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BACKGROUND: Problematic mitral regurgitation (MR) may develop following lung transplantation (LTx). There is limited information on the management of MR in LTx patients, as such we sought to evaluate our centre's experience. METHODS: From 2000 to 2019, 1,054 patients underwent LTx at our centre (896 bilateral, 158 single). We identified patients in whom significant MR developed at any point post-LTx. The aetiology of MR, management and outcome were retrospectively analysed. RESULTS: Eight (8) patients developed severe MR post-LTx, six following bilateral LTx and two following single LTx. Lung transplantation indications included interstitial lung disease (n=5), chronic obstructive pulmonary disease (n=2) and pulmonary arterial hypertension (n=1). Severe MR occurred intraoperatively (n=1), postoperative day 1 (n=1) with the remaining six cases between 80 and 263 days post-LTx. The aetiology was noted to be due to severe left ventricular dysfunction following unmasking of a chronically pulmonary hypertension-related under-preloaded left ventricle in one case, and in the remaining seven patients causes included myxomatous degeneration, ischaemic MR, and functional MR due to annular dilatation. In the patient with intraoperative severe MR, the MR became mild with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and in the remaining seven patients a variety of procedures were used, including mitral valve repair, valve replacement and transcatheter edge-to-edge mitral valve repair. All patients survived the mitral procedure. Two (2) deaths occurred at 12.9 years (stroke) and 5 years (cancer) from mitral valve surgery. CONCLUSIONS: Development of significant mitral valve regurgitation is a rare but morbid complication after lung transplantation. This may represent the progressive natural history of pre-existing degenerative mitral valve disease and rarely, early after transplantation may be related to changes in ventricular geometry. Management of severe MR can follow the same management approach as in the non-transplant community, with the expectation of similarly good results.
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Transplante de Pulmão , Insuficiência da Valva Mitral , Humanos , Transplante de Pulmão/efeitos adversos , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
There is an ever increasing demand for donor lungs in patients waiting for transplantation. Lungs of many potential donors will be rejected if the standard criteria for donor assessment are followed. We have expanded our donor lung pool by accepting marginal donors and establishing a donation after circulatory death program. We have achieved comparable results using marginal donors and accepting donor lungs following donation after circulatory death. We present our assessment and technical guidelines on lung procurement taking into consideration an increasingly complex cohort of lung donors. These guidelines form the basis of the lung procurement training program involving surgical Fellows at the Alfred Hospital in Melbourne, Australia.
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Educação de Pós-Graduação em Medicina , Transplante de Pulmão/educação , Pulmão/cirurgia , Cirurgiões/educação , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/métodos , HumanosRESUMO
In patients requiring left ventricular assist device (LVAD) support, it can be difficult to ascertain suitability for long-term mechanical support with LVAD and eventual transplantation. LVAD implantation in a shocked patient is associated with increased morbidity and mortality. Interest is growing in the utilization of extracorporeal life support (ECLS) as a bridge-to-bridge support for these critically unwell patients. Here, we reviewed our experience with ECLS double bridging. We hypothesized that ECLS double bridging would stabilize end-organ dysfunction and reduce ventricular assist device (VAD) implant perioperative mortality. We conducted a retrospective review of prospectively collected data for 58 consecutive patients implanted with a continuous-flow LVAD between January 2010 and December 2013 at The Alfred Hospital, Melbourne, Victoria, Australia. Twenty-three patients required ECLS support pre-LVAD while 35 patients underwent LVAD implantation without an ECLS bridge. Preoperative morbidity in the ECLS bridge group was reflected by increased postoperative intensive care duration, blood loss, blood product use, and postoperative renal failure, but without negative impact upon survival when compared with the no ECLS group. ECLS stabilization improved end-organ function pre-VAD implant with significant improvements in hepatic and renal dysfunction. This series demonstrates that the use of ECLS bridge to VAD stabilizes end-organ dysfunction and reduces VAD implant perioperative mortality from that traditionally reported in these "crash and burn" patients.
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Oxigenação por Membrana Extracorpórea/instrumentação , Insuficiência Cardíaca/terapia , Coração Auxiliar , Oxigenadores de Membrana , Adulto , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda , VitóriaRESUMO
Cardiac fibromas are rare neoplasms of myocardial fibroblasts. We present a case of a right ventricular fibroma and review the surgical management of these neoplasms.
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Procedimentos Cirúrgicos Cardíacos/métodos , Fibroma/cirurgia , Neoplasias Cardíacas/cirurgia , Ventrículos do Coração/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Adulto , Ponte Cardiopulmonar , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Valva Mitral/cirurgia , ReoperaçãoRESUMO
Synovial sarcoma is an extremely rare form of primary malignancy of the pericardium. We present a case of primary synovial sarcoma of the pericardium followed by a review of the literature.
