Perioperative kinetics of endocan in patients undergoing cardiac surgery with and without cardiopulmonary bypass.

INTRODUCTION: Endothelial Specific Molecule-1 or endocan is a novel biomarker associated with the development of acute lung injury (ALI) in response to a systemic inflammatory state such as trauma. Acute Respiratory Distress syndrome (ARDS), a severe form of ALI is a devastating complication that can occur following cardiac surgery due to risk factors such as the use of cardiopulmonary bypass (CPB) during surgery. In this study we examine the kinetics of endocan in the perioperative period in cardiac surgical patients. METHODS: After ethics approval, we obtained informed consent from 21 patients undergoing elective cardiac surgery (3 groups with seven patients in each group: coronary artery bypass grafting (CABG) with the use of CPB, off-pump CABG and complex cardiac surgery). Serial blood samples for endocan levels were taken in the perioperative period (T0: baseline prior to induction, T1: at the time of heparin administration, T2: at the time of protamine, T2, T3, T4 and T5 at 1, 2, 4 and 6h following protamine administration respectively). Endocan samples were analysed using the enzyme-linked immunosorbent assay (ELISA) method. Statistical analysis incorporated the use of test for normality. RESULTS: Our results reveal that an initial rise in the levels of serum endocan from baseline in all patients after induction of anaesthesia. Patients undergoing off-pump surgery have lower endocan concentrations in the perioperative period than those undergoing CPB. Endocan levels decrease following separation from CPB, which may be attributed to haemodilution following CPB. Following administration of protamine, endocan concentrations steadily increased in all patients, reaching a steady state between 2 and 6h. The baseline endocan concentrations were elevated in patients with hypertension and severe coronary artery disease. CONCLUSION: Baseline endocan concentrations are higher in hypertensive patients with critical coronary artery stenosis. Endocan concentrations increased after induction of anaesthesia and decreased four hours after separation from CPB. Systemic inflammation may be responsible for the rise in endocan levels following CPB.

Long Term Survival Benefits of Different Conduits Used in Coronary Artery Bypass Graft Surgery- A Single Institutional Practice Over 20 Years.

Objective: This study determined hazard factors and long-term survival rate of total arterial coronary artery bypass graft surgery over 20 years in an extensively large, population-based cohort. Methods: A total of 2979 patients who underwent isolated CABG from April 1999 to March 2020 were studied in 4 groups- Group-A (bilateral internal mammary artery ± radial artery), Group-B (single internal mammary artery + radial artery ± saphenous vein), Group-C (single internal mammary artery ± saphenous vein; no radial artery), and Group-D (radial artery ± saphenous vein; no internal mammary artery). The study endpoints analysed the correlation between the number and types of grafts with the survival time following isolated CABG surgery. Results: The total arterial revascularization (Group A) group had an admirable mean long-term survival of ~19 years, compared to 18.6 years (Group B), 15.86 years (Group C), and 10.99 years (Group D). A Kaplan-Meier curve demonstrated confidence interval (CI) for study groups- (95% CI 18.33-19.94), (95% CI 18.14-19.06), (95% CI 15.40-16.32), and (95% CI 9.61-12.38) in Group A, B, C, D respectively. In the Holm-Sidak method analysis, significant associations existed between the number of arterial grafts and the long-term outcome. A statistically significant (P≤0.05) long-term survival advantage for arterial grafting was demonstrated, especially total arterial revascularisation over all other combinations except single internal mammary artery + radial artery grafting. Conclusion: In this series, over 20 years, total arterial CABG use has excellent long-term survival, achieving complete myocardial revascularisation. There is no significant difference between the BIMA group and SIMA with radial artery. However, there is a reduced survival with decreased use of arterial conduits.

Survival and Independent Predictors of Mortality Following Coronary Artery Bypass Graft Surgery in a Single-Unit Practice in the United Kingdom Over 20 Years.

