Challenges and possibilities of developing cardiac surgery in a peripheral hospital of low- and middle-income countries.

OBJECTIVE: Over a million cardiac surgeries are performed every year around the globe. However, approximately 93% of world population living in low- and middle-income countries have no access to cardiac surgery. The incidence of rheumatic and congenital heart disease is high in Nepal, while only 2,500-3,000 cardiac surgeries are performed annually. The aim of our study is to analyze challenges and opportunities of establishing a cardiac surgery program in a peripheral hospital of Nepal. METHODS: We analyzed our effort to establish a cardiac surgery program in a peripheral hospital in Nepal. RESULTS: Out of 2,659 consulted and diagnosed patients, we performed 85 open-heart surgeries in 4 years. Mean age of patients was 38.35 ± 14.13 years. The majority of patients were male (62.4% of patients) with 65.9% suffering from rheumatic heart disease. Average intensive care unit stay and hospital stay were 2.32 ± 1.1 and 8.29 ± 2.75 days, respectively. No in-hospital mortality was observed. CONCLUSION: We conclude that developing cardiac surgical care in a peripheral hospital of a developing country is feasible with support from government, foreign colleagues, local teams, and non-governmental organizations. The availability of a regular cardiac surgery service in the periphery of the country makes such services more accessible for the patients and helps in reducing the long waiting lists and unmanageable workload in the established cardiac centers in the capital city.

Congenital absence of right coronary artery: a rare coronary anomaly: case report.

Single coronary artery is a rare congenital anomaly in which a single coronary artery arises from the aortic root that supplies the entire heart. It has variable clinical presentations ranging from a completely benign course to sudden cardiac death. Identifying and categorizing to high-risk type based on clinical presentation and anatomical features can present adverse cardiac events and provides better prognosis.

Persistent Patent Arterial Duct Rather Than a Ligament in the Setting of Diverticulum of Kommerell.

We report a rare case of persistent patent arterial duct (PDA) in the combination of diverticulum of Kommerell, aberrant left subclavian artery, and total anomalous pulmonary venous connection (TAPVC). Surgical correction of the defect was done by ligating and dividing the PDA and correcting the TAPVC. (Level of Difficulty: Intermediate.).

Cardiac Surgery and Small Island States: A Bridge Too Far?

BACKGROUND: Small island developing states (SIDS) make up nearly 1% of the world's population, with 65 million people across 58 countries. Small island developing states have some of the highest rates of rheumatic heart disease in addition to a substantial burden of congenital heart defects and a growing burden of ischemic heart disease. Here, we present an overview of cardiac surgical services in SIDS, with a focus on Papua New Guinea, the Maldives, and Aruba. METHODS: We performed a literature review using the PubMed/MEDLINE and Google Scholar databases to identify articles describing cardiac surgery services in SIDS. Case studies of the history and current state of cardiac surgery in Papua New Guinea, the Maldives, and Aruba were developed and informed by local clinical experience. RESULTS: Nine SIDS have independent cardiac surgical centers and 5 SIDS have local centers supported by visiting teams. Papua New Guinea started cardiac surgery in 1993 and is served by a public center, performing nearly 100 cardiac surgeries per year. The Maldives introduced cardiac surgery services in 2018, with 1 local cardiac surgeon supported by Nepalese cardiac surgeons, performing 33 cardiac surgeries in 15 months. In Aruba, no local cardiac center exists and over 150 patients are sent abroad for cardiac surgery, representing 12% of total health spending. CONCLUSIONS: Small island developing states have limited availability of cardiac surgery but pressing clinical needs. Independent cardiac centers exist with acceptable outcomes and lower costs than foreign treatment, which suggests the need to strengthen regionalization models to deliver cardiac surgical care in SIDS.

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy.

BACKGROUND: Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization. METHODS: We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6 months following discharge. RESULTS: Mean age of patients was 52.5 ± 9.8 years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46 days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent. CONCLUSIONS: Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

Rheumatic Heart Disease Screening Among School Children in Central Nepal.

Rheumatic heart disease is the most common heart disease in developing countries. This Global Health Report uses the results of screening 28,050 school children clinically with 2-dimensional echocardiography. A total of 1,739 students had cardiac murmur, with the most dominant lesion being rheumatic mitral regurgitation. This report concluded that the burden of rheumatic heart disease is decreasing, but it is still significant in Nepal. That is why echocardiographic screening is important in early diagnosis and management. (Level of Difficulty: Beginner.).