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Neoplasias Cardíacas/cirurgia , Pericárdio , Sarcoma Sinovial/cirurgia , Adulto , Procedimentos Cirúrgicos Cardíacos , Ponte de Artéria Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/cirurgia , Diagnóstico por Imagem , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/patologia , Humanos , Achados Incidentais , Masculino , Infarto do Miocárdio/etiologia , Reoperação , Sarcoma Sinovial/complicações , Sarcoma Sinovial/diagnóstico , Sarcoma Sinovial/patologia , EsternotomiaRESUMO
INTRODUCTION: Donation after circulatory death (DCD) is an evolving method for lung transplantation (LTx) with results comparable to donation after brain death (DBD). MATERIALS AND METHODS: DCD lung transplant program requires a systematic approach for an efficient utilization of hospital resources. The surgical techniques have been developed to minimize the ischemic time during lung procurement. We have presented our management protocol and the surgical techniques as used at the Alfred Hospital in Melbourne, Australia. RESULTS: We have transplanted 92 recipients with lungs procured from 91 donors over an 8 year period from May 2006 to July 2014. This accounted for an extra 19% lung transplant operations performed during this time period. Operative mortality was 1% and 8 year survival was 71% in DCD lung recipients. CONCLUSIONS: DCD lung transplantation provides an additional significant pool of lung donors with satisfactory short and long term outcomes.
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Transplante de Pulmão/mortalidade , Transplante de Pulmão/métodos , Traumatismo por Reperfusão/mortalidade , Traumatismo por Reperfusão/prevenção & controle , Coleta de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/métodos , Citratos/farmacologia , Criopreservação/métodos , Morte , Sobrevivência de Enxerto , Humanos , Soluções para Preservação de Órgãos/farmacologia , Perfusão/métodos , Preservação de Tecido/métodosRESUMO
Sternal re-entry represents a critical step during redo cardiac surgery. We describe a simple method that relies on opening of the posterior table of the sternum with a laminectomy retractor after dividing the anterior table with an oscillating saw.
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Procedimentos Cirúrgicos Cardíacos/instrumentação , Laminectomia/instrumentação , Reoperação/instrumentação , Esternotomia/instrumentação , Esternotomia/métodos , HumanosRESUMO
BACKGROUND: Although postoperative atrial fibrillation (POAF) frequently occurs early after cardiac surgery, there is a paucity of data evaluating predictors and timing of late atrial fibrillation (AF) recurrence. OBJECTIVES: The authors sought to evaluate predictors of late AF recurrence in patients undergoing cardiac surgery. METHODS: We retrospectively reviewed cardiac surgery patients from 2010 to 2018 with no preoperative diagnosis of AF or atrial flutter. We recorded incidence and timing of late AF recurrence, defined as occurring ≥12 months following surgery. RESULTS: 1,031 patients were included (mean age at surgery 64 ± 12 years, 74% male). Early POAF was recorded in 445 patients (43%). POAF was usually transient, with total AF duration <48 hours in 72% and reversion to sinus rhythm at discharge in 91%. At 4.7 ± 2.4 years follow-up, late AF occurred in 139 patients (14%). Median time to AF recurrence was 4.4 years post-surgery (Q1-Q3: 2.6-6.2 years). Late AF was significantly more likely among patients with early POAF than those without (23% vs 6%; P < 0.001), with highest incidence (38%) in those with POAF duration >48 hours. In a multivariable analysis, early POAF duration >48 hours was a significant predictor of late AF recurrence (HR: 5.9). Surgery type and CHA2DS2-VASc score were not predictive of late AF events. CONCLUSIONS: Post-operative AF episodes of duration ≥48 hours predict recurrent AF episodes over long-term follow-up after cardiac surgery. Implications for arrhythmia surveillance and anticoagulation in patients with longer duration POAF episodes require further study.
