume of individual hospitals and surgeons. In this study, we aimed to investigate the results and learning curves of acute type A aortic dissection operations performed by early-career cardiovascular surgeons. Methods: A total of 248 surgical repairs of acute type A aortic dissections were conducted at a tertiary medical center between 2010 and 2018. By using the cumulative sum test, cardiovascular surgeons in their early career were identified, and their performances were assessed. The outcomes of patients who were operated by early-career cardiovascular surgeons were compared with those by experienced or senior surgeons. Results: During the study period, 202 (81.5%) of the 248 acute type A aortic dissection operations were performed primarily by the 4 newly appointed attending cardiovascular surgeons. In cumulative sum curves, all surgeons exhibited a steady performance throughout the study period. On the basis of our institutional result of acute type A aortic dissection operation, early career was defined as performing fewer than 32 acute type A aortic dissection operations. The 30-day mortality rates of acute type A aortic dissection operations performed by early-career surgeons were equivalent to those performed by experienced/senior surgeons (10.9% vs 12.5%, P = .844). There was also no difference in mid-term overall survival and aortic event-free survival between the 2 groups (P = .638 and P = .574, respectively). Conclusions: In a center with a well-established program, cardiovascular surgeons could accomplish surgical repair of acute type A aortic dissection with adequate early- and mid-term results from the initiation of their careers.

Simultaneous Thrombolysis and Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Emboli.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been used in patients with circulatory collapse or extremely unstable hemodynamics caused by acute massive pulmonary embolism (PE). The effectiveness of simultaneous thrombolytic therapy has been rarely investigated in these patients after being stabilized with ECMO. METHODS: From January 2008 to December 2018 consecutive patients with acute massive PE requiring ECMO supported in a tertiary medical center were included for retrospective analysis. RESULTS: Thirteen patients with PE underwent ECMO implantation and received subsequent thrombolytic therapy as a definite treatment for PE. All patients survived their ECMO courses to a successful decannulation, with a mean ECMO support duration of 6.23 ± 4.69 days. Eleven patients (84.62%) survived to hospital discharge. All survivors were alive during follow-up, although 2 patients (18.2%) had permanent dysfunctional neurologic complications. Major bleeding complications occurred in 4 patients (30.77%), whereas no patient had intracranial hemorrhage. Systemic thrombolysis showed comparable outcomes of catheter-directed thrombolysis in our patients who underwent ECMO. CONCLUSIONS: Thrombolysis-based therapeutic strategy under ECMO could be a relatively safe and effective definitive treatment for patients with acute massive PE, even for those who were resuscitated. Bleeding complications remain a major concern and should be monitored and managed immediately.

Initial Experience With Patent Ductus Arteriosus Ligation in Pre-term Infants With Bidirectional Shunt Pattern.

Background: Patent ductus arteriosus (PDA) with a bidirectional shunt reflects critical clinical conditions. The operability of PDA with a bidirectional shunt in pre-term infants is still not clearly clarified. This study aimed to investigate the feasibility and the outcomes of PDA ligation in pre-term infants with a bidirectional shunt PDA. Methods: All pre-term infants receiving PDA ligation between 2013 and 2019 were enrolled in this prospective study. Patients were allocated into two groups based on the shunting direction of PDA, which were the left-to-right group (group A) and the bidirectional group (group B). Clinical characteristics and pre-op comorbidities were analyzed. Intraoperative complications, post-op neurological sequelae, necrotizing enterocolitis, survival, and mortality were compared between these two groups. Results: Thirty-seven pre-term infants were enrolled (18 in group A, 19 in group B). The mean post-menstrual age at PDA surgery was 32.0 ± 1.3 and 32.8 ± 1.5 weeks, respectively. Before surgery, 44.4 and 89.5% (group A vs. B) of the patients were using invasive mechanical ventilator (p < 0.01). The requirement of high-frequency oscillatory ventilatory support was significantly higher in group B. PDA rupture-related bleeding during exposing PDA or ligating PDA occurred in four infants, and all were all in group B, including one with delayed hemothorax. Early surgical mortality within 30 days of surgery was higher in group B (0 vs. 21.1%, p < 0.05), but only one death could be attributed to the surgery, which was caused by a pain-induced pulmonary hypertension crisis. The 5-year survival was 100% in group A, and 73.7% in group B (p < 0.05). Conclusion: We did not recommend routine PDA ligation in pre-term infants with a bidirectional shunt. However, a bidirectional shunt should not be an absolute contraindication if they fulfill indications of PDA closure. Unexpected intraoperative PDA rupture and delayed hemothorax in a bidirectional shunt PDA should be carefully monitored. Aggressive post-op pain control is also warranted to avoid pulmonary hypertension crisis. The post-op early mortality rate was higher in the bidirectional group, which could be inherent to their poor pre-operative lung condition. Only one death was directly related to the surgery.

