Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial.

OBJECTIVES: Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery. DESIGN: This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022). SETTINGS: This study was conducted in a single institution, which is an academic university hospital. PARTICIPANTS: Eighty-six elective cardiac surgical patients with median sternotomy were recruited. INTERVENTIONS: Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry. CONCLUSIONS: Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.

Effect of colchicine on perioperative atrial fibrillation and myocardial injury after non-cardiac surgery in patients undergoing major thoracic surgery (COP-AF): an international randomised trial.

BACKGROUND: Higher levels of inflammatory biomarkers are associated with an increased risk of perioperative atrial fibrillation and myocardial injury after non-cardiac surgery (MINS). Colchicine is an anti-inflammatory drug that might reduce the incidence of these complications. METHODS: COP-AF was a randomised trial conducted at 45 sites in 11 countries. Patients aged 55 years or older and undergoing major non-cardiac thoracic surgery were randomly assigned (1:1) to receive oral colchicine 0·5 mg twice daily or matching placebo, starting within 4 h before surgery and continuing for 10 days. Randomisation was done with use of a computerised, web-based system, and was stratified by centre. Health-care providers, patients, data collectors, and adjudicators were masked to treatment assignment. The coprimary outcomes were clinically important perioperative atrial fibrillation and MINS during 14 days of follow-up. The main safety outcomes were a composite of sepsis or infection, and non-infectious diarrhoea. The intention-to-treat principle was used for all analyses. This trial is registered with ClinicalTrials.gov, NCT03310125. FINDINGS: Between Feb 14, 2018, and June 27, 2023, we enrolled 3209 patients (mean age 68 years [SD 7], 1656 [51·6%] male). Clinically important atrial fibrillation occurred in 103 (6·4%) of 1608 patients assigned to colchicine, and 120 (7·5%) of 1601 patients assigned to placebo (hazard ratio [HR] 0·85, 95% CI 0·65 to 1·10; absolute risk reduction [ARR] 1·1%, 95% CI -0·7 to 2·8; p=0·22). MINS occurred in 295 (18·3%) patients assigned to colchicine and 325 (20·3%) patients assigned to placebo (HR 0·89, 0·76 to 1·05; ARR 2·0%, -0·8 to 4·7; p=0·16). The composite outcome of sepsis or infection occurred in 103 (6·4%) patients in the colchicine group and 83 (5·2%) patients in the placebo group (HR 1·24, 0·93-1·66). Non-infectious diarrhoea was more common in the colchicine group (134 [8·3%] events) than the placebo group (38 [2·4%]; HR 3·64, 2·54-5·22). INTERPRETATION: In patients undergoing major non-cardiac thoracic surgery, administration of colchicine did not significantly reduce the incidence of clinically important atrial fibrillation or MINS but increased the risk of mostly benign non-infectious diarrhoea. FUNDING: Canadian Institutes of Health Research, Accelerating Clinical Trials Consortium, Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, Population Health Research Institute, Hamilton Health Sciences, Division of Cardiology at McMaster University, Canada; Hanela Foundation, Switzerland; and General Research Fund, Research Grants Council, Hong Kong.

Initial Asian experience of the branched E-vita open NEO in complex aortic pathologies.

Background: Aortic arch pathology often requires staged segmental repairs. Total aortic arch replacement with frozen elephant trunk (FET) offers surgical options for these pathologies. The Jotec E-vita Open NEO™ branched prosthesis was introduced in 2020; we sought to share our initial experience focusing on the prosthesis selection strategies, surgical techniques, anastomosis-bleeding and graft-oozing control methods, and early clinical outcomes from two Asian centers. Methods: We performed a retrospective cohort study in patients with aortic arch pathologies who underwent total arch replacement using the FET procedure with Jotec E-vita Open NEO™ branched prosthesis from two Asian centers between October 2020 and August 2021. The primary outcome was overall 30-day mortality, and the secondary outcomes were operative complications. Results: Twenty-five consecutive patients underwent total arch replacement with FET with the novel hybrid prosthesis. Overall 30-day mortality from both centers was 0%. Overall mean operative, cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion times were 353.4±80.5, 183.2±39.6, 57.2±14.7, and 138.2±28.6 minutes, respectively. No patient developed stroke. Permanent spinal cord injury (SCI) was recorded in one patient (4%) and one (4%) had transient lower limb weakness that resolved after spinal drainage. There was no requirement of re-sternotomy for hemostasis. Conclusions: We reported a multicenter Asian case series with the novel FET hybrid prosthesis demonstrating the feasibility and safety of promising initial clinical outcomes. The technique of circumferential reinforcement of vascular anastomosis for hemostasis may be one of the methods for lowering the rates of re-sternotomy for hemostasis, and proper surgical or transfusion strategies would overcome the excessive oozing of the prosthesis. Long-term follow-up is required for further evaluation of aortic pathology progression and device-related outcomes.