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Fibrilação Atrial , Procedimentos Cirúrgicos Cardíacos , Complicações Pós-Operatórias , Recidiva , Humanos , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Masculino , Feminino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estudos Retrospectivos , Idoso , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Incidência , Fatores de TempoRESUMO
Importance: Vascular complications after transfemoral transcatheter aortic valve implantation (TAVI) remain an important cause of procedure-related morbidity. Routine reversal of anticoagulation with protamine at the conclusion of transfemoral TAVI could reduce complications, but data remain scarce. Objective: To evaluate the efficacy and safety of routine protamine administration after transfemoral TAVI. Design, Setting, and Participants: The ACE-PROTAVI trial was an investigator-initiated, double-blind, placebo-controlled randomized clinical trial performed at 3 Australian hospitals between December 2021 and June 2023 with a 1-year follow-up period. All patients accepted for transfemoral TAVI by a multidisciplinary heart team were eligible for enrollment. Interventions: Eligible patients were randomized 1:1 between routine protamine administration and placebo. Main Outcomes and Measures: The coprimary outcomes were the rate of hemostasis success and time to hemostasis (TTH), presented as categorical variables and compared with a χ2 test or as continuous variables as mean (SD) or median (IQR), depending on distribution. The major secondary outcome was a composite of all-cause death, major and minor bleeding complications, and major and minor vascular complications after 30 days, reported in odds ratios (ORs) with 95% CIs and P values. Results: The study population consisted of 410 patients: 199 patients in the protamine group and 211 in the placebo group. The median (IQR) patient age in the protamine group was 82 (77-85) years, and 68 of 199 patients receiving protamine (34.2%) were female. The median (IQR) patient age in the placebo group was 80 (75-85) years, and 89 of 211 patients receiving the placebo (42.2%) were female. Patients receiving up-front protamine administration had a higher rate of hemostasis success (188 of 192 patients [97.9%]) than patients in the placebo group (186 of 203 patients [91.6%]; absolute risk difference, 6.3%; 95% CI, 2.0%-10.6%; P = .006); in addition, patients receiving up-front protamine had a shorter median (IQR) TTH (181 [120-420] seconds vs 279 [122-600] seconds; P = .002). Routine protamine administration resulted in a reduced risk of the composite outcome in the protamine group (10 of 192 [5.2%]) vs the placebo group (26 of 203 [12.8%]; OR, 0.37; 95% CI, 0.1-0.8; P = .01). This difference was predominantly driven by the difference in the prevalence of minor vascular complications. There were no adverse events associated with protamine use. Conclusions and Relevance: In the ACE-PROTAVI randomized clinical trial, routine administration of protamine increased the rate of hemostasis success and decreased TTH. The beneficial effect of protamine was reflected in a reduction in minor vascular complications, procedural time, and postprocedural hospital stay duration in patients receiving routine protamine compared with patients receiving placebo. Trial Registration: anzctr.org.au Identifier: ACTRN12621001261808.
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Phrenic nerve injury is a well-recognised complication of cardiac surgery that can lead to disabling effects from diaphragmatic dysfunction, especially in children and patients with a history of chronic obstructive airway disease. Various mechanisms of injury have been recognised including hypothermia, mechanical trauma and possibly ischaemia. A clear understanding of these mechanisms is important in order to modify surgical techniques to prevent this serious complication of cardiac surgery.
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Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Traumatismos dos Nervos Periféricos/prevenção & controle , Nervo Frênico/lesões , Adolescente , Criança , Pré-Escolar , Humanos , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/patologiaRESUMO
Heart-lung transplantation is a mature therapy but has perioperative complications, such as phrenic nerve dysfunction and mediastinal bleeding. We report our technical modifications to simplify the procedure.
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Transplante de Coração-Pulmão , Transplante de Pulmão , Humanos , Transplante de Coração-Pulmão/métodos , Mediastino , Nervo Frênico/cirurgia , HemorragiaRESUMO
Postinfarct ventricular septal defect (PIVSD) is associated with high mortality and the management of these patients has been a challenge with little improvement in outcomes. We commenced a protocol of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for those patients who present in cardiogenic shock with the aim to improve end-organ function before definitive surgical repair to reduce postoperative mortality. This study reviewed the results of this strategy. This was a single-center, retrospective review of all patients who were admitted to our institution with PIVSD in cardiogenic shock from September 2015 to November 2019. Clinical and investigative data were evaluated. Eight patients were referred with PIVSD during this period in cardiogenic shock. One patient had an anterior PIVSD and the other seven had inferior PIVSD. Six patients underwent surgical repair at a median (interquartile range, IQR) of 7 (5-8) days after initiation of VA ECMO. Two patients did not undergo surgical repair. Five patients survived after surgery and one patient died postoperatively due to multiorgan failure. Preoperative use of VA ECMO is a feasible strategy for PIVSD and may improve the results of repair.
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Oxigenação por Membrana Extracorpórea , Comunicação Interventricular , Humanos , Choque Cardiogênico/etiologia , Choque Cardiogênico/cirurgia , Oxigenação por Membrana Extracorpórea/métodos , Comunicação Interventricular/cirurgia , Estudos Retrospectivos , MorteRESUMO
We present the case of acute myocardial infarction secondary to spontaneous coronary artery dissection in a patient 2 weeks post orthotopic heart transplantation. (Level of Difficulty: Advanced.).
