Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair.

BACKGROUND: Concerns remain that minimally invasive atrial septal defect (ASD) repair may compromise patient outcomes. We compared clinical outcomes of adult patients undergoing ASD repair via a minimally invasive endoscopic approach versus a "gold standard" sternotomy. METHODS: We retrospectively reviewed the clinical outcomes of consecutive patients who underwent ASD patch repair at our institution between 2002 and 2012. We compared in-hospital/30-day mortality, postoperative complications, length of stay in hospital and in the intensive care unit and blood product requirements between patients who underwent right mini-thoracotomy (MT) and those who underwent conventional sternotomy. RESULTS: During the study period, 73 consecutive patients underwent ASD patch repair at our institution: 51 (age 47 ± 16 yr, 66.7% women) in the MT group and 22 (age 46 ± 21 yr, 59.1% women) in the sternotomy group. In-hospital mortality was similar between the 2 groups (MT 0% v. sternotomy 4.5%, p = 0.30). There were no significant differences in any postoperative complications or blood product requirements. No patients in the MT group suffered stroke, retrograde aortic dissection or leg ischemia. Mean intensive care unit (MT 1.2 ± 1.2 d v. sternotomy 1.7 ± 2.2 d, p = 0.26) and hospital length of stays (MT 5.1 ± 2.2 d v. sternotomy 6.3 ± 3.6 d, p = 0.17) were similar between the groups; however, there was a trend toward fewer patients requiring prolonged hospital stays (> 10 d) in the MT group (3.9% v. 18.2%, p = 0.06). CONCLUSION: Repair of ostium secundum and sinus venosus ASD can be performed safely via MT endoscopic approach with similar outcomes as sternotomy. Patient preference for a more cosmetically appealing incision may be considered without concern of compromised outcomes.

CONTEXTE: Des inquiétudes persistent au sujet des résultats potentiellement négatifs chez les patients soumis à une intervention de réparation de communication interauriculaire (CIA) minimalement effractive. Nous avons comparé les résultats cliniques chez des patients adultes soumis à une réparation de CIA par approche endoscopique minimalement effractive ou par sternotomie classique ­ « l'étalon-or ¼. MÉTHODES: Nous avons passé en revue de manière rétrospective les résultats cliniques chez des patients consécutifs qui ont subi un traitement d'occlusion de leur CIA dans notre établissement, entre 2002 et 2012. Nous avons comparé la mortalité en cours d'hospitalisation et à 30 jours, les complications postopératoires, la durée des séjours à l'hôpital et aux soins intensifs et le recours aux produits sanguins chez les patients selon qu'ils avaient subi une mini-thoracotomie (MT) ou une sternotomie classique. RÉSULTATS: Durant la période de l'étude, 73 patients consécutifs ont subi un traitement d'occlusion de leur CIA dans notre établissement : 51 (âge 47 ± 16 ans, 66,7 % femmes) dans le groupe MT et 22 (âge 46 ± 21 ans, 59,1 % femmes) dans le groupe sternotomie. La mortalité perhospitalière a été similaire entre les 2 groupes (MT 0 % c. sternotomie 4,5 %, p = 0,30). On n'a noté aucune différence significative quant aux complications postopératoires et aux besoins en produits sanguins. Aucun patient du groupe MT n'a subi d'AVC, de dissection aortique rétrograde ou d'ischémie à la jambe. La durée moyenne des séjours aux soins intensifs (MT 1,2 ± 1,2 j c. sternotomie 1,7 ± 2,2 j, p = 0,26) et à l'hôpital (MT 5,1 ± 2.2 j c. sternotomie 6,3 ± 3,6 j, p = 0,17) a été similaire entre les groupes; toutefois, on a noté une tendance à un nombre moindre de patients nécessitant une hospitalisation prolongée (> 10 j) dans le groupe MT (3,9 % c. 18,2 %, p = 0,06). CONCLUSION: La réparation de la CIA au niveau de l'ostium secundum et du sinus veineux peut se faire de manière sécuritaire par approche endoscopique MT, avec des résultats similaires à ceux de la sternotomie. On peut tenir compte de la préférence des patients pour une incision plus acceptable au plan esthétique sans crainte de compromettre les résultats.

Successful treatment of mechanical mitral valve thrombosis without thrombolytic therapy or surgery.