Functional Magnetic Resonance Imaging in the Evaluation of the Elastic Properties of Ascending Aortic Aneurysm.

OBJECTIVE: To evaluate the aortic wall elasticity using the maximal rate of systolic distension (MRSD) and maximal rate of diastolic recoil (MRDR) and their correlation with the aortic size index (ASI). METHODS: Forty-eight patients with thoracic aortic aneurysm were enrolled in this study. A standard magnetic resonance imaging (MRI) protocol was used to calculate MRSD and MRDR. Both MRSD and MRDR were expressed as percentile of maximal area/10-3 sec. ASI (maximal aortic diameter/body surface area) was calculated. A correlation between MRSD, MRDR, ASI, and the patient's age was performed using regression plot. RESULTS: A significant correlation between MRSD (t=-4,36; r2=0.29; P≤0.0001), MRDR (t=3.92; r2=0.25; P=0.0003), and ASI (25±4.33 mm/m2; range 15,48-35,14 mm/m2) is observed. As ASI increases, aortic MRSD and MRDR decrease. Such inverse correlation between MRSD, MRDR, and ASI indicates increased stiffness of the ascending aorta. A significant correlation between the patient's age and the decrease in MRSD and MRDR is observed. CONCLUSION: MRSD and MRDR are significantly correlated with ASI and the patient's age. They seem to describe properly the increasing stiffness of aortas. These two new indexes provide a promising, accessible, and reproducible approach to evaluate the biomechanical property of the aorta.

Relationships Between Phenotype and Function of Blood CD4+ T-Cells and Ascending Thoracic Aortic Aneurysm: an Experimental Study.

INTRODUCTION: Non-familial ascending thoracic aorta dilation and aneurysms (TAAs) are silent diseases in elderly patients. Histopathology revealed that functionally polarized infiltrating CD4+ T-cells play a key role in aortic wall weakening. OBJECTIVE: To evaluate the possible associations between phenotype and cytokine production of circulating CD4+ T-lymphocytes and the presence of TAA in patients with aortic valve disease (AVD). METHODS: We studied blood samples from 10 patients with TAA and 10 patients with AVD. Flow cytometry was used to quantify: a) CD4+ T-lymphocytes surface expression of CD25, CD28, and chemokine receptors (CCR5, CXCR3, CX3CR1); b) fractions of in vitro stimulated CD4+ T-cells producing cytokines (interferon gamma [IFN-γ], interleukin [IL]-17A, IL-21, IL-10); c) CD4+CD25highFoxP3+ regulatory T-cells (Treg) fraction. Enzyme-linked immunosorbent assays (ELISA) were performed for cytokines (IFN-γ, IL-6, IL-10, IL-17A, IL-23, transforming growth factor beta [TGF-ß]) and chemokines (RANTES, CX3CL1). RESULTS: The total CD4+CD28±CD4+/CX3CR1+ T-cells fraction was higher (P=0.0323) in AVD (20.452±4.673) than in TAA patients (8.633±2.030). The frequency ratio of CD4+ T-lymphocytes producing IFN-γ vs. IL-17A+IL-21 cytokine-producing CD4+ T-cells was higher (P=0.0239) in AVD (2.102±0.272) than in TAA (1.365±0.123) patients. The sum of CD4+CD28±CD4+/CX3CR1+ T-cells correlated positively with values of the previous cytokine ratio (P=0.0002, R=0.732). The ratio of CD4+CD28±CD4+/CX3CR1+ T-cells vs. Treg was higher (P=0.0008) in AVD (20.859±3.393) than in TAA (6.367±1.277) patients. CONCLUSION: Our results show that the presence of TAA in subjects with AVD is associated with imbalance between phenotypic and cytokine-producing subsets of circulating CD4+ T-lymphocytes, prevalently oriented towards a pro-fibrotic and IFN-γ counteracting effect to functional polarization.