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Optimal management of heart failure is collaborative, with the involvement of specialist heart failure physicians, nurses, interventionalists, and surgeons. In addition to medical optimisation and cardiac resynchronisation therapy, surgery plays a valuable role in many patients. We herein study the evidence and the role of surgical intervention in functional mitral regurgitation, coronary revascularisation in ischaemic cardiomyopathy, and surgical ventricular reconstruction. Additionally, we describe techniques of temporary and durable mechanical circulatory support, with their relative advantages and disadvantages, and applications. Finally, we describe the history and nomenclature around heart transplants, their indications, techniques, present-day outcomes, complications, and new developments in the field.
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Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca , Insuficiência da Valva Mitral , Isquemia Miocárdica , Insuficiência Cardíaca/cirurgia , Ventrículos do Coração , Humanos , Insuficiência da Valva Mitral/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Right ventricular (RV) failure after left ventricular assist device (VAD) implantation is a difficult problem. One solution is the implantation of continuous-flow VADs in a biventricular configuration. Disappointing survival and a concerning incidence of right-sided pump thrombosis have been previously reported. METHODS: From May 2017 to April 2020, a total of 12 patients underwent implantation of HeartMate 3 (HM3) biventricular VADs (BiVADs) as a bridge to cardiac transplantation. The right-sided pump was implanted in the right atrium in all cases. Adverse events and patient outcomes were determined. RESULTS: Patients were male, and the mean age was 44 years. The etiology was dilated cardiomyopathy (6 patients), sarcoid heart disease (2 patients), ischemic cardiomyopathy (1 patient), anthracycline cardiomyopathy (1 patient), non-compaction cardiomyopathy (1 patient), and arrhythmogenic RV cardiomyopathy with biventricular involvement (1 patient). There was 1 death from multisystem failure. There were 3 episodes of right VAD thrombus (thrombosis or clot ingestion); 1 managed medically, 1 recognized intraoperatively treated with clot retrieval, and 1 requiring pump exchange. There were 3 driveline infections. At 18 months after the procedure, 5 patients (41.7%) had undergone cardiac transplantation, 5 patients (41.7%) were alive and on biventricular support, 1 patient had died (8.3%), and 1 patient had VAD explantation for myocardial recovery (8.3%). Actuarial survival at 18 months was 91.7%. CONCLUSIONS: In this small study, HM3 BiVAD in these critically ill patients was used with low mortality. This suggests that the timely deployment of biventricular support with HM3 can be associated with favorable outcomes.
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Insuficiência Cardíaca/terapia , Ventrículos do Coração/diagnóstico por imagem , Coração Auxiliar , Adolescente , Adulto , Ecocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: The objective of this study was to report the procedural incidence and patient outcomes after the 2009 introduction of an institutional resuscitative thoracotomy (RT) programme. Emergency physicians, general surgeons and emergency nursing trauma team members were trained to perform RT on thoracic trauma patients with an unresponsive systolic blood pressure (SBP) <70 mmHg within 30 min of arrival, prior to cardiothoracic team back-up. METHODS: A retrospective cohort study was conducted on patients who underwent RT from 2009 to 2017. The primary outcome measures were the incidence of the procedure and patients' survival to hospital discharge. Variables associated with survival were assessed using univariable logistic regression analyses. RESULTS: There were 12 399 major trauma patients, including 7657 with major thoracic trauma and 315 presenting with SBP <70 mmHg. There were 32 RTs performed (incidence of 0.4%; 95% confidence interval [CI] 0.3-0.6) among patients with major thoracic trauma and 10.2% (99% CI 7.3-13.4) among patients with major thoracic trauma and SBP <70 mmHg. There were eight (25%; 95% CI 13.2-42.1) survivors to hospital discharge and no late mortality (mean follow-up 2.8 years). Survival was significantly associated with the procedure performed within 30 min of arrival (odds ratio 0.09; 95% CI 0.01-0.67) while mortality was associated with the procedure being performed in the setting of traumatic cardiac arrest (odds ratio 18.3; 95% CI 2.4-140.4). CONCLUSIONS: A formal training and credentialing programme was associated with a low incidence of the procedure, yet achieved a survival rate of 25%, which is comparable to other reported literature.
