Right Coronary Artery and Left Anterior Descending Artery Occlusion after Aortic Valve Replacement.

Coronary artery stenosis is a potentially life-threatening complication after heart valve surgery. The details are presented of a patient with unobstructed coronary arteries, who underwent routine aortic valve replacement and developed dissection of the right coronary artery (RCA) on the third postoperative day, and occlusion of the left anterior descending (LAD) artery one month after surgery. This complication required prompt clinical recognition and diagnosis by repeat coronary angiography, and a rapid intervention with coronary artery bypass grafting or with angioplasty and stenting.

A systematic review of the safety and efficacy of distal coronary artery anastomotic devices in MIDCAB and TECAB surgery.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) techniques may improve recovery and reduce hospital stay following coronary artery bypass surgery (CABG). However, working in a limited space with indirect visualisation would greatly benefit from a simple, high-quality and reproducible automated distal anastomotic method. Several devices have been developed; however, their uptake has been limited due to uncertainty around their impact on patient outcomes. METHODS: A systematic review of the literature identified six studies, incorporating 139 subjects undergoing MIDCAB or TECAB surgery using a distal anastomotic device. RESULTS: The overall 30-day mortality was 0.7% (1/137). No cardiac specific mortality was observed. For each outcome of perioperative myocardial infarction (MI), postoperative stroke and haemorrhage, only a single event was observed for each (n=1/136, 1/138 and 1/136, respectively). The overall device failure rates were low, with the use of additional sutures only reported in a single case with the Magnetic Vascular Port (MVP) device. Anastomotic time ranged from a mean of 3.32 minutes with the MVP device to 20 minutes with the C-Port device. CONCLUSIONS: These results demonstrate the overall acceptable early outcomes of distal anastomotic devices for use in minimally invasive coronary bypass surgery. Future research should focus on designing adequately powered, comparative, randomised trials, focusing on major adverse cardiac and cerebrovascular events (MACCE) outcomes in both the short and long-term, with clear case-by-case reasons for device failure and a comparison of anastomotic times. In this way, we may determine whether such devices will facilitate the minimal access and robotic coronary procedures of the future.

Retrospective study assessing outcomes in cardiac surgery after implementation of Quantra.

BACKGROUND: The Quantra QPlus System is a cartridge-based device with a unique ultrasound technology that can measure the viscoelastic properties of whole blood during coagulation. These viscoelastic properties correlate directly with hemostatic function. The primary objective of this study was to assess blood product utilization in cardiac surgery patients before and after the implementation of the Quantra QPlus System. METHODS: Yavapai Regional Medical Center implemented the Quantra QPlus System to aid in their efforts to reduce the transfusion of allogenic blood products and improve outcomes in patients undergoing cardiac surgery. A total of 64 patients were enrolled prior to the utilization of the Quantra (pre-Quantra cohort), and 64 patients were enrolled after (post-Quantra cohort). The pre-Quantra cohort had been managed via standard laboratory assays along with physician discretion for transfusion decisions. The utilization of blood products and frequency of transfusions were compared and analyzed between the two cohorts. (using the Student's t-test) RESULTS: The implementation of the Quantra resulted in a change in the pattern of blood product utilization leading to a demonstrated decrease in the amount of blood products transfused and the associated costs. The amount of FFP transfused was significantly decreased by 97% (P = 0.0004), whereas cryoprecipitate decreased by 67% (P = 0.3134), platelets decreased by 26% (P = 0.4879), and packed red blood cells decreased by 10% (P = 0.8027) however these trends did not reach statistical significance. The acquisition cost of blood products decreased by 41% for total savings of roughly $40,682. CONCLUSIONS: Use of the Quantra QPlus System has the potential to improve patient blood management and decrease costs. STUDY REGISTERED AT CLINICALTRIALS.GOV: NCT05501730.

Aortic valve endocarditis with splenic and brain abscesses: difficult management issues.

Staphylococcus aureus endocarditis is associated with a high incidence of complications, a poor prognosis, and high operative mortality. We present a complex case of aortic valve endocarditis in a critically ill patient, highlight the difficult management issues, and report a good outcome.