BACKGROUND:  The types of graft conduits and surgical techniques may impact the long-term outcomes of patients after coronary artery bypass graft (CABG) revascularization. This study observed a long-term survival rate following CABG surgery over 20 years in the United Kingdom. METHODS:  A total of 2979 isolated CABG patients were studied from 1999 to 2020, and postoperative data were obtained from the hospital-recorded mortality by the data quality team of the information department. Postdischarge survival was estimated using the Kaplan-Meier method, and statistical significance was obtained with log-rank tests and the Gehan-Breslow test, and the Holm-Sidak method was used for multiple pairwise comparisons. RESULTS:  The study observed male predominance (80%), and the median age was statistically significant (P <0.001) among the groups, 66 years (interquartile range 58-73) and 72 years (interquartile range 66-78) in survivor and non-survivor groups, respectively. In the Holm-Sidak method analysis, the best survival rate (mean 18.7 years) was observed in the total arterial group with significantly decreased survival for the mixed arterial and venous group (mean 16.12 years) and only the vein group (10.44 years). The Cox regression model observed that the New York Heart Association (NYHA) class III-IV (HR 1.57), chest re-exploration (HR 2.14), preoperative dialysis (HR 3.13), and redo surgery (HR 3.04) were potential predictors of the postoperative mortality (P ≤0.05). CONCLUSION:  In our series over 20 years, albeit off-pump and on-pump CABG observed similar survival rates, the total arterial myocardial revascularization population has significantly better long-term survival benefits.

The Convergent Ablation and AtriClip Exclusion of the Left Atrial Appendage in Long-Standing Persistent Atrial Fibrillation.

We here present a case of a 54-year-old man with longstanding persistent atrial fibrillation refractory to direct current electrical cardioversion who underwent a concurrent convergent ablation and Atriclip exclusion of left atrial appendage. His preoperative echocardiography revealed dilated 5.8 cm left atrium with a normal left ventricular ejection fraction of 50%. Transmural isolation of pulmonary veins was performed through a subxiphoid approach, and 3 left-sided video-assisted thoracoscopic surgery ports were utilised to occlude the base of the left atrium appendage with the Atriclip device. A peri-operative transoesophageal echocardiogram confirmed left atrium appendage base occlusion, and the patient was in sinus rhythm after having a single 200 kJ direct current cardioversion shock. The postoperative period was uneventful, and the patient was discharged with preprocedural anticoagulant after 24 hours of the procedure and advised to come for follow up after 3 months.

Practice considerations of early aspirin administration following coronary artery bypass surgery.

Thrombotic occlusion of saphenous vein grafts (SVG), the conduits most commonly used in coronary artery bypass grafting (CABG) surgery, causes significant morbidity and mortality. There is class 1A evidence that early aspirin administration following CABG reduces thrombotic SVG occlusion, as well as overall morbidity and mortality. The American Heart Association/American College of Cardiology and the European Association of Cardiothoracic Surgeons have issued guidelines recommending that 150 to 325 mg aspirin be administered within 6 hours following CABG. We carried out a clinical audit of our practice to identify any reasons for deviation from these standards of care and to implement any corrective measures. We prospectively collected data on 200 consecutive patients who underwent CABG to assess both the compliance in prescribing and administering aspirin and the effect on blood loss and transfusion requirements. Sixty-nine percent of patients received an aspirin loading dose 6 hours postoperatively. The reasons for nonadministration of aspirin were postoperative bleeding (10%), lack of a prescription despite aspirin being clinically indicated (13%), and a prescription for aspirin but no administration (9%). Reasons included inadequate handover between clinical teams (4%), aspirin loading ≤24 hours preoperatively (2%), and administration after the first 6 hours (3%). Our audit showed that early aspirin administration did not cause further bleeding or increase blood or blood product transfusion. We followed the recommendations in the majority of cases, but there is scope for improvement in this practice and a need to address "gray areas" not covered by the guidelines.