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Traumatismos Torácicos , Toracotomia , Adulto , Serviço Hospitalar de Emergência , Humanos , Ressuscitação , Estudos Retrospectivos , Traumatismos Torácicos/cirurgia , Centros de TraumatologiaRESUMO
BACKGROUND: A donor arterial PO2/FiO2 (P/F ratio) of less than the 300 threshold would frequently result in either exclusion of the donor or placement of the lungs on ex vivo lung perfusion (EVLP). The aim was to investigate the veracity of the P/F ratio threshold of 300 for donor lung acceptability. METHODS: In 93 brain dead lung donors, arterial blood gases were drawn in the intensive care unit (ICU) just before procurement and each of the 4 donor pulmonary veins in the operating room (OR). No donor lungs were rejected for transplantation based on the last ICU or OR P/F ratio, and EVLP was not used. The recipients were followed up 6 and 12 months following transplantation. RESULTS: There were 93 recipients of bilateral lung transplantation. An arterial P/F ratio of < 300 was largely driven by a low P/F ratio in the lower lobes. There were no differences between the recipients receiving donor lungs where the ICU P/F ratio was < 300 compared with ≥ 300 in the time to extubation, grade of primary graft dysfunction, pulmonary function at 6 and 12 months, and 12-month survival. CONCLUSIONS: From this study:(1) If a donor P/F threshold of 300 was adhered to, 36% would have been rejected, and (2) The donor P/F ratio threshold of 300 is excessively conservative and results in the wastage of donor lungs and the application of unnecessary EVLP.
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Circulação Extracorpórea/métodos , Sobrevivência de Enxerto/fisiologia , Transplante de Pulmão/métodos , Pulmão/metabolismo , Preservação de Órgãos/métodos , Perfusão/métodos , Doadores de Tecidos , Adulto , Feminino , Seguimentos , Humanos , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Driveline infections remain a major complication of ventricular assist device (VAD) implantation. This study aimed to characterize in vivo microbial biofilms associated with driveline infections and host tissue integration of implanted drivelines. METHODS: A total of 9 infected and 13 uninfected drivelines were obtained from patients with VAD undergoing heart transplantation in Australia between 2016 and 2018. Each driveline was sectioned into 11 pieces of 1.5 cm in length, and each section was examined by scanning electron microscopy (SEM) and viable counts for microbial biofilms. Microorganisms were cultured and identified. Host tissue integration of clinical drivelines was assessed with micro-computed tomography (CT) and SEM. An in vitro interstitial biofilm assay was used to simulate biofilm migration in the driveline tunnel, and time-lapse microscopy was performed. RESULTS: Of the 9 explanted, infected drivelines, all had organisms isolated from varying depths along the velour section of the drivelines, and all were consistent with the swab culture results of the clinically infected exit site. SEM and micro-CT suggested insufficient tissue integration throughout the driveline velour, with microgaps observed. Clinical biofilms presented as microcolonies within the driveline tunnel, with human tissue as the sub-stratum, and were resistant to anti-microbial treatment. Biofilm migration mediated by a dispersal-seeding mechanism was observed. CONCLUSIONS: This study of explanted infected drivelines showed extensive anti-microbial-resistant biofilms along the velour, associated with microgaps between the driveline and the surrounding tissue. These data support the enhancement of tissue integration into the velour as a potential preventive strategy against driveline infections by preventing biofilm migration that may use microgaps as mediators.
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Biofilmes , Coração Auxiliar/efeitos adversos , Infecções Relacionadas à Prótese/diagnóstico , Microtomografia por Raio-X/métodos , Seguimentos , Insuficiência Cardíaca/terapia , Coração Auxiliar/microbiologia , Humanos , Estudos ProspectivosRESUMO
OBJECTIVE: Midline sternotomy remains the most common access incision for cardiac operations. Traditionally, the sternum is closed with stainless steel wires. Wires are well known to stretch and break, however, leading to pain, nonunion, and potential deep sternal wound infection. We hypothesized that biocompatible plastic cable ties would achieve a more rigid sternal fixation, reducing postoperative pain and analgesia requirements. METHODS: A prospective, randomized study compared the ZIPFIX (De Puy Synthes, West Chester, Pa) sternal closure system (n = 58) with standard stainless steel wires (n = 60). Primary outcomes were pain and analgesia requirements in the early postoperative period. Secondary outcome was sternal movement, as assessed by ultrasound at the postoperative follow-up visit. RESULTS: Groups were well matched in demographic and operative variables. There were no significant differences between groups in postoperative pain, analgesia, or early ventilatory requirements. Patients in the ZIPFIX group had significantly more movement in the sternum and manubrium on ultrasound at 4 weeks. CONCLUSIONS: ZIPFIX sternal cable ties provide reliable closure but no demonstrable benefit in this study in pain or analgesic requirements relative to standard wire closure after median sternotomy.