Retrospective record review on timing of COVID-19 vaccination and cardiac surgery.

BACKGROUND: Novel clinical challenges are faced by cardiac surgeons under the coronavirus disease 2019 (COVID-19) pandemic. Amidst the uncertainties faced due to the socioeconomic and public health impact, there is little evidence surrounding COVID-19 vaccination in patients undergoing cardiac surgery. Timing of vaccination and postvaccination adverse effects are required parameters to discuss with cardiac surgical patients. METHODS: This is a single-center, retrospective observational study. All patients who underwent adult cardiac surgery at the Prince of Wales Hospital, Hong Kong from January 2021 to December 2021 were included. Postoperative clinical outcomes, COVID-19 vaccination status, and vaccination-related adverse effects were collected. RESULTS: A total of 426 patients; 117 (27%) underwent isolated coronary artery bypass grafting, 111 (26%) underwent valvular surgery, and 97 (23%) underwent aortic surgery. Patients received either Sinovac CoronaVac or Pfizer BNT162b2 vaccine. Overall vaccination rate with at least 1 dose was 52% (n = 212), 15% (n = 63) received the first dose before surgery, 36% (n = 149) received the first dose vaccination after surgery. Rate of completion with second and third doses of vaccination were 22% (n = 89) and 4.9% (n = 20), respectively. The mean timing of first dose of vaccine after surgery was 216 ± 84 days from operation. Three (1.4%) patients recorded vaccination-related complications. CONCLUSIONS: COVID-19 vaccination is safe in patients who received major cardiac surgery, with low adverse effects recorded and no vaccine-related mortality observed. A time frame of 3-6 months after cardiac surgery receiving COVID-19 vaccination is reasonable and could serve as a guidance for future COVID-19 vaccination booster programs.

Midterm clinical outcome of a case of aortic arch aneurysm treated with a novel arch stentgraft system.

INTRODUCTION: Open surgery is the gold standard treatment for aortic arch disease. However, due to its complexity, open arch replacement is associated with considerable risk of mortality and morbidity. METHOD: We report a case of a 71-year-old gentleman with multiple comorbidities and symptomatic 7 cm aortic arch aneurysm who was treated with a single-stage carotid-carotid and left carotid-axillary bypass followed by zone 0 aortic arch stenting with bimodular Nexus™ stent graft. RESULTS: Post-operatively, the patient suffered from a minor stroke with full neurological recovery. Follow-up computed tomography of the aorta 3 years post-stenting showed excellent stent position with no endoleak and complete resolution of the saccular aneurysm. DISCUSSION: The midterm result of our patient who was successfully treated with an off-the-shelf single branch, bimodular stent graft system is excellent with complete resolution of the arch saccular aneurysm at 3-year after the operation.

The misnomer of uncomplicated type B aortic dissection.