Chylopericardium associated with constrictive pericarditis assessed by multimodality imaging.

Acute-onset presentation with breathlessness and calcific pericardial thickening encapsulating the heart. Extremely chylous pericardium, which is by itself rare, in combination with constriction assessed with multiple imaging modalities.

Transaortic mitral valve repair in double valve infective endocarditis.

We present a case of a transaortic mitral valve repair in double valve infective endocarditis. Through a conventional oblique aortotomy, the aneurysmal part of the anterior leaflet of the mitral valve was excised, an artificial neo chorda was implanted, and the aortic valve was replaced.

Long-term outcomes for different surgical strategies to treat left ventricular outflow tract obstruction in hypertrophic cardiomyopathy.

AIMS: Surgical intervention is used to treat dynamic left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy. This study assesses the effect of different surgical strategies on long-term mortality and morbidity. METHODS AND RESULTS: In total, 347 patients underwent surgical intervention for LVOTO (1988-2015). Group A (n = 272) underwent septal myectomy; Group B (n = 33), septal myectomy and mitral valve (MV) repair; Group C (n = 22), myectomy and MV replacement; and Group D (n = 20), MV replacement alone. Median follow-up was 5.2 years (interquartile range 1.9-7.9). The mean resting LVOT gradient improved post-operatively from 71.9 ± 39.6 mmHg to 13.4 ± 18.5 mmHg (P < 0.05). Overall, 72.4% of patients improved by >1 New York Heart Association (NYHA) class; 58.9% of patients undergoing MV replacement alone did not improve their NYHA class. There were 5 perioperative deaths and 20 late deaths (>30 days). Survival rates at 1, 5 and 10 years respectively were 98.4, 96.9, 91.9% in Group A; 97.0, 92.4, 61.6% in Group B; 100.0, 100.0, 55.6% in Group C; and 94.7, 85.3, 85.3% in Group D (log-rank, P < 0.05). Long-term (>30 days) complications included atrial fibrillation (29.6%), transient ischaemic attack/stroke (2.4%) and heart failure hospitalisation (3.2%). There were 16 repeat surgical interventions at 3.0 years. CONCLUSION: Septal myectomy is a safe procedure resulting in symptomatic improvement in the majority of patients. The annual incidence of non-fatal disease-related complications after surgical treatment of LVOTO is relatively high. Patients who underwent MV replacements had poorer outcomes with less symptomatic benefit in spite of a similar reduction in LVOT gradients.

Effects of cell saver autologous blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing cardiac surgery on- versus off-cardiopulmonary bypass: a randomised trial.

OBJECTIVE: Off-pump CABG is potentially associated with reduced intraoperative blood loss and homologous blood transfusion in comparison to on-pump CABG. In this randomised controlled study we investigated the effects of autologous cell saver blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing CABG on- versus off-CPB. METHODS: Eighty patients were randomised into one of four groups: (A) on-CPB with cell saver blood transfusion (CSBT), (B) on-CPB without CSBT, (C) off-pump with CSBT and (D) off-pump without CSBT. Volume of intraoperative autologous blood transfusion, postoperative mediastinal blood loss and homologous blood transfusion requirements were measured. Homologous blood was transfused when haemoglobin concentration fell below 8 g/dl postoperatively. Pre- and postoperatively prothrombin time and partial thromboplastin time were measured. RESULTS: Preoperative patient characteristics were well matched among the four groups. The amount of salvaged mediastinal blood available for autologous transfusion was significantly higher in the on-pump group (A) compared to the off-CPB group (C) (433+/-155 ml vs 271+/-144 ml, P=0.001). Volume of homologous blood transfusion was significantly higher in group B vs groups A, C and D (595+/-438 ml vs 179+/-214, 141+/-183 and 230+/-240 ml, respectively, P<0.005). The cell saver groups (A and C) received significantly less homologous blood than the groups without cell saver (160+/-197 ml vs 413+/-394 ml, respectively, P<0.005). Patients undergoing off-CPB surgery received significantly less homologous blood than those undergoing on-CPB CABG irrespective of cell saver blood transfusion (184+/-214 ml vs 382+/-397 ml, P<0.05). Postoperative blood loss was similar in the four groups (842+/-276, 1023+/-291, 869+/-286 and 903+/-315 ml in groups A to D, respectively, P>0.05). Clotting test results revealed no significant difference between the groups. There was no significant difference in postoperative morbidity between groups. CONCLUSION: Off-pump CABG is associated with significant reduction in intraoperative mediastinal blood loss and homologous transfusion requirements. Autologous transfusion of salvaged washed mediastinal blood reduced homologous transfusion significantly in the on-CPB group. Cell saver caused no significant adverse impact on coagulation parameters in on- or off-CPB CABG. Postoperative morbidity and blood loss were not affected by the use of CPB or autologous blood transfusion. We recommend the use of autologous blood transfusion in both on- and off-pump CABG surgery.

