Surgical and endoscopic management of a pericardioesophageal fistula after radiofrequency pulmonary vein isolation.

INTRODUCTION: The most feared complication of pulmonary vein isolation (PVI) is an atrioesophageal fistula (AEF). While rare (0.1-0.25%), primary surgical closure (as opposed to esophageal stenting) is associated with lower mortality. Pericardioesophageal fistula (PEF) may present prior to fistulization into the atrium. Unfortunately, data on the optimal management of PEFs are lacking. CASE REPORT: Seventy-one-year-old male with AF presented with chest pain 3 weeks after radiofrequency PVI. Computed tomography angiography (CTA) chest and echocardiogram showed pneumopericardium. Barium esophagram showed extravasation from esophagus into the pericardium without connection to the left atrium. Sternotomy with mediastinal exploration exposed the pericardial defect, over which a CorMatrix patch was placed. The fistula was then stented endoscopically with endosuture fixation. Poststent esophagram did not show barium leak, and the patient was discharged home. One week later, the patient returned with enterococcal and candida bacteremia and an acute right parietal/occipital lobe infarct. Barium esophagram showed contrast extravasation into the pericardium. The patient rapidly succumbed to his illness and died. Autopsy revealed pericardial abscess posterior to the LA in communication with the esophagus. Extension to the LA was not seen. CONCLUSION: While the surgical treatment of AEF is relatively well established, there is no consensus in the management of PEF. While prior small series have suggested PEF may be managed with esophageal stenting, our case illustrates the limitations of this approach.

Carotid Stenosis in Cardiac Surgery-No Difference in Postoperative Outcomes.

BACKGROUND: Debate over revascularization of asymptomatic carotid stenosis before cardiac surgery is ongoing. In this study, we analyze cardiac surgery outcomes in patients with asymptomatic carotid stenosis at a single hospital. METHODS: In this study, 1,781 patients underwent cardiac surgery from January 2012 to June 2013; 1,357 with preoperative screening carotid duplex were included. Patient demographics, comorbidities, degree of stenosis, postoperative complications, and mortality were evaluated. Chi-square test and logistic regression analysis were performed. RESULTS: Asymptomatic stenosis was found in 403/1,357 patients (29.7%; 355 moderate and 48 severe). Patients with stenosis, compared with those without, were older (71.7 ± 11 vs. 66.3 ± 12 years; p < 0.01). Females were more likely to have stenosis (odd ratio, = 1.7; 95% confidence interval, 1.4-2.2); however, patients were predominantly male in both groups. There were no significant differences in the rates of mortality and postoperative complications, including stroke and transient ischemic attack (TIA). Postoperative TIA occurred in 3/1,357(0.2%); only one had moderate stenosis. Inhospital stroke occurred in 21/1,357 (1.5%) patients; stroke rates were 2.3% (8/355) with moderate stenosis and 2.1% (1/48) severe stenosis. There were 59/1,357 (4.3%) deaths; patients with stenosis had a mortality rate of 4.2% (17/403); however, no postoperative stroke lead to death. Multivariable logistic regression analysis with adjustment for age, gender, race, comorbidities, and postoperative complications did not show an impact of carotid stenosis on postoperative mortality and development of stroke after cardiac surgery. CONCLUSION: This study suggests that patients with asymptomatic carotid stenosis undergoing cardiac surgery are not at increased risk of postoperative complications and mortality; thus, prophylactic carotid revascularization may not be indicated.

Risk of Stroke with Impella Placement Is Not Associated with Access Vessel.

Objective: The Impella heart pump is an intravascular microaxial device that provides short-term mechanical circulatory support and can be placed through the femoral, axillary, or central vessels. One of the most feared complications is stroke. It is unclear if patient stroke risk varies based on access vessel. Methods: A retrospective review of consecutive patients who underwent Impella placement at an academic institution from January 1, 2007, through September 15, 2018, was performed. Four groups were compared: (1) minimally invasive Impella (femoral or axillary access), (2) minimally invasive Impella upgraded to another minimally invasive Impella, (3) minimally invasive Impella upgraded to a central Impella (ascending aorta), and (4) central Impella. Patient charts were reviewed to identify baseline characteristics. Outcome measures included length of stay, stroke, and mortality. Results: A total of 349 patients (or 407 Impellas) were identified, and the majority of the devices were inserted through a minimally invasive approach (n = 248, 60.9%), while the remainder were implanted via central access (n = 159, 39.1%). Minimally invasive Impellas were upgraded in 44 patients. The risk of stroke for the entire cohort was 10.3% (n = 36), with no difference observed in any particular group. Overall mortality was 44.4% (n = 155). Of the patients who initially received a minimally invasive Impella, those who were upgraded had higher rates of mortality (56.8% vs 39.4%, P = 0.03), postoperative dialysis (50.0% vs 27.4%, P < 0.01), and sepsis (43.2% vs 20.0%, P < 0.01). Conclusions: This study found no statistically significant difference in rates of postoperative stroke based on initial access vessel.

A Rare Case of Chylothorax after Heart Transplantation.