Do patients in congestive cardiac failure undergoing cardiac surgery demonstrate worse outcomes compared with those with a history of cardiac failure?

OBJECTIVES: Cardiac surgery in patients with symptoms of congestive cardiac failure (CCF) carries a significant risk of mortality and morbidity. Except for emergencies and in unstable cases, the recommendation has been to delay the operation until the patient is fully recovered. The objective of this study was to determine the consequences of cardiac surgery in patients with acute decompensated heart failure and to compare their outcomes with the results of the operation in patients with previous CCF. METHODS: We compared the outcomes of patients with CCF (n = 707) at the time of cardiac surgery (valve replacement or coronary artery bypass grafting [CABG]) with those with a history of CCF (n = 1583). The EuroSCORE was significantly higher in CCF patients (P < .001). Impaired renal function was also more commonly observed in patients with CCF (P < .001). After adjusting for preoperative characteristics, we compared the 2 groups with respect to postoperative complications, postoperative creatine kinase MB values, and in-hospital mortality. RESULTS: Before adjusting for preoperative characteristics, we found that in-hospital mortality (15.5%) and postoperative complications, such as arrhythmias (31%), renal failure (19%), stroke (4.7%), and myocardial infarction (MI) (3%), were significantly higher in the CCF group than in those with a previous history of CCF. When the patients were matched for preoperative characteristics, the rates of postoperative MI and arrhythmia were the main complications that were significantly higher in the CCF group, compared with the patients with previous CCF. The 2 groups were not significantly different with respect to in-hospital mortality. The results were not affected by the type of procedure (valve or CABG), and the main factor influencing mortality was the EuroSCORE. CONCLUSION: Despite the significant risk of mortality and morbidity in patients with current CCF, cardiac surgery to reverse the cause should not be delayed in these patients, because doing so may lead to further deterioration. Other risk factors, however, should be taken into consideration on an individual basis.

Cannulating a dissecting aorta using ultrasound-epiaortic and transesophageal guidance.

Management of acute Stanford type A aortic dissection remains a major surgical challenge. Directly cannulating the ascending aorta provides a rapid establishment of cardiopulmonary bypass but consists of risks such as complete rupture of the aorta, false lumen cannulation, subsequent malperfusion and propagation of the dissection.We describe a technique of cannulating the ascending aorta in patients with acute aortic dissection that can be performed rapidly in hemodynamically unstable patients under ultrasound-epiaortic and transesophageal (TEE) guidance.

Single-stage repair of aneurysm of the ascending aorta associated with aortic coarctation.

A 38-year-old man with a history of uncontrolled hypertension was investigated for atypical chest pains and found to have an aneurysm of the ascending aorta and a coexisting coarctation of the aorta. The timing and sequence of surgical repair of these 2 pathologies are controversial. We report an elective single-stage operation in which the ascending aorta was replaced and an extracardiac bypass from the ascending to the descending aorta was performed with excellent results.

Genetic and Nongenetic Implications of Racial Variation in Response to Antiplatelet Therapy.

Race has been identified as an independent risk factor for poor prognosis and an independent predictor of survival in coronary artery disease. Race-related dissimilarities have been identified in cardiovascular patients in terms of age of presentation, co-morbidities, socioeconomic status, and treatment approach as well as genetically driven race-related disparities in responsiveness to medications. Antiplatelet therapy represents a fundamental component of therapy in cardiovascular patients, especially in patients presenting with acute coronary syndromes. It has been argued that the different level of platelet reactivity and varying response to antiplatelet therapy among races may account in part for worse outcomes in certain populations. The purpose of this review is to describe genotypic and phenotypic race-related differences in platelet reactivity and responsiveness to cardiovascular treatment, focusing on antiplatelet therapy to highlight the need establish a more effective and targeted antithrombotic strategy.

Transcatheter Aortic Valve Replacement in Patients With Symptomatic Severe Aortic Stenosis and Prior External Chest Radiation.