Right-Sided Minithoracotomy as a Surgical Approach for the Concomitant Treatment of Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia diagnosed in humans and therefore causes a high socioeconomic burden. The Cox-Maze IV procedure is the gold standard treatment for atrial fibrillation. Minimally invasive surgery for the treatment of AF is also promising. OBJECTIVES: Our aim is to evaluate the feasibility, safety, and immediate plus medium-term results of concomitant AF ablation therapy in patients undergoing minimally invasive valve surgery through right-sided minithoracotomy. PATIENTS AND METHODS: Retrospective data were collected from January 2012 to December 2013. Seventy-five consecutive patients underwent radiofrequency ablation during valve surgery through a right-sided minithoracotomy. RESULTS: All 75 patients underwent radiofrequency ablation. The pulmonary vein was isolated in 6 (8%) by encircling the left and right pulmonary veins. In 9 (12%) patients, endocardial box lesions were created using a monopolar probe, while in 47 (62.7%), epicardial box lesions were produced with a monopolar probe. Thirteen (17.3%) patients received a box lesion created with a bipolar probe. Finally, in 22 (29.3%) patients, a line of lesions was produced leading up to the posterior mitral annulus. Only 1 (1.3%) perioperative death was observed. At discharge, 43 (57.3%) patients were in sinus rhythm and 30 (40%) were in AF. After a mean follow-up of 21.6 ± 10.1 months, 46 patients (63%) were in a stable sinus rhythm and 27 were in (37%) in AF; 26 (56.5%) patients were free from antiarrhythmic therapy, while 19 (42.2%) were still taking at least one drug. CONCLUSIONS: We can conclude that treatment of AF using a right-sided minithoracotomy approach and RF energy in patients undergoing cardiac surgery for various valve diseases is feasible, safe, and reproducible.

Relationships between phenotype and function of blood cd4+ t-cells and ascending thoracic aortic aneurysm: an experimental study

Abstract Introduction: Non-familial ascending thoracic aorta dilation and aneurysms (TAAs) are silent diseases in elderly patients. Histopathology revealed that functionally polarized infiltrating CD4+ T-cells play a key role in aortic wall weakening. Objective: To evaluate the possible associations between phenotype and cytokine production of circulating CD4+ T-lymphocytes and the presence of TAA in patients with aortic valve disease (AVD). Methods: We studied blood samples from 10 patients with TAA and 10 patients with AVD. Flow cytometry was used to quantify: a) CD4+ T-lymphocytes surface expression of CD25, CD28, and chemokine receptors (CCR5, CXCR3, CX3CR1); b) fractions of in vitro stimulated CD4+ T-cells producing cytokines (interferon gamma [IFN-γ], interleukin [IL]-17A, IL-21, IL-10); c) CD4+CD25highFoxP3+ regulatory T-cells (Treg) fraction. Enzyme-linked immunosorbent assays (ELISA) were performed for cytokines (IFN-γ, IL-6, IL-10, IL-17A, IL-23, transforming growth factor beta [TGF-β]) and chemokines (RANTES, CX3CL1). Results: The total CD4+CD28±CD4+/CX3CR1+ T-cells fraction was higher (P=0.0323) in AVD (20.452±4.673) than in TAA patients (8.633±2.030). The frequency ratio of CD4+ T-lymphocytes producing IFN-γ vs. IL-17A+IL-21 cytokine-producing CD4+ T-cells was higher (P=0.0239) in AVD (2.102±0.272) than in TAA (1.365±0.123) patients. The sum of CD4+CD28±CD4+/CX3CR1+ T-cells correlated positively with values of the previous cytokine ratio (P=0.0002, R=0.732). The ratio of CD4+CD28±CD4+/CX3CR1+ T-cells vs. Treg was higher (P=0.0008) in AVD (20.859±3.393) than in TAA (6.367±1.277) patients. Conclusion: Our results show that the presence of TAA in subjects with AVD is associated with imbalance between phenotypic and cytokine-producing subsets of circulating CD4+ T-lymphocytes, prevalently oriented towards a pro-fibrotic and IFN-γ counteracting effect to functional polarization.

Functional magnetic resonance imaging in the evaluation of the elastic properties of ascending aortic aneurysm

Abstract Objective: To evaluate the aortic wall elasticity using the maximal rate of systolic distension (MRSD) and maximal rate of diastolic recoil (MRDR) and their correlation with the aortic size index (ASI). Methods: Forty-eight patients with thoracic aortic aneurysm were enrolled in this study. A standard magnetic resonance imaging (MRI) protocol was used to calculate MRSD and MRDR. Both MRSD and MRDR were expressed as percentile of maximal area/10-3 sec. ASI (maximal aortic diameter/body surface area) was calculated. A correlation between MRSD, MRDR, ASI, and the patient's age was performed using regression plot. Results: A significant correlation between MRSD (t=-4,36; r2=0.29; P≤0.0001), MRDR (t=3.92; r2=0.25; P=0.0003), and ASI (25±4.33 mm/m2; range 15,48-35,14 mm/m2) is observed. As ASI increases, aortic MRSD and MRDR decrease. Such inverse correlation between MRSD, MRDR, and ASI indicates increased stiffness of the ascending aorta. A significant correlation between the patient's age and the decrease in MRSD and MRDR is observed. Conclusion: MRSD and MRDR are significantly correlated with ASI and the patient's age. They seem to describe properly the increasing stiffness of aortas. These two new indexes provide a promising, accessible, and reproducible approach to evaluate the biomechanical property of the aorta.

