The role of ministernotomy in aortic valve surgery-A prospective randomized study.

BACKGROUND AND AIMS: The purpose of this prospective randomized study was to compare the early and midterm outcomes of aortic valve replacement (AVR) through upper ministernotomy with conventional AVR through median sternotomy. METHODS: One hundred patients undergoing elective AVR were randomized into two groups: the M group (upper ministernotomy group, n = 50) and the C group (conventional sternotomy group, n = 50). The operative data, major adverse outcomes, and postoperative variables were compared between the two groups of patients. A cross-sectional follow-up was performed 24.9 ± 5.8 months after surgery. RESULTS: The aortic cross-clamp time and cardiopulmonary bypass time were significantly longer in the M group. Similar incidences of major cardiac, neurologic and renal complications were recorded in both groups. Two patients (4%) in the C group developed wound infections. The length of ICU stay was similar in both groups. The patients in the M group had a shorter hospital stay compared with the patients in the C group (7.6 ± 2 days vs 9.3 ± 4.8 days; P = 0.022). Follow-up revealed that the time period needed to reach full recovery was significantly shorter in the ministernotomy group (1.7 ± 1.2 months vs 2.8 ± 1.6 months; P = 0.001). Morbidity and mortality data did not differ between the two groups. CONCLUSIONS: There was no difference in the major outcomes between the patients who underwent upper ministernotomy and those who underwent full sternotomy. The benefits of the minimally invasive approach were the shorter hospital stay and significantly faster recovery of patients after discharge from the hospital.

Challenging surgery of giant right coronary aneurysm associated with coronary sinus fistula.

Coronary artery fistula is a rare congenital or acquired anomaly. It involves an abnormal connection between the coronary artery and the cardiac chambers or the large thoracic vessels. In some cases, the feeding coronary artery can become extremely dilated. The treatment includes a transcatheter or a surgical intervention depending on the complexity of the anomaly. We present the surgical treatment of the coronary artery to coronary sinus fistula, which includes the complete exclusion of the giant right coronary artery and followed by triple bypass surgery.

Surgical treatment of a left ventricular pseudoaneurysm with an extracellular matrix patch.

Left ventricle pseudoaneurysm is a rare and life-threatening complication of myocardial infarction that is formed as a result of left ventricle free wall rupture contained by the overlying pericardium. Urgent surgical repair is crucial, and in most reports, left ventricle was reconstructed with a Dacron or bovine pericardial patch. We present a case of a 66-year-old female with left ventricle pseudoaneurysm which was successfully repaired with an extracellular matrix patch. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01669-3.

Surgical Reconstruction of the Anomalous Left Coronary Artery From the Pulmonary Artery.

The anomalous left coronary artery from the pulmonary artery is a rare congenital disease. Early surgical reconstruction is mandatory to prevent adverse cardiac events. Direct coronary button transfer, vein graft interposition, ligation, and coronary artery bypass construction are the most commonly used techniques. This case report presents a modified technique of Dacron graft interposition and reimplantation anomalous left coronary artery from the pulmonary artery on the ascending aorta.

Same-Day Carotid Artery Stenting and Coronary Artery Bypass Surgery.

BACKGROUND: The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting. METHODS: From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures. RESULTS: The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17-43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%. CONCLUSION: The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.

Successful surgical aortic valve replacement in a patient with progeria.

The progeroid syndrome includes a group of rare, severe genetic disorders clinically characterized by premature physical ageing. Severe aortic stenosis has been described in progeria patients, but no previous surgical aortic valve replacement was reported. We describe a successful surgical aortic valve replacement combined with coronary artery bypass grafting in a progeria patient with severe aortic stenosis and a small aortic annulus.

Low-Risk Surgical Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation.