Prosthetic valve thrombosis is an uncommon, life-threatening complication that often mandates urgent repeat surgery or thrombolytic therapy. We present an alternative approach in a patient with rheumatic heart disease who presented with subacute thrombosis of a recently implanted On-X mechanical mitral valve (On-X Life Technologies Inc, Austin, TX), diagnosed on echocardiography and valve fluoroscopy. The patient refused surgery, hence we elected to treat the patient with high-dose antithrombotic therapy alone. Echocardiographic monitoring demonstrated complete reabsorption of the thrombus within 6 months without any embolic complications. Endogenous fibrinolysis with appropriate antithrombotic therapy might be a suitable option for select, high-risk patients with mechanical mitral valve thrombosis.

Repair of atrioventricular canal with double-outlet right ventricle, transposition, or truncus arteriosus.

Atrioventricular canal and conotruncal anomalies are a heterogeneous group of lesions presenting unique challenges for surgical repair. These are the establishment of unobstructed pathways from left ventricle (LV) to aorta and from right ventricle (RV) to pulmonary artery, closure of the inlet ventricular septal defect (VSD) and atrial septal defect (ASD) ostium primum, and the avoidance of significant left and right atrioventricular valve (AV) regurgitation. Repair of complete atrioventricular canal (CAVC) with tetralogy of Fallot (TOF) has been most commonly achieved, either using a single-patch or a 2-patch technique. In patients with CAVC with double-outlet right ventricle (DORV) with subaortic VSD extension, the 2-patch repair is not unlike that of CAVC with TOF. However, biventricular repair is most challenging in patients with CAVC and complete origin of the aorta from the RV, as in CAVC with DORV and noncommitted VSD and those with CAVC with transposition of the great arteries (TGA) and LVOTO. The technique of VSD translocation allows anatomic biventricular repair for these particularly challenging patients. The arterial switch operation with CAVC repair can be used for patients with CAVC with DORV with subpulmonary VSD extension and CAVC with TGA without left ventricular outflow tract obstruction. Biventricular repair is achievable in most patients with balanced complete atrioventricular canal and conotruncal anomaly. The extreme heterogeneity of CAVC with conotruncal anomalies requires a highly individual approach that is tailored to the specific constellation of lesions in each patient.

Contemporary patterns of management of tetralogy of Fallot: data from the Society of Thoracic Surgeons Database.

BACKGROUND: The Society of Thoracic Surgeons Database was queried to ascertain current trends in management of tetralogy of Fallot (TOF) and to determine the prevalence of various surgical techniques. METHODS: The study population (n = 3059 operations) was all index operations in 2002-2007, age 0-18 years with Primary Diagnosis of TOF, and Primary Procedure TOF repair or palliation. Patients with Pulmonary Atresia, Absent Pulmonary Valve, and Atrioventricular Canal were excluded. RESULTS: 294 patients had initial palliation, including 178 neonates. 2534 patients had repair of TOF as the initial operation (primary repair), including 154 neonates. 217 patients had repair of TOF after prior palliation. Of patients who had primary repair (n = 2534), 975 had repair at 3 to 6 months, 614 at 6 months to 1 year, 492 at 1 to 3 months, and 154 at 0 to 30 days. Of patients who had repair following prior palliation (n = 217), 65 had repair in the first 6 months of life, 111 at 6 months to 1 year, and only 41 (18.9%) at more than 1 year of age. Type of repair: Of 2534 primary repairs, 581 (23%) had no ventriculotomy, 571 (23%) had nontransanular patch, 1329 (52%) had transanular patch, and 53 (2%) had right ventricle to pulmonary artery conduits. Of repairs after prior palliation (n = 217), 20 (9%) had no ventriculotomy, 30 (14%) had nontransanular patch, 144 (66%) had transanular patch, and 24 (11%) had conduits. Discharge mortality (95% confidence interval; CI) was 22 of 294 (7.5%; CI: 4.7%-11.1%) for initial palliation, 33 of 2534 (1.3%; CI: 0.9%-1.8%) for primary repair, and 2 of 217 (0.9%; CI: 0.1%-3.3%) for secondary repair. For neonates, discharge mortality was 11 of 178 (6.2%; CI: 3.1%-10.8%) for palliation and 12 of 154 (7.8%; CI: 4.1%-13.2%) for primary repair. CONCLUSIONS: Primary repair in the first year of life is the most prevalent strategy. Despite contemporary awareness of the late consequences of pulmonary insufficiency, ventriculotomy with transanular patch remains the most prevalent technique, both for primary repair and for repair following palliation.