Modified exchange technique for management of dysfunctional tunneled hemodialysis catheters in the presence of exit-site infection: a quality improvement report.

BACKGROUND: Over-the-wire exchange is a standard treatment for patients with tunneled hemodialysis catheters (THCs) that fail to maintain sufficient extracorporeal blood flow. However, this well-known procedure is unsuitable in the presence of exit-site infection (ESI). In such cases, a modified exchange technique with introduction of the new THC through a remote exit site and the preexisting subcutaneous tunnel may be a solution. STUDY DESIGN: Quality improvement report. SETTING & PARTICIPANTS: Since 2005, a total of 28 consecutive dysfunctional THCs with ESI in 23 patients who did not have tunnel infection or bacteremia before the procedures was included. QUALITY IMPROVEMENT PLAN: Introduction of the new THC through a remote exit site and preexisting subcutaneous tunnel. MEASUREMENTS: Technical success, perioperative complications, infection rates, and catheter function were recorded for analysis. RESULTS: There was only 1 failure, giving an overall technical success rate of 96%. The other 27 exchanged THCs achieved satisfactory flow during subsequent hemodialysis, and the ESI gradually resolved within 2 weeks. Although 8 episodes of new ESI occurred, no subcutaneous tunnel infection or bacteremia occurred within 120 days. Bedridden patients had more occurrences of new ESIs than nonbedridden patients (6 of 9 versus 2 of 13 patients; P = 0.03). Primary catheter patency rates were 100% at 30 days, 82% at 90 days, and 77% at 120 days. Secondary catheter patency rates were 100% at 30 days, 91% at 90 days, and 91% at 120 days. LIMITATION: A small number of cases and comparison with previous studies of THC exchange. CONCLUSIONS: For dysfunctional THCs with ESI, exchange through remote exit sites and preexisting subcutaneous tunnels is feasible and can be used repeatedly for patients prone to ESI, such as the bedridden. This modified exchange technique is also preferable for operators who question the sterility of previous exit sites and are reluctant to use the over-the-wire technique.

"Mantle-style" modification of Cabrol shunt for hemostasis after extended aortic reconstruction in acute type A aortic dissection.

Cabrol shunt and several of its modifications have been used as adjunctive procedures to control inaccessible bleeding occurring after aortic root surgeries. Nevertheless, the hemostatic effect of the shunt is suboptimal when the reconstructive procedure extends to the aortic arch and coronary arteries. We propose a "Mantle-style" modified Cabrol shunt to facilitate hemostasis of the exsanguination from the neo-root after aortic root replacement with concomitant arch and coronary reconstruction.

Cardiopulmonary Bypass Time Predicts Early Postoperative Enterobacteriaceae Bloodstream Infection.