Open surgical aortic valve replacement (SAVR) is a viable alternative to transcatheter implantation in low-risk patients. In this light, we evaluated the safety and effectiveness of SAVR performed through conventional and less invasive surgical approaches in a high-volume center. We retrospectively reviewed the records of 395 consecutive patients who underwent open SAVR from January 2019 through December 2019 in our center. We evaluated and compared the operative results and postoperative major adverse outcomes of 3 surgical approaches: full median sternotomy (n=267), upper ministernotomy (ministernotomy) (n=106), and right anterior thoracotomy (minithoracotomy) (n=22). Overall, the 30-day all-cause mortality rate was 0.8% (3 patients). Stroke occurred in 8 patients (2%), disabling stroke in 4 patients (1%), myocardial infarction in 1 (0.2%), and surgical site infection in 13 (3.2%). There was no difference in 30-day mortality rate or incidence of postoperative major adverse events among the 3 surgical groups. Stroke and surgical site infection occurred more frequently, but not significantly so, in the full-sternotomy group. The mean hospital stay was longer after full sternotomy (9.1 ± 5.5 d) than after ministernotomy (7.5 ± 2.9 d) or minithoracotomy (7.4 ± 1.9 d) (P=0.012). Our findings suggest that open SAVR performed in a high-volume center is associated with a low early mortality rate and that less invasive approaches result in faster postoperative recovery and shorter hospital stays.

Long-term results after simultaneous carotid and coronary revascularisation.

BACKGROUND: The revascularisation strategy for concomitant carotid and coronary disease is unknown. Simultaneous or stage coronary artery stenting and carotid endarterectomy are the most common revascularisation approach in the CABG population. This study aimed to evaluate long-term results after simultaneous carotid artery stenting or carotid endarterectomy in patients who underwent coronary artery bypass surgery. METHODS: This is a prospective cohort non-randomised single-institution study. During the period from 2012 to 2015, sixty consecutive patients (65.9 ± 7.41 mean) underwent simultaneous carotid artery stenting and coronary artery bypass surgery (n = 30) or simultaneous carotid endarterectomy and coronary artery bypass surgery (n = 30). The primary endpoints were short- and long-term rates of adverse events (transient ischemic attack, stroke, myocardial infarction, and death). The mean follow-up was 62.05 ± 11.12 months. RESULTS: In-hospital mortality was insignificantly higher in the carotid endarterectomy, and coronary artery bypass surgery group (6.6% vs. 0%), the rate of stroke and myocardial infarction was similar (13.3% and 0% in the carotid endarterectomy and coronary artery bypass surgery group vs. 6.6% and 3.3% in the carotid artery stenting and coronary artery bypass surgery group, respectively). The intensive care unit readmission was significantly higher in the surgical revascularisation approach; it was an independent predictor of hospital mortality. The overall mortality during the follow-up period was 14.28% in both groups. Freedom of the composite adverse outcomes (stroke, myocardial infarction, and death) was 78.55%. CONCLUSION: Comparing two revascularisation strategies is not straightforward due to different anatomical indications for carotid artery stenting and endarterectomy. We consider that each technique has an essential role in carotid revascularisation. Good selection of patients, according to indications, contributes to satisfactory short- and long-term results.

Steroids and statins: an old and a new anti-inflammatory strategy compared.

OBJECTIVES: This study compared the anti-inflammatory effects of methylprednisolone (MP) and atorvastatin and analysed their influences on clinical variables in patients undergoing coronary revascularization. METHODS: Ninety patients with compromised left ventricular ejection fraction (≤30%) undergoing elective coronary surgery were equally randomized to one of three groups: statin group, treatment with atorvastatin (20 mg/day) 3 weeks before surgery; methylprednisolone group, a single shot of methylpredniosolone (10mg/kg); and control group. RESULTS: Postoperative IL-6 was higher in the control group when compared to the methylprednisolone and statin groups (p<0.01). IL-6 was higher in the statin-treated patients (p<0.05 versus methylprednisolone). Administration of methylprednisolone as well as statin treatment increased postoperative cardiac index, left ventricular stroke work index, decreased postoperative atrial fibrilation rate and reduced ICU stay (p<0.05 versus control). The number of patients requiring inotropic support was lower in the methylprednisolone group when compared with the other two groups (p<0.01). Tracheal intubation time was reduced in patients who received methylprednisolone (p<0.01 versus control). CONCLUSIONS: Preoperative administration of either methylprednisolone or atorvastatin reduced pro-inflammatory cytokine release, improved haemodynamics, decreased postoperative atrial fibrilation rate and reduced ICU stay in patients with significantly impaired cardiac function undergoing coronary revascularization. Treatment with methylprednisolone was associated with less inotropic support requirements and reduced mechanical ventilation time.