The effect of using microplegia on perioperative morbidity and mortality in elderly patients undergoing cardiac surgery.

Old age is a significant risk factor for perioperative morbidity and mortality following cardiac surgery and optimal myocardial protection strategy should be sought in this group of patients. We, therefore, reviewed the data on 295 consecutive patients older than 75 years who underwent any cardiac surgical procedure. Microplegia was used in 144 patients compared to 151 patients who had the standard 4:1 blood cardioplegia. Logistic regression analysis was used for propensity matching to balance the differences between the two groups. The microplegia group included more females and sicker patients as indicated by higher Parsonnet scores. There were differences in the pump time, aortic cross-clamp time, procedure type and surgeons between the two groups. These differences were balanced using the propensity matching. In-hospital mortality, acute renal injury and confusion were higher in the microplegia group (17%, 34%, 35%, respectively) compared to the standard 4:1 cardioplegia group (9%, 23%, 24%, respectively) (P=0.04, 0.04, 0.04, respectively). These differences were not statistically significant after propensity matching. These results demonstrate that the use of microplegia is safe in patients older than 75 years who are undergoing cardiac surgery and results in similar in-hospital morbidity and mortality to the standard 4:1 blood cardioplegia.

Could we still improve early and interim outcome after prosthetic systemic-pulmonary shunt? A risk factors analysis.

OBJECTIVE: To identify factors associated with in-hospital and interim mortality in children with a systemic-to-pulmonary shunt (SPS). METHODS: Between January 1988 and April 2005, 226 children with a median age of 17 days, and weight of 3.4 kg, underwent an isolated SPS for pulmonary atresia (PA)-VSD/ tetralogy (n=124, 54.9%), functional single ventricle PA (n=35, 5.5%), PA-intact septum (IS, n=31, 13.7%), transposition of the great arteries VSD-PA (n=30, 13.3%), and double outlet right ventricle-PA (n=6, 2.6%). Surgery was performed through sternotomy (group S, n=46) or thoracotomy (group T, n=180). The origin of the SPS was either the innominate artery (n=38) or ascending aorta (n=8) in group S, and the subclavian artery (n=180) in group T. RESULTS: In-hospital mortality was 5.7%. Univariate and logistic regression analysis revealed younger age (p=0.01), lower body weight (p<0.04), a diagnosis of PA-IS with severe right ventricle hypoplasia (p=0.005), preoperative intubation (p=0.03), increased length of intubation (p<0.0001), longer ICU stay (p<0.0001), and group S (p=0.03) as risk factors for in-hospital death. Group S had a longer median ventilation time (112 vs 30 h, p<0.0001) despite the similar median age, weight, mean indexed shunt size (1.19 vs 1.15 mm/kg, p=0.2), and the number of patients with antegrade pulmonary flow. Interim mortality was 7% (n=15), and younger age (p=0.03), and group T (p=0.03) were independent risk factors for death prior to second-stage surgery. Absence of antiplatelet agents or anticoagulants was not a risk factor for interim mortality. CONCLUSIONS: In-hospital mortality and longer ventilation time after SPS by sternotomy may be related to pulmonary over circulation due to shunt insertion origin and/or size, and pathologic features. Early and interim outcomes can be improved by using a smaller shunt or changing the SPS insertion origin when using a sternotomy approach.

Total arterial coronary revascularization using arterial bypass circle with multiple inflows.

Coronary artery bypass techniques, currently applied to maximize the benefits of multiple arterial coronary conduits, render the newly constructed myocardial flow dependent on a single source "inflow" of blood. We describe a technique for total arterial coronary revascularization with multiple inflows; the distal end of the pedicled right internal thoracic artery is anastomosed to the distal end of a free radial artery, and the other end of the radial artery is then connected to the ascending aorta. This vascular circle, passed in a retro-cardiac fashion, is used to revascularize the inferio-lateral surface of the heart using multiple side-to-side anastomoses. The "sacred" left internal thoracic artery is reserved to revascularize the anterior wall of the myocardium, independent of the arterial circle.

Stem cell transplantation: potential impact on heart failure.

Cell transplantation is a promising new modality in treating damaged myocardium after myocardial infarction and in preventing postmyocardial infarction LV remodelling. Two strategies are plausible: the first uses adult tissue stem cells to replace the scar tissues and amend the lost myocardium, whilst the second strategy uses embryonic stem cells in an attempt to regenerate myocardium and/or blood vessels.