Custodiol cardioplegia for temporary mechanical circulatory support.

Several patients requiring biventricular mechanical circulatory support in the acute setting will not be candidates for less invasive advanced heart failure therapies not requiring median sternotomy. Temporary biventricular assist device may provide reliable short term support bridging patients to recovery or further advanced treatments. However, this exposes patients to increased risk of reoperation due to bleeding and further exposure to blood products. This article outlines the practical details necessary in performing this technique while minimizing potential complications.

Infective endocarditis: acne to zoonoses on the valve, an A to Z perspective.

Cutibacterium acnes (C. acnes), previously known as Propionibacterium acnes, is a rare cause of infective endocarditis (IE). We provide a review of the literature and describe two recent cases from a single centre to provide insight into the various clinical presentations, progression and management of patients with this infection. The primary objective of our review is to highlight the difficulty in the initial assessment of these patients with an aim to improve the time and accuracy of diagnosis and expedite subsequent treatment. There are currently no guidelines in the literature specific to the management of IE caused by C. acnes. Our secondary objectives are to disseminate information about the indolent course of the disease and add to the growing body of evidence around this rare, yet complex, cause of IE.

Management of Patients With Aortocoronary Saphenous Vein Graft Aneurysms: JACC State-of-the-Art Review.

Saphenous vein graft aneurysms (SVGAs) following coronary artery bypass grafting (CABG) surgery were first described in 1975. Although rare, in the absence of a prompt diagnosis, SVGAs can be responsible for serious complications and adverse outcomes. The clinical presentation of SVGAs described in the literature can vary from an asymptomatic patient with an incidental radiological finding to a profoundly shocked patient with life-threatening hemorrhage secondary to SVGA rupture. Improvements in diagnostic tools within the last decade, such as multislice computed tomographic scanning, has enabled early detection of SVGAs, and therefore, an expansion of the current management options. In this review, the current data and knowledge about clinical presentation, diagnosis, natural history, and treatment of SVGAs are updated, with a specific emphasis on the evolution of management strategies of this rare complication over the last 45 years. Finally, a clinical algorithm to guide decision-making and management is proposed.

Predicting Readmission to Intensive Care After Cardiac Surgery Within Index Hospitalization: A Systematic Review.

Readmission to the cardiac intensive care unit after cardiac surgery has significant implications for both patients and healthcare providers. Identifying patients at risk of readmission potentially could improve outcomes. The objective of this systematic review was to identify risk factors and clinical prediction models for readmission within a single hospitalization to intensive care after cardiac surgery. PubMed, MEDLINE, and EMBASE databases were searched to identify candidate articles. Only studies that used multivariate analyses to identify independent predictors were included. There were 25 studies and five risk prediction models identified. The overall rate of readmission pooled across the included studies was 4.9%. In all 25 studies, in-hospital mortality and duration of hospital stay were higher in patients who experienced readmission. Recurring predictors for readmission were preoperative renal failure, age >70, diabetes, chronic obstructive pulmonary disease, preoperative left ventricular ejection fraction <30%, type and urgency of surgery, prolonged cardiopulmonary bypass time, prolonged postoperative ventilation, postoperative anemia, and neurologic dysfunction. The majority of readmissions occurred due to respiratory and cardiac complications. Four models were identified for predicting readmission, with one external validation study. As all models developed to date had limitations, further work on larger datasets is required to develop clinically useful models to identify patients at risk of readmission to the cardiac intensive care unit after cardiac surgery.

Is it safe to move away from a full sternotomy for aortic valve replacement?

BACKGROUND: Minimally invasive surgical approaches have gained popularity among patients and surgeons. The aim of this project was to assess the safety of initiating aortic valve replacement via an anterior right thoracotomy program. METHODS: Between May 2015 and May 2019, data of all isolated primary aortic valve replacements were extracted retrospectively from our prospectively collected database and categorized into conventional median sternotomy, hemisternotomy, and anterior right thoracotomy cases. In total, 661 patients underwent isolated primary aortic valve replacement, of whom 429 (65%) had a median sternotomy, 126 (19%) had a hemisternotomy, and 106 (16%) had an anterior right thoracotomy. Preoperative characteristics were similar in each of the three groups. Statistical testing of the surgical groups was undertaken using the chi-square test for categorical variables and one-way analysis of variance with Tukey post-hoc pairwise tests (where appropriate) for continuous variables, to identify differences between pairs of data. RESULTS: Cardiopulmonary bypass and crossclamp times were significantly longer in the anterior right thoracotomy group compared to the hemisternotomy and median sternotomy groups (p < 0.001). Blood loss was significantly less and hospital stay significantly shorter in the hemisternotomy group compared to median sternotomy group but not the anterior right thoracotomy group. Mortality, stroke, renal, gastrointestinal and respiratory complications showed no statistical differences. CONCLUSION: Surgical aortic valve replacement had a very low mortality and morbidity in our experience, and it is safe to start a minimal access program for aortic valve replacement.