Management of patients undergoing coronary artery bypass graft surgery with mild to moderate aortic stenosis.

BACKGROUND AND AIM OF THE STUDY: The management of patients undergoing coronary artery bypass graft (CABG) surgery with mild to moderate aortic stenosis (AS) remains controversial. The study aim was to examine the outcome in patients with mild to moderate AS undergoing CABG. METHODS: A retrospective analysis was carried out of 200 patients with coronary artery disease requiring CABG and with a peak AS gradient < 40 mmHg measured by Doppler echocardiography, between 1990 and 2000. Among patients, 154 underwent isolated CABG (group A) and 46 CABG + aortic valve replacement (AVR) (group B). RESULTS: Mortality was 2.6% (n = 4) in group A and 6.5% (n = 3) in group B (p = NS). The median AS gradients were 34 and 40 mmHg, respectively. Thirty patients (20%) in group A were in NYHA class III-IV compared to 20 (44%) in group B (p = 0.002). There was no significant difference in postoperative complications. The mean intensive care unit stay was 2.3 and 2.2 days, respectively (p = NS); median postoperative stay was 6 and 8 days, respectively (p = 0.02). During the median follow up period of 4.2 years no patient in group A required AVR. Nine late deaths occurred in group B, none of which was cardiac-related. CONCLUSION: Morbidity and mortality in patients who underwent combined surgery was comparable with that in patients who had isolated CABG. However, none of the patients who underwent only CABG required AVR during the follow up period. It is concluded that patients with mild AS at the time of CABG should not undergo AVR. It is possible that a cut-off AS gradient > 40 mmHg should be considered for combined surgery.

The role of coronary angiography in acute type A aortic dissection.

OBJECTIVES: In recent years, non-invasive methods have replaced angiography in the diagnosis of aortic dissection. Angiography maybe used to evaluate coexisting coronary artery disease (CAD), which can delay surgery and increase the risk of rupture. We set out to examine the role of angiography in acute aortic dissection. METHODS: A retrospective analysis of patients who underwent repair of acute aortic dissection between January 1992 and June 2002 was conducted. The effect of angiography on the need for concomitant coronary artery surgery (CABG), delay to surgery and outcome were analysed. RESULTS: Seventy-four patients were identified. Initial diagnosis was established by non-invasive techniques. Twenty-three patients (31%) underwent angiography (Group I) in three this was unsuccessful. Three in Group I and four in the non-angiography group (Group II, n=51) had history of angina. One patient in Group I underwent concomitant CABG compared to seven in Group II. The patient who underwent CABG in Group I; and four out of seven in Group II died (NS). Patients who underwent concomitant CABG had a significantly higher mortality rate (P=0.04). Mortality in Group I was 35% (n=8) and in Group II was 29% (n=15) (NS). Mortality rate was also significantly higher in patients who presented with syncope (P=0.01) or hypotension (P=0.04). Median transfer time from arrival at our centre to the operating room was 5 h in Group I and 1.5 h in Group II (P<0.001). Mortality rate was higher in patients who took longer to transfer to the operating room, but this did not reach statistical significance. CONCLUSIONS: We have shown that coronary angiography did not affect the occurrence of CABG and was not associated with improved hospital survival. Furthermore, there is a considerable delay to surgery caused by angiography. Therefore in this setting coronary angiography is not recommended.