BACKGROUND/PURPOSE: Surgical aortic valve replacement (SAVR) in patients with symptomatic severe aortic stenosis (AS) and prior chest radiation is associated with poor outcomes in comparison with patients without prior radiation. Our objective was to compare clinical outcomes of patients with and without prior chest radiation undergoing transcatheter aortic valve replacement (TAVR) for symptomatic severe AS. METHODS/MATERIALS: Between January 2003 and January 2017, 1150 patients underwent TAVR at our institution. Of these, 44 had prior chest radiation. Baseline demographic and clinical characteristics, procedural details, and clinical outcomes were prospectively collected. RESULTS: Patients with prior chest radiation were younger, 76 ±â€¯13 years, compared with those without prior chest radiation, 82 ±â€¯8 years (p = 0.002). Median Society of Thoracic Surgeons score for chest radiation patients was 7 ±â€¯4, compared to 8 ±â€¯5 in those without prior radiation. Despite higher prevalence of complete heart block, there was no significant difference between the 2 groups with regard to the need for permanent pacemaker implantation. There was a trend toward longer length of intensive care unit stay in chest radiation patients, but there was no significant difference in 30-day or 1-year mortality. CONCLUSIONS: Thus, TAVR appears to be a safe treatment option in the short and medium term for patients with symptomatic severe AS and prior chest radiation.

Does stopping amiodarone after successfully treating atrial fibrillation occurring after cardiac surgery increase the risk of recurrence?

OBJECTIVES: Atrial fibrillation (AF) following cardiac surgery is common and can complicate postoperative recovery. Amiodarone is a drug frequently used for cardioversion. Some clinicians advocate only in-hospital use of amiodarone until cardioversion, whereas others continue its use for several weeks following cardiac surgery. Inadvertent long-term administration of the drug could be harmful. This study assessed the risk of AF recurrence under 2 different regimens of amiodarone treatment. METHODS: From January 2005 to July 2007, we reviewed 296 patients who developed postoperative AF. Group A consisted of 198 patients who were discharged on amiodarone treatment, and group B consisted of 98 patients who were discharged without amiodarone treatment. The patients were followed for 8 weeks after cardiac surgery and were observed for the development of symptoms such as palpitations, transient ischemic attack (TIA), stroke, and recurrence of or readmission for AF. In addition, we evaluated a control group of 145 patients with similar characteristics and no postoperative AF for the incidence of stroke and AF and compared the results with their rates in the study groups. RESULTS: Patients discharged on amiodarone therapy were more likely to experience episodes of palpitations than those not on amiodarone (13% versus 10%); however, the rates of AF recurrence were almost the same for the 2 groups (8% and 9%, respectively). The 2 groups also showed no difference in the incidence of TIA and stroke (5% versus 4%). A low incidence of stroke and AF (1%-2%) was observed in patients with no perioperative AF. CONCLUSIONS: Long-term treatment of patients with amiodarone should be reconsidered, because it may not be as effective as previously thought in preventing symptoms and AF recurrence. The surprising incidence of neurologic events requires further investigation.

Emergent valve-in-valve transcatheter aortic valve replacement in patient with acute aortic regurgitation and cardiogenic shock with preoperative extracorporeal membrane oxygenator: A case report and review of the literature.

We describe a challenging case of successful use of emergent veno-arterial extracorporeal membrane oxygenation and valve-in-valve transcatheter aortic valve implantation with a Sapien S3 valve.

Multi-slice computed tomography in coronary artery disease.

Multi-slice computed tomography technology is emerging as a realistic investigation in patients with suspected disease in native, stented or grafted coronary arteries. A non-invasive diagnostic tool is desirable as these patients are at high risk for complications of invasive angiography. A 64-slice CT may achieve the desired diagnostic accuracy, and overcome the limitations of spatial resolution, respiratory motion, artifacts from calcification and stents, and radiation dose considerations to produce reliable image quality. These advances, as well as the capacity for integrated functional cardiac assessment, may change the referral patterns in patients who have had previous bypass surgery or percutaneous intervention. This review outlines the debated issues about 64-slice cardiac CT in patients before and after coronary artery bypass surgery, as well as coronary stenting and functional assessment. A review of the recent literature on native coronary artery and bypass graft assessment by multi-slice CT is also performed.