Rheumatoid nodule on the anterior mitral valve leaflet.

Symptomatic cardiac rheumatoid nodules are a rare but recognized manifestation of rheumatoid arthritis. We describe the surgical management of a rheumatic nodule involving the anterior leaflet of the mitral valve.

Reusing the patent internal mammary artery as a conduit in redo coronary artery bypass surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in patients with previous internal mammary artery/internal thoracic artery (ITA) grafts, can the internal mammary artery/ITA be reused/recycled in redo coronary artery bypass surgery? Fourteen papers were found using the reported search of which 10 represented the best evidence to answer the clinical question. There was variation in patient selection, the number of patients reported, outcome measures recorded, and methods and duration of follow-up. The results were mostly in favour of using a recycled ITA when it could be safely harvested. Most studies were retrospective. One large series of 60 patients who underwent redo coronary artery bypass grafting (CABG) using previously implanted ITAs had a mean time to reoperation of 117 ± 68 months. They reported no operative deaths; no patients required further or subsequent target vessel revascularization; 30-day mortality was 8.3% and myocardial infarction rate was 3%. Another two series of 16 and 12 patients underwent recycling of arterial grafts during coronary artery revascularization with no perioperative deaths in either. Postoperative angiography was performed in 10 patients in one of these studies, which showed excellent flow in all redone left internal thoracic artery (LITA) grafts. One study reported results from a prospective cohort of 9 patients who underwent redo coronary artery bypass grafting. Interval between operations was between 1 and 132 months. There was no perioperative mortality, but 1 patient required reintervention (to an interposition vein graft). A further study of 4 patients who underwent redo CABG using ITAs that were patent but with severe stenosis at the distal anastomosis had no mortality. Postoperative angiography showed patency of all grafts. There have also been 4 case reports on reusing the ITA/ITA in redo CABG with no damage to the reused LITA, no perioperative mortality and satisfactory follow-up at up to 29 months. Evidently, the recycled ITA can be used in redo coronary artery bypass grafting. Papers found were retrospective series or case reports. As such, there is no direct comparison in outcomes between the recycled ITA and first-time ITA harvest or any other conduit for CABG. In conclusion, we find that when it is possible to harvest a previously used ITA, studies have shown it to be a safe and viable conduit in redo CABG with good long-term outcomes.

Is there a role for HbA1c in predicting mortality and morbidity outcomes after coronary artery bypass graft surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was is there a role for HbA1c in predicting morbidity and mortality outcomes after coronary artery bypass surgery? Eleven studies presented 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. The studies presented analyse the relationship between preoperative HbA1c levels and postoperative outcomes following coronary artery bypass graft (CABG) in diabetic, non-diabetic or mixed patient groups. Four studies found significant increases in early and late mortality at higher HbA1c levels, regardless of a preoperative diagnosis of diabetes. One study demonstrated that 30-day survival outcomes were significantly worse in patients with previously undiagnosed diabetes and elevated HbA1c compared with those with good control [HbA1c >6%; odds ratio 1.53, confidence interval (CI) (1.24-1.91); P = 0.0005]. However, four studies of early mortality outcomes in diabetic patients only showed no significant differences between patients with normal and those with deranged HbA1c levels (P = 0.99). There were mixed reports on morbidity outcomes. Three studies identified a significant increase in infectious complications in patients with poorly controlled HbA1c, two of which were irrespective of previous diabetic status [deep sternal wound infection (P = 0.014); superficial sternal wound infection (P = 0.007) and minor infections (P = 0.006) in poorly controlled diabetics only]. Four studies presented outcomes for total length of stay (LOS). Three of these papers looked specifically at diabetic patients, of which two found no significant differences in length of stay between good and poor preoperative glycaemic control [LOS: P = 0.59 and 0.86 vs P < 0.001]. However, elevated HbA1c vs normal HbA1c was associated with prolonged stay in hospital and in intensive care unit (ICU) in patients irrespective of previous diabetic status [total LOS (P < 0.001)]. Elevated HbA1c levels were also a significant predictor of reduced intraoperative insulin sensitivity in diabetic patients (R = -0.527; P < 0.001). Furthermore, higher HbA1c levels were associated with a reduced incidence of postoperative atrial fibrillation (P = 0.001). We conclude that elevated HbA1c is a strong predictor of mortality and morbidity irrespective of previous diabetic status. In particular, the mortality risk for CABG is quadrupled at HbA1c levels >8.6%. Some studies have called into question the predictive value of HbA1c on short-term outcomes in well-controlled diabetics; however, long-term outcomes in this population have not been reported.