Pulmonary artery perforation by plug anchoring system after percutaneous closure of left appendage.

Patients receiving oral anticoagulant therapy for atrial fibrillation who are at high risk of bleeding are increasingly referred for percutaneous left atrial appendage exclusion. Although effective, this procedure is not free from risk. We report a case of pericardial tamponade due to pulmonary artery tear caused by a trespassing anchoring hook of an AGA plug. Intraoperatively, no actual bleeding was found from the left appendage, a proof of its complete occlusion by the device. The patient underwent successful surgical repair and radio-frequency ablation of atrial fibrillation was performed by pulmonary veins encircling.

Aorta-to-right ventricular outflow tract fistula with coronary cusp prolapse.

We describe a rare case of aorta-to-right ventricular fistula in a 20-year-old man who presented with signs and symptoms of congestive heart failure. He was successfully treated by closing the fistula with a Dacron patch from the aortic side. At follow-up, he was asymptomatic with no left-to-right shunt.

Age-dependent changes in elastic properties of thoracic aorta evaluated by magnetic resonance in normal subjects.

OBJECTIVES: Aortic stiffness is an independent cardiovascular risk factor. Cardiac magnetic resonance (CMR) allows evaluation of aortic elastic properties by different indexes such as distensibility, the maximum rate of systolic distension (MRSD) and pulse wave velocity (PWV). We sought to define age-dependent changes of indexes of elastic properties of the thoracic aorta in healthy subjects. METHODS: We enrolled 85 healthy subjects (53 males) free of overt cardiovascular disease subdivided into 6 classes of age (from 15 to >60 years). Distensibility, MRSD and PWV were measured by the analysis of CMR images acquired using a 1.5 T clinical scanner. RESULTS: MRSD and distensibility decreased progressively through the classes of age (P < 0.001) after an initial plateau between 20 and 30 years in males and 15 and 20 years in females. Pulse wave velocity increased progressively with the age (P < 0.001). Distensibility was related to body mass index (P = 0.002), surface area (P < 0.005), weight (P = 0.005) and to left ventricular parameters such as mass index (P < 0.001) and end-diastolic volume index (P = 0.002). MRSD was related to end-diastolic volume index (P < 0.001) but not to body parameters. PWV was not related to body and ventricular parameters. CONCLUSIONS: This study confirmed that physiological ageing is associated with a progressive impairment of the elastic properties of the aortic wall. Results of this study may be useful for the early identification of subjects with impaired aortic wall properties providing referral values of elasticity indexes assessed by CMR in different classes of age.

Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Which cannulation (ascending aortic cannulation or peripheral arterial cannulation) is better for acute type A aortic dissection surgery?' Altogether 393 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Femoral artery cannulation has the highest rate of mortality, stroke rate and other complications including retrograde cerebral embolization, organ malperfusion and perfusion of the false lumen. Five out of 14 papers were found to be reporting in favour of axillary (or subclavian) artery cannulation over femoral artery cannulation. In a total of 1829 patients evaluated in these studies, 1068 patients demonstrated a significantly lower complication rate with axillary artery cannulation than femoral artery cannulation. Some of the larger studies showed femoral artery cannulation has higher mortality and stroke rates ranging from 6.5% to 40% and 3% to 17%, respectively. Meanwhile, mortality and stroke rates were ranging from 3% to 8.6% and 1.75% to 4%, respectively, in the favour of axillary artery cannulation. A total of seven studies evaluated direct aortic cannulation for the establishment of cardiopulmonary bypass (CPB). They demonstrated mortality and stroke rates from 0% to 15% and 3.8% to 21%, respectively. Central cannulation has promising results with a lower mortality rate but a higher stroke rate. Direct cannulation of the true lumen is a promising method for quick and easy establishment of CPB. Axillary artery cannulation with a side graft, although it takes more time to construct, is proven to be safe and straightforward, with fewer local and systemic complications including lower mortality and neurological complications.