BACKGROUND: A bloodstream infection in patients undergoing cardiovascular operations is crucial because it can result in significantly worse outcomes. However, microbiological patterns have rarely been investigated in these patients. METHODS: We retrospectively reviewed the data of 1,041 adult patients who underwent cardiovascular operations using cardiopulmonary bypass from January 2013 to December 2017 at the National Cheng Kung University Hospital, Tainan, Taiwan. The microbiological pattern and associated variables were analyzed in patients with early postoperative primary bloodstream infection. RESULTS: Primary bloodstream infection developed in 28 patients (2.7%) within 7 days after cardiovascular operations using cardiopulmonary bypass. In patients with early primary bloodstream infection, 36 microorganisms were isolated, and a gram-negative bacillus was identified to be the predominant pathogen (28 of 36 [77.8%]). The most common microorganisms comprised the Enterobacter (n = 8) and Acinetobacter (n = 7) species, and 16 of the 28 gram-negative bacilli belonged to the Enterobacteriaceae family. Compared with those without postoperative bloodstream infection, patients with Enterobacteriaceae family-related early postoperative bloodstream infections had a significantly longer cardiopulmonary bypass time and also worse early and late survival rates. CONCLUSIONS: Most patients with early primary bloodstream infection after cardiovascular operations using cardiopulmonary bypass were infected with gram-negative bacilli, and the Enterobacteriaceae family was the most common microorganism observed. Endogenous bacterial translocation after prolonged cardiopulmonary bypass is a possible mechanism of Enterobacteriaceae family-related early primary bloodstream infection in these patients. Prophylactic use of an antibiotic regimen with broader gram-negative bacteria coverage in cardiovascular surgical patients with prolonged cardiopulmonary bypass should be considered.

Resuscitation for an octogenarian with ruptured abdominal aortic aneurysm using endovascular balloon.

Ruptured abdominal aortic aneurysm is a true emergency for emergency physicians and surgeons. Achieving effective proximal control may ameliorate further hemodynamic deterioration and buy time for patients awaiting further repair. An 82-year-old man was referred to our hospital with shock resulting from a ruptured abdominal aortic aneurysm. At the moment of impending cardiac arrest, aortic occlusion was achieved with a transfemoral endovascular balloon, without fluoroscopic guidance. The octogenarian then underwent a prosthetic graft reconstruction and recovered well. In this report, the safeguards and pitfalls of aortic occlusion using an endovascular balloon are discussed. This procedure is not only effective in vascular control but also valuable in resuscitation.

The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: A 10-year experience.

Whether critically ill neonates needing a surgical intervention should be transferred to an operating room (OR) or receive the intervention in a neonatal intensive care unit (NICU) is controversial. In this study, we report our experience in performing surgical procedures in a NICU including air cleanliness.This was a retrospective study performed at a metropolitan hospital. The charts of all neonates undergoing surgical procedures in the NICU and OR were retrospectively reviewed from January 2007 to June 2017. Data on baseline characteristics, procedure and duration of surgery, ventilator use, hypothermia, instrument dislocations, surgery-related infections and complications, and outcomes were analyzed.Ninety-two neonates were enrolled in this study, including 44 in the NICU group and 48 in the OR group. The air cleanliness was International Organization for Standardization (ISO) 14644-1 class 7 in the NICU and class 5-6 in the OR. The NICU group had a younger gestational age and lower birth body weight than the OR group. The OR group had a higher incidence of hypothermia than in the NICU group (56.3% vs 9.1%, P < .001). However, there were no significant differences in surgical site related infections or mortality between the 2 groups.This study suggests that performing surgical procedures in a NICU with air cleanliness class 7 is as safe as in an OR, as least in part, when performing patent ductus arteriosus ligation and exploratory laparotomy.

Successful conservative management with positive end-expiratory pressure for massive haemothorax complicating pacemaker implantation.

Haemothorax resulting from injury to a great vessel is a potential complication during transvenous pacemaker implantation that can be caused by perforation by the electrode. If the amount of bleeding is massive, control needs thoracotomy. We report on a 70-year-old man who had a massive haemothorax following transvenous pacemaker implantation. This complication was controlled successfully by using positive end-expiratory pressure (PEEP). We conclude that this simple but reproducible experience may offer effective haemostasis for a massive haemothorax caused by transvenous catheter perforation.