Axonal growth towards Xenopus skin in vitro is mediated by matrix metalloproteinase activity.

We have previously demonstrated that the growth of peripheral nervous system axons is strongly attracted towards limb buds and skin explants in vitro. Here, we show that directed axonal growth towards skin explants of Xenopus laevis in matrigel is associated with expression of matrix metalloproteinase (MMP)-18 and also other MMPs, and that this long-range neurotropic activity is inhibited by the broad-spectrum MMP inhibitors BB-94 and GM6001. We also show that forced expression of MMP-18 in COS-7 cell aggregates enhances axonal growth from Xenopus dorsal root ganglia explants. Nidogen is the target of MMPs released by cultured skin in matrigel, whereas other components remain intact. Our results suggest a novel link between MMP activity and extracellular matrix breakdown in the control of axonal growth.

Arteriovenous malformation in the anterior mediastinum.

Arteriovenous malformations of the mediastinum are exceedingly rare. A literature search found fewer than 10 reported cases of congenital, posterior mediastinal arteriovenous malformations in adults. We describe a giant anterior mediastinal arteriovenous malformation in a 29-year-old man.

Is it safe to perform endoscopic vein harvest?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in [patients undergoing coronary revascularisation] is [endoscopic vein harvest] superior to [open harvest] in improving [clinical outcome and cost effectiveness]? Altogether >166 papers were found using the reported search, of which eight represented the best evidence to answer the clinical question. All papers agree that endoscopic vein harvesting (EVH) reduces the level of postoperative pain (pain score for EVH=0.52+/-0.95; open technique=1.02+/-1.51; P=0.03) and wound complications (range from 3 to 7.4% for EVH and 13 to 19.4% for conventional technique). These clinical benefits were associated with a high level of patient satisfaction. On average, four papers found that the length of hospital stay was reduced in the EVH group [weighted mean difference (WMD) -1.04 to -0.85; confidence interval (CI) -1.92 to -0.16; P=0.02]. The overall occlusion rates of venous grafts after six months were 21.7% for EVH and 17.6% for open technique. There were no differences in the six months occlusion and disease rates between EVH and conventional vein harvest (CVH), as determined by means of univariate analysis (P=0.584). However, some papers (PREVENT-IV sub-analysis and Yun et al.) called into question EVH by reporting high vein occlusion rates. At six months, this was 21.7% for EVH and 17.6% for open technique rising to 46.7% vs. 38.0% (P<0.001) at 12-18 months. At three years, endoscopic harvesting was also associated with higher rates of death, myocardial infarction, or repeat revascularisation (20.2% vs. 17.4%; P=0.04), death or myocardial infarction (9.3% vs. 7.6%; P=0.01), and death (7.4% vs. 5.8%; P=0.005). We conclude that EVH reduces the level of postoperative pain and wound complication, with a high-level of patient satisfaction but a sub-analysis of a large RCT has recently called into question the medium- to long-term patency of grafts endoscopically harvested.

Right upper video-assisted thoracoscopic lobectomy for early stage lung cancer.

Lobectomies are commonly performed through an open approach. The proven safety and efficacy of minimal access video-assisted thoracic surgery (VATS) is changing the way we manage this operation. We present our definition of VATS lobectomy and describe our technique for VATS right upper lobectomy in clear, easy to follow steps. Finally, we provide some operative tips and a preference card.