Complete Resolution of Wegener's Granulomatosis Lung Granuloma After Aortic Root Replacement.

Wegner's granulomatosis (WG) is an autoimmune systemic vasculitis that results in necrotizing granulomas. We report a WG patient with a lung granuloma and aortic root dilatation, who underwent aortic root replacement on cardiopulmonary bypass (CPB). Intraoperatively, the patient suffered an aortic dissection, which was repaired immediately under deep hypothermic circulatory arrest (DHCA). Follow-up imaging showed complete granuloma resolution, despite absence of immunosuppressive therapy. Immune stimulation following CPB is well described; here, the opposite was observed and DHCA effects are discussed.

Mitral valve repair using a semirigid ring: patient selection and early outcomes.

BACKGROUND: Commonly used complete mitral annuloplastic rings include saddle-shaped and semirigid rings, with no clear indication for either type. A semirigid ring may be preferred in patients whose native mitral saddle shape is well maintained. We present our experience of using semirigid rings for mitral valve repair. METHODS: We routinely measured the annular height-to-commissural width ratio by 3-dimensional transesophageal echocardiography prior to mitral repair. We generally chose a semirigid (Memo 3D) ring in patients whose annular height-to-commissural width ratio was normal (≥ 15%). The same semirigid ring with an additional chordal guiding system (Memo 3D ReChord) was selected for patients with anterior leaflet or bileaflet pathology. Over an 18-month period, 66 patients with severe degenerative (n = 60) or functional (n = 6) mitral regurgitation had Memo 3D (n = 32) or Memo 3D ReChord (n = 34) rings implanted. RESULTS: Postoperative 3-dimensional transesophageal echocardiography was completed in all patients (mean follow-up 7 ± 5 months). The majority of patients had no or mild residual mitral regurgitation; only two had moderate (2+) mitral regurgitation. There was no mortality at 30-days or on midterm follow-up. CONCLUSIONS: Our series represents the first Asian clinical experience using the Memo 3D ReChord ring. Although the long-term durability of mitral repair with this type of semirigid annuloplastic ring warrants further validation, our current clinical data are encouraging.

Management of a left atrial intramural hematoma after percutaneous intervention.

Left atrial intramural hematoma is a rare complication of percutaneous intervention. We report the case of a 69-year-old man with recurrent angina after CABG 19 years ago who was admitted for percutaneous intervention. After an attempt to recanalize the native circumflex artery and the vein graft, he had a cardiac arrest and was resuscitated successfully. Transesophageal echocardiography showed a large expanding hematoma within the left atrial wall causing obstruction of the mitral valve and compressing the right atrium from across the septum. An emergency thoracotomy was performed and with transesophageal echocardiography guidance and left atrial intramural hematoma was drained successfully.

Surgical revascularisation of the acute coronary artery syndrome.

Although the European Society of Cardiology and American Heart Association/American College of Cardiology guidelines provide some suggestions regarding coronary artery bypass grafting (CABG) in the acute coronary syndrome (ACS), the exact indications for surgery in this diverse spectrum of disease requires further clarification. ACS may present with different scenarios, from NSTEMI to cardiogenic shock. Primary percutaneous coronary intervention is the first-line treatment in most cases; however, there may be a subgroup of ACS patients in whom CABG may be preferred over percutaneous coronary intervention, particularly in the setting of triple vessel disease. CABG can be performed with reasonably low mortality and excellent outcome, particularly in the case of NSTEMI. Furthermore, off-pump or on-pump beating heart techniques may further improve the feasibility and outcomes of CABG. Where possible every patient should be immediately referred to a tertiary centre and evaluated by the 'heart team'. Here risk stratification and intervention according to the expert consensus may be rapidly implemented in order to improve both morbidity and mortality.