Bilateral persistent sciatic arteries complicated with acute left lower limb ischemia.

Persistent sciatic artery (PSA) is a rare congenital malformation. In the early embryonic stage, the sciatic artery is the major blood supply for the lower limb bulb and is later replaced by the iliofemoral artery as the limb develops. Its failure to regress, sometimes associated with femoral arterial hypoplasia, and therefore becoming the dominant inflow to the lower extremity is called PSA. This anomaly is often associated with a higher rate of aneurysm formation or thromboembolic complications causing lower extremity ischemia. Here, we describe a 79-year-old male patient who presented with acute left lower extremity ischemia. He was treated initially with conventional embolectomy through inguinal and popliteal incisions. The bilateral PSA with thrombosed aneurysms was not identified at first on computed tomographic angiography. It was later diagnosed intraoperatively due to the discontinuity of the superficial femoral artery and popliteal artery found with embolectomy catheter, and was managed successfully with ePTFE graft bypass. Careful interpretation of the imaging study may be helpful in preoperative diagnosis.

Effect of false lumen partial thrombosis on repaired acute type A aortic dissection.

OBJECTIVE: Studies on the partial thrombosis of a false lumen after repairing a type A acute aortic dissection (TAAAD) have reported conflicting results. We investigated the effects of a partially thrombosed false lumen on the segmental growth rates, distal aortic reoperations, and long-term survival. METHODS: The postoperative computed tomography scans of 67 patients were retrospectively reviewed. A false lumen was independently defined at 3 segments of the descending thoracic aorta (DTA) on the last follow-up computed tomography scan: the proximal segment near the aortic arch, the distal segment near the diaphragm, and the middle segment. RESULTS: The segmental aortic growth rate of completely thrombosed, completely patent, and partially thrombosed false lumens was -0.10±0.31, 0.09±0.22, and 0.35±0.60 mm/mo at the proximal DTA (P=.001), -0.04±0.18, 0.12±0.19, and 0.28±0.28 mm/mo at the middle DTA (P<.001), and -0.02±0.13, 0.07±0.07, and 0.16±0.14 mm/mo at the distal DTA (P<.001), respectively. The corresponding freedom from reoperation rates for the proximal DTA at 10 years were 100%, 88%, and 62% (P=.013). The overall 10-year survival rate was 89% and was not significantly different among the study groups. CONCLUSIONS: Partial thrombosis at each segment of a residual false lumen after TAAAD repair correlated with a faster regional aortic growth rate and predicted a greater reoperation rate but did not affect long-term overall survival.

Extracorporeal membrane oxygenation as a bridge to definite surgery in recurrent postinfarction ventricular septal defect.

A recurrent shunt after a postinfarction ventricular septal defect (PI-VSD) repair is common. We treated a case of cardiogenic shock caused by a large recurrent shunt after the patch repair of an apical PI-VSD with percutaneous extracorporeal membrane oxygenation (ECMO) for 4 days until a secondary definite repair. This suggests that percutaneous ECMO support is reliable before and after secondary definitive surgery in recurrent PI-VSD and may imply using a delayed surgical strategy with ECMO support to restore hemodynamic stability and avoid primary surgery on freshly fragile infarcted myocardium.

Improved pulmonary artery geometry after a Norwood procedure by using a Venaflo II graft as an RV-MPA conduit.

Sano's modification of the right ventricle to main pulmonary artery shunt improves the surgical results of the Norwood procedure for hypoplastic left heart syndrome. Usually the transected distal stump of the main pulmonary artery is reconstructed by direct suturing of a polytetrafluoroethylene tube or suturing on a pericardial bifurcation patch. However, the resulting pulmonary artery geometry significantly affects the outcome of the staged procedure. Herein, we report our surgical strategy to improve the pulmonary artery geometry by using a commercially available Venaflo II graft (Bard, Tempe, AZ) as the right ventricle to main pulmonary artery conduit, to avoid the potential for pulmonary artery stenosis after the Norwood procedure.