Cardio-microcurrent device for chronic heart failure: first-in-human clinical study.

AIMS: Most devices for treating ambulatory Class II and III heart failure are linked to electrical pulses. However, a steady electric potential gradient is also necessary for appropriate myocardial performance and may be disturbed by structural heart diseases. We investigated whether chronic application of electrical microcurrent to the heart is feasible and safe and improves cardiac performance. The results of this study should provide guidance for the design of a two-arm, randomized, controlled Phase II trial. METHODS AND RESULTS: This single-arm, non-randomized pilot study involved 10 patients (9 men; mean age, 62 ± 12 years) at two sites with 6 month follow-up. All patients had New York Heart Association (NYHA) Class III heart failure and non-ischaemic dilated cardiomyopathy, with left ventricular ejection fraction (LVEF) <35%. A device was surgically placed to deliver a constant microcurrent to the heart. The following tests were performed at baseline, at hospital discharge, and at six time points during follow-up: determination of LVEF and left ventricular end-diastolic/end-systolic diameter by echocardiography; the 6 min walk test; and assessment of NYHA classification and quality of life (36-Item Short-Form Health Survey questionnaire). Microcurrent application was feasible and safe; no device-related or treatment-related adverse events occurred. During follow-up, rapid and significant signal of efficacy (P < 0.005) was present with improvements in LVEF, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and distance walked. For eight patients, NYHA classification improved from Class III to Class I (for seven, as early as 14 days post-operatively); for one, to Class II; and for one, to Class II/III. 36-Item Short-Form Health Survey questionnaire scores also improved highly significantly. CONCLUSIONS: Chronic application of microcurrent to the heart is feasible and safe and leads to a rapid and lasting improvement in heart function and a near normalization of heart size within days. The NYHA classification and quality of life improve just as rapidly.

Repair of hammock mitral valve with hypoplastic posterior leaflet in an adult.

BACKGROUND AND AIM OF THE STUDY: Congenital hammock mitral valves are rarely discovered in adulthood. The case is presented of a 29-year-old woman in NYHA functional class III and with markedly depressed left ventricular (LV) function, who underwent surgery for severe mitral regurgitation. METHODS AND RESULTS: Preoperative transthoracic echocardiography showed grade 3+/4 mitral regurgitation due to restricted leaflet motion, and an almost immobile posterior leaflet due to the attachment of fibrotic chordae high on the posterior LV wall. At surgery, limited motion of both leaflets and partial agenesis of the posterior leaflet were found. The valve was repaired by resecting the posterior leaflet defect, mobilizing the papillary muscle, and then widening the posterior leaflet. Postoperative echocardiography revealed no further mitral regurgitation, and the valve remained competent despite a postoperative episode of cardiac decompensation. CONCLUSION: Hammock mitral valve repair is a highly challenging procedure, particularly in patients presenting with LV dilatation. The greatest degree of leaflet mobility must be restored in order to prevent tethering. Thus, it is strongly recommended that the posterior leaflet is systematically widened, even in the presence of an apparently large leaflet surface.

Risk factors for neurological dysfunctions after surgical repair of acute aortic dissection type A.