Ruptured saphenous vein graft aneurysm.

Ruptured saphenous vein graft (SVG) aneurysm is a rare source of significant morbidity and mortality. SVG is a common technique of coronary artery bypass grafting (CABG), but vein graft aneurysm and ruptured SVG aneurysm have not received the required attention as only few case reports exist. We present the case of a 50-year old man with ruptured vein graft aneurysm who had significant postoperative complications following surgery, and outline some preventive/management strategies.

Leiomyosarcoma of pulmonary vein presenting as left atrial mass: an outline of management principles.

Leiomyosarcoma of the pulmonary vein is rare and has poor prognosis. Its clinical features are nonspecific and mimic benign conditions. Early diagnosis is challenging. Most cases have been diagnosed only at autopsy or on postoperative histology specimens. Treatment is essentially palliative complete surgical excision. We outline the principles of management with the case of a 39-year-old man with leiomyosarcoma of the left pulmonary veins extending into the left atrium. Extensive investigation to achieve early diagnosis and determine extent of disease is essential. Frozen section guided adequate excision of all cardiac tumours and resection of involved lung tissue achieve local disease control. Adjuvant chemoradiotherapy has been shown to enhance survival.

Omental herniation: a rare complication of vacuum-assisted closure of infected sternotomy wound.

Vacuum-assisted closure (VAC) has recently been adopted as an acceptable modality for management of sternotomy wound infections. Although generally efficacious, the use of negative pressure devices has been associated with complications such as bleeding, retention of sponge, and empyema. We report the first case of greater omental hernia as a rare complication of vacuum-assisted closure of sternal wound infection following coronary artery bypass grafting.

Effect of valve suture technique on incidence of paraprosthetic regurgitation and 10-year survival.

BACKGROUND: The primary objective was to estimate the risk of paraprosthetic regurgitation (PPR) after aortic (AVR) and mitral valve replacement (MVR) using interrupted (IN) or semicontinuous (SC) sutures. The secondary objective was to estimate the risk of redo valve surgery and 10-year survival after valve replacement performed using either suture technique. METHODS: Patients who underwent mechanical AVR or MVR using a St. Jude prosthesis between December 1991 and June 1997 were included. Eighteen patients had MVR and 43 had AVR using IN sutures; 49 and 83 patients received MVR and AVR, respectively, using SC sutures. The majority of these patients were part of a randomized controlled trial with different end points, presented elsewhere. Patients were followed for 10 years with annual transthoracic echocardiography, and clinical data were collected retrospectively. Kaplan-Meier survival analysis was performed. Cox's regression analysis was performed to identify factors predicting mortality as a function of time. Forward stepwise logistic regression was performed to analyze risk factors predicting PPR. Mann-Whitney U test was used for continuous and nonparametric data, and chi2 test and Fisher's exact test were used for categorical data. A probability value less than 0.05 was considered significant. RESULTS: The overall risk of PPR after MVR and AVR was higher in the SC group than in the IN group. The need for redo AVR was significantly higher in the SC group. The suture technique did not affect the 10-year survival after either AVR or MVR. CONCLUSIONS: Use of SC technique increases the risk of significant PPR after AVR and MVR compared with IN technique independent of the size of prosthesis, degree of annular calcification, disease of the excised valve, or the implanting surgeon. Although 10-year survival is independent of suture technique, SC technique increases the risk of redo valve replacement after AVR.