Chylothorax is an exceedingly rare but serious complication of orthotopic heart transplantation (OHT). Prompt diagnosis and appropriate management are essential for a good outcome. Management is similar to that of nontransplant patients, but special attention must be given to patients' nutritional and immunological status. Relevant literature on this topic is limited. We describe our experience in the management of chylothorax after OHT and provide a summary of reported cases of this complication after isolated heart and combined heart/lung transplant.

Improved operative and recovery times with mini-thoracotomy aortic valve replacement.

BACKGROUND: The small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy. METHODS: We retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared. RESULTS: Of the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67-113) minutes; vs. 117 (93.5-139.5); vs. 102.5 (85.5-132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5-9) days; vs. 7 (5-14.5); vs 9 (6-15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)]. CONCLUSIONS: Minimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy.

Patients with Infectious Endocarditis and Drug Dependence Have Worse Clinical Outcomes after Valvular Surgery.

BACKGROUND: Patients with infective endocarditis (IE) are at high risk for post-operative morbidity and death, which might be associated with drug abuse. The purpose of this study is to evaluate the impact of drug dependence on outcomes in patients who have IE and undergo valvular surgery (VS). PATIENTS AND METHODS: The Nationwide/National Inpatient Sample 2001-2012 was queried to select patients with IE who had elective VS using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes. Among them, patients with drug dependence (PDD) were identified, and their health status and post-operative outcomes were compared with those in patients without drug dependence (control group). Chi-square and Wilcoxon rank sum tests as well as multi-variable regression analysis were used for statistics. RESULTS: A total of 809 (12.9%) PDD of the 6,264 patients who underwent VS were evaluated. They were younger compared with those in the control group (39.0 ± 10.8 y vs. 54.4 ± 14.8 y; p < 0.0001), had less age-related co-morbidities such as hypertension, diabetes mellitus, congestive heart failure, renal failure, obesity, but greater rates of alcohol abuse, liver disease, and psychoses. Despite the younger age and fewer co-morbidities, PDD compared with control patients were more likely to have post-operative complications develop overall (odds ratio [OR] = 1.6; 95% confidence interval [CI] 1.34-2.01), including infectious complications (OR = 1.5; 95% CI 1.27-1.78), specifically pneumonia (OR = 1.4; 95% CI 1.14-1.74) and sepsis (OR = 1.4; 95% CI 1.16-1.63), renal complications (OR = 1.5; 95% CI 1.23-1.77), and pulmonary embolism (OR = 1.9; 95% CI 1.44-2.52). Further, PDD had 11% longer hospital length of stay than those in the control groups (p < 0.0001). We did not find significant difference in hospital deaths, however, between these groups. CONCLUSION: Drug dependence is associated with worse post-operative outcomes in patients with infective endocarditis who underwent valvular surgery and lengthens their hospital stay.

Improved pain control after cardiac surgery: results of a randomized, double-blind, clinical trial.

OBJECTIVE: We sought to determine whether a continuous regional infusion of a local anesthetic delivered to the operative site would result in decreased levels of postoperative pain and narcotic requirements for patients who undergo a standard median sternotomy for cardiac surgery. METHODS: A double-blind, randomized, controlled trial was conducted at a single center. Patients who were undergoing elective coronary artery bypass graft surgery alone or combined with laser transmyocardial revascularization received bilateral intercostal nerve blocks with either ropivacaine or saline. At wound closure, 2 catheters with multiple side openings were inserted percutaneously and placed directly over the sternum. The same agent (ropivacaine vs saline) was then administered as a continuous regional infusion for 48 hours through an elastomeric pump. Requirements for postoperative systemic narcotic analgesics and pain assessment scores were recorded for 72 hours after the operation. Secondary outcome measures were hospital length of stay and pulmonary function test results. Pain scores and narcotic use on the second postoperative day were also compared to avoid the confounding influence of anesthesia administered at the time of the operation. RESULTS: The total amount of narcotic analgesia required by the ropivacaine group was significantly less than that of the control group (47.3 vs 78.7 mg, respectively; P =.038). The ropivacaine group required less narcotics on postoperative day 2 as well (15.5 vs 29.4 mg, P =.025). The mean overall pain scores for the ropivacaine group were significantly less than the mean overall scores for the normal saline group (1.6 vs 2.6, respectively; P =.005). Patients receiving ropivacaine had a mean length of stay of 5.2 days compared with 8.2 days for patients in the normal saline group (P =.001). Excluding the data from outliers (length of stay = 39 days), the normal saline group mean length of stay was 6.3 days (P <.01). There was no difference in assessment of pulmonary function. CONCLUSION: Continuous delivery of local anesthetics significantly improved postoperative pain control while decreasing the amount of narcotic analgesia required in patients who underwent standard median sternotomy. There was also a significant decrease in hospital length of stay, which is likely to result in significant cost reductions.

Creation of a diaphragm patch to facilitate placement of the AbioCor implantable replacement heart.

One of the concerns when placing a total artificial heart is whether the device will fit in the thoracic cavity without impinging on vital structures. We report the creation of a patch in a recipient of the AbioCor Implantable Replacement Heart that allowed for an appropriate fit of the device without adversely affecting pulmonary and hemodynamic functions.