INTRODUCTION: Technical improvement and new operative strategies significantly influence survival and outcomes after the treatment of acute aortic dissection type A (AADA). However, postoperative complications and particularly neurological dysfunctions (ND) are still very common. AIM: To identify preoperative and intraoperative factors as well as immediate postoperative conditions with an influence on the occurrence of neurological complications of surgical treatment of AADA and accordingly take action to reduce them. MATERIAL AND METHODS: Between January 2013 and December 2018, 240 patients with AADA were emergently surgically treated. All patients were divided into two groups: group I - patients with postoperative ND (subgroup Ia - patients with mild, transient ND and Ib - patients with severe ND) and group II - patients without ND. RESULTS: Neurological damage after the operation was registered in 87 (39.5%) patients. Thirty (13.6%) patients had mild ND and 57 (25.9%) severe. Presence of preoperative neurological deficit, reduced level of consciousness, supra-aortic vessel dissection, hemodynamic instability, and excessive postoperative bleeding with hypotension are factors with a highly statistically significant association with the occurrence of severe ND. Neurological complications were not identified in 66.7% of patients who were axillary cannulated versus 55.9% of patients cannulated in the other way but the difference did not reach statistical significance (p = 0.1099). CONCLUSIONS: Advanced neuroprotective strategies during surgical treatment of AADA are associated with favorable neurological outcomes, especially in a group of patients with identified risk factors for ND.

Unusual Presentation of Patent Ductus Arteriosus in Elderly Patient.

We presented a case of a 56-year-old man with giant pulmonary artery aneurysm caused by a misdiagnosed patent ductus arteriosus, severe multivalvular disease and active aortic valve endocarditis successfully treated by surgery. The correct diagnosis was missed despite preoperative diagnostics because the small patent ductus arteriosus was located at the distal part of common pulmonary trunk and a huge regurgitant signal overlapped its Doppler signal. Thorough evaluation of every patient, regardless of age, is necessary to recognize and treat this congenital anomaly.

Initial experience with the Perceval S sutureless aortic valve.

INTRODUCTION: Surgical treatment of the aortic valve represents the gold standard, and thus aortic valve replacement (AVR) is one of the most commonly performed cardiac operations. AIM: To evaluate the early outcome of aortic valve replacement with the Perceval S sutureless aortic bioprosthesis. MATERIAL AND METHODS: This was a retrospective analysis of 24 patients (mean age: 71 ±5 years), who underwent aortic valve replacement with a Perceval S valve. Concomitant coronary artery bypass grafting (CABG) was performed in 9 patients. Patients were evaluated preoperatively, at hospital discharge, and once during follow-up. RESULTS: A total of 15 of 24 patients underwent isolated sutureless aortic valve replacement (mean aortic cross-clamp time: 60 ±14 minutes; mean bypass time: 90 ±23 minutes). Coronary bypass grafting was performed in 9 patients (mean aortic cross-clamp time: 78 ±23 minutes; mean bypass time: 111 ±31 minutes). Hospital mortality was nil. Mean and peak transvalvular pressure gradients were 10 ±2 mm Hg and 21 ±3 mm Hg at follow-up, respectively. Moderate or severe aortic regurgitation did not develop in any patients during the follow-up period. No valve thrombosis, thromboembolic events, or structural valve deterioration were observed. CONCLUSIONS: In our experience with sutureless aortic valve replacement, the surgical procedure is shown to be safe. The early haemodynamic performance seems favourable. By shortening the aortic cross-clamp and bypass times we can notice advantages, especially in high-risk patients. Minimally invasive access seems to be facilitated. Larger studies are needed to confirm our data and determine the long-term durability of the Perceval S sutureless bioprosthesis.

Midterm Results After Simultaneous Carotid Artery Stenting and Cardiac Surgery.