Assessment of the Initial and Modified Parsonnet score in mortality prediction of the patients operated in the Sarajevo Heart center.

This study has been conducted in an effort to establish more suitable and accurate scoring model we use in everyday practice. Among the specific outcome prediction models, in 1989 Parsonnet et al elaborated a method of uniform risk stratification for evaluation of the results of cardiac surgery procedures. We have tested two forms of the Parsonnet score, Initial and Modified Parsonnet score, in our patients. In the first half of the year 2007, 145 patients were operated in Sarajevo Heart center. All operated patients in that period, have participated in this study. The overall hospital mortality was 4,13 (6 deaths). This study shows that the initial and modified Parsonnet's scores are predictive for operative mortality in adult cardiac surgery patients.

Might type A acute dissection repair with the addition of a frozen elephant trunk improve long-term survival compared to standard repair?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with an acute type A dissection (TAAD) is a frozen elephant trunk in addition to standard aortic dissection repair advantageous in terms of improved long-term mortality and closure of the distal false lumen? Altogether more than 138 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Jakob et al. (23 patients stented vs. 22 patients non-stented), showed similar early outcome but lower false lumen patency rate and lower need of reintervention in the stented group. Pochettino et al. (36 patients stented vs. 42 patients non-stented) reported higher circulatory arrest time and higher incidence of spinal cord and bowel ischemia but a lower false lumen patency rate in stented group. Uchida and co-workers (65 patients stented vs. 55 patients non-stented) reported similar early outcome but better long-term survival and freedom from aortic events in the stented group. Consecutively, Uchida et al. reported the follow-up of the stented group demonstring false lumen thrombosis in all patients one month postoperatively, and complete after three years. Sun and co-workers (107 patients operated with an hybrid approach) showed a hospital mortality of 4.67% and neurological complications rate of 5.6%. At follow-up (35+/-14 months), 95% of the patients had false lumen thrombosis and no distal reoperations were needed. We conclude that the frozen elephant trunk is still rarely adopted during TAAD repair. However, this procedure can be performed safely without increase the operative mortality and morbidity but with an overall higher cardiopulmonary bypass and circulatory arrest time. Spinal cord ischemia and malperfusion syndrome represents the main complications associated with this procedure. Despite few studies, this procedure seems to allow early thrombosis of the false lumen and a reduction of late thoraco-abdominal aneurysm formation and reoperations rate.

Multiple recurrent periprosthetic leak after a mitral valve replacement in a 30-year-old man.

Partial detachment of intracardiac prosthesis is a common reality in cardiac surgical practice. Its identification and surgical correction can be very crucial for a patient, as well as for the surgeon. In this paper, we report a case of a 30-year-old man with partial detachment of mechanical mitral valve prosthesis. He recently underwent his seventh heart surgery procedure; five of them were caused by recurrent dehiscence of mitral valve prosthesis.

Minimally invasive mitral valve surgery through right thoracotomy in patients with patent coronary artery bypass grafts.

We report our institutional experience, with 25 consecutive patients with patent coronary artery bypass grafts (71.8+/-12.7 years), who underwent video-assisted minithoracotomic approach for mitral valve surgery. The surgical technique includes: right minithoracotomy, femoral cannulation and hypothermic ventricular fibrillation. Mean preoperative EuroSCORE was 10.2+/-2.4 and mean ejection fraction was 45+/-9%. Operative mortality was 4% (1/25). No patient required a conversion to sternotomy. Procedures performed were: mitral valve repair in 15 patients (60%), replacement in 10 (40%) and associated tricuspid repair in seven (28%). Mean blood transfusion was 1.2 package/patient. No cardiological, neurological, vascular and wound complications were observed. Postoperative major morbidity includes: severe pulmonary dysfunction in two patients (8%) and acute renal failure in one (4%). Mean ICU and hospital stay were 3.4+/-2.9 and 10.6+/-7.9 days. Echocardiographic follow-up (22.8+/-14.9 months) revealed trace or mild mitral valve regurgitation in all the mitral repair patients. When interrogated, all the surviving patients preferred the minithoracotomic approach rather than the sternotomy. In conclusion, minimally invasive right thoracotomy can be safely performed in patients with functioning coronary bypass grafts requiring mitral valve operation. Low blood transfusion, the avoidance of deep wound infection and the high patient satisfaction are the main advantages of this approach.