BACKGROUND: The presence of carotid artery disease is known risk factor for perioperative stroke in cardiac surgery. The optimal management of patients with concomitant heart and carotid artery disease is not known. Simultaneous or staged carotid endarterectomy has been proposed to prevent stroke. In an attempt to reduce perioperative morbidity and death, simultaneous carotid stenting and cardiac surgery were implemented (hybrid procedure). This study evaluated early and midterm results after the hybrid procedure. METHODS: From November 2012 through November 2018, 54 patients (36 men; an average age, 65.8 ± 7.3 years) underwent the hybrid procedure. The primary end points were the occurrence of perioperative cerebral stroke, transient ischemic attack (TIA), acute myocardial infarction, bleeding, or death. The mean follow-up period was 30 months. RESULTS: The 30-day mortality was 0%. Periprocedural incidence of stroke and transient ischemic attack were 1.9% and 7.6%, respectively, and acute myocardial infarction occurred in 1 patient (1.9%). No patients required repeat thoracotomy for bleeding. Four patients (7.6%) died during follow-up. The cause of death was stroke in 2 patients (3.8%), heart failure in 1 (1.9%), and multiorgan failure in 1 (1.9%). In-stent restenosis of the carotid artery occurred in 1 patient (1.9%). CONCLUSIONS: In this small group of patients, the hybrid procedure proved to be a safe and efficient treatment for patients with concomitant carotid and cardiac diseases. The low rate of perioperative complications and good midterm results are encouraging.

A rare case of pacemaker lead endocarditis successfully treated with open heart surgery.

BACKGROUND: Cardiac device-related endocarditis has emerged as a serious complication in the era of advanced medical technology. Pacemaker related infections are rare and life-threatening with incidence from 0.06% to 7% and high mortality rate (30-35%). Diagnosis is hard, frequently delayed and could be even missed due to poor clinical findings. The average delay in diagnosis is 5.5 month. We report a case of the late-onset of pacemaker lead endocarditis caused by S. epidermidis successfully treated with open heart surgery. CASE REPORT: Patient with persistent high fever for 11 month and suspicion for infective endocarditis was admitted in Cardiovascular Institute. No clinical signs of endocarditis were observed. TTE revealed large vegetation 30 × 17 mm attached to the atrial electrodes with high embolic potential. This finding was verified by transesophageal echocardiography (TEE), although CT scan did not reveal vegetation. Blood cultures were negative. A sternotomy with cardiopulmonary bypass was performed and electrodes were extracted with large vegetation. Intraoperative finding revealed large thrombus with vegetation around pacemaker leads. Cultures of the electrodes and vegetation revealed Staphylococcus epidermidis. Surgery was followed up with antibiotic treatment for 6 weeks. He has been followed up for the next 2 years, and without complications. CONCLUSION: The absence of criteria for endocarditis and negative blood cultures should not keep the physician from ruling out lead endocarditis. This complication carries high risk of mortality if left untreated.

Preoperative Insight Into the Quality of Radial Artery Grafts.

We investigated the impact of preoperative ultrasonography of the forearm circulation on radial artery conduit selection. Preoperative ultrasound of the forearm circulation was performed routinely in 536 patients planned for radial artery harvesting. The safety assessment of the harvest included the following algorithm of tests: the ultrasound, the Allen test, and pulse oximetry. The quality criteria that were used to exclude a radial artery from harvesting were small size of the artery, diffuse atherosclerosis, calcifications, and severe neointimal hyperplasia. The overall rejection rate due to safety reasons was 16.4%. Seventy-one (13.2%) radial arteries did not fulfill the conduit quality criteria and consequently these arteries were not harvested. In 13.4% of radial arteries, localized arterial wall disease was found in the distal third of the artery. The distal part of the artery was discarded and the rest was used as a conduit. Our results indicate that the ultrasound provides an accurate preoperative insight into the radial artery morphology, enabling selection of the arteries with favorable morphological features.

Unusual presentation of patent ductus arteriosus in elderly patient

Abstract We presented a case of a 56-year-old man with giant pulmonary artery aneurysm caused by a misdiagnosed patent ductus arteriosus, severe multivalvular disease and active aortic valve endocarditis successfully treated by surgery. The correct diagnosis was missed despite preoperative diagnostics because the small patent ductus arteriosus was located at the distal part of common pulmonary trunk and a huge regurgitant signal overlapped its Doppler signal. Thorough evaluation of every patient, regardless of age, is necessary to recognize and treat this congenital anomaly.