BACKGROUND: Acute type B aortic dissection (TBAD) is a rare condition that can be divided into complicated (CoTBAD) and uncomplicated (UnCoTBAD) based on certain presenting clinical and radiological features, with UnCoTBAD constituting the majority of TBAD cases. The classification of TBAD directly affects the treatment pathway taken, however, there remains confusion as to exactly what differentiates complicated from uncomplicated TBAD. AIMS: The scope of this review is to delineate the literature defining the intervention parameters for UnCoTBAD. METHODS: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on intervention parameters and protocols for UnCoTBAD. RESULTS: A TBAD without evidence of malperfusion or rupture might be classified as uncomplicated but there remains a subgroup who might exhibit high-risk features. Two clinical features representative of "high risk" are refractory pain and persistent hypertension. First-line treatment for CoTBAD is TEVAR, and whilst this has also proven its safety and effectiveness in UnCoTBAD, it is still being managed conservatively. However, TBAD is a dynamic pathology and a significant proportion of UnCoTBADs can progress to become complicated, thus necessitating more complex intervention. While the "high-risk" UnCoTBAD do benefit the most from TEVAR, yet, the defining parameters are still debatable as this benefit can be extended to a wider UnCoTBAD population. CONCLUSION: Uncomplicated TBAD remains a misnomer as it is frequently representative of a complex ongoing disease process requiring very close monitoring in a critical care setting. A clear diagnostic pathway may improve decision making following a diagnosis of UnCoTBAD. Choice of treatment still predominantly depends on when an equilibrium might be reached where the risks of TEVAR outweigh the natural history of the dissection in both the short- and long-term.

Open conversion with Crawford extent 3 thoracoabdominal aortic replacement after candy-plug implantation.

A patient who underwent candy-plug insertion in the year 2016 developed type 1B endoleak with rapid enlargement of distal descending thoracic aortic aneurysm in the year 2021 despite the initial successful false lumen occlusion and thrombosis. Open conversion with Crawford extent 3 thoracoabdominal aortic replacement was performed successfully and the patient was discharged home without any major complications.

A human pluripotent stem cell-based model of SARS-CoV-2 infection reveals an ACE2-independent inflammatory activation of vascular endothelial cells through TLR4.

To date, the direct causative mechanism of SARS-CoV-2-induced endotheliitis remains unclear. Here, we report that human ECs barely express surface ACE2, and ECs express less intracellular ACE2 than non-ECs of the lungs. We ectopically expressed ACE2 in hESC-ECs to model SARS-CoV-2 infection. ACE2-deficient ECs are resistant to the infection but are more activated than ACE2-expressing ones. The virus directly induces endothelial activation by increasing monocyte adhesion, NO production, and enhanced phosphorylation of p38 mitogen-associated protein kinase (MAPK), NF-κB, and eNOS in ACE2-expressing and -deficient ECs. ACE2-deficient ECs respond to SARS-CoV-2 through TLR4 as treatment with its antagonist inhibits p38 MAPK/NF-κB/ interleukin-1ß (IL-1ß) activation after viral exposure. Genome-wide, single-cell RNA-seq analyses further confirm activation of the TLR4/MAPK14/RELA/IL-1ß axis in circulating ECs of mild and severe COVID-19 patients. Circulating ECs could serve as biomarkers for indicating patients with endotheliitis. Together, our findings support a direct role for SARS-CoV-2 in mediating endothelial inflammation in an ACE2-dependent or -independent manner.

Pre-emptive BioGlue priming of the branched Evita Open NEO hybrid prosthesis: tackling excessive oozing.

Excessive oozing after total arch replacement with the frozen elephant trunk technique through the fabric of the E-vita Open NEO raised concern about its early adaptation. The mechanism is speculated to be multifactorial. Our goal was to report our approach using pre-emptive BioGlue priming on the fabric against the oozing phenomenon.

Paving the way for E-vita open NEO hybrid prosthesis implantation for complex aortic arch disease in Asia-Pacific.

We report first in man implantations of the newly designed Evita-open-NEO hybrid prosthesis for complex aortic arch disease from three different countries in Asia-Pacific including instructions on how to proceed with perioperative coagulation management.

Valiant NAVION stent graft system application: First Asian case-series analysis.

BACKGROUND AND AIM: The Valiant NavionTM stent graft system is a third-generation low profile thoracic endograft designed for thoracic endovascular aortic repair. In this population analysis, we report on the first Asian all-comers experience and outcomes who underwent thoracic endovascular aortic repair with the use of this new stent graft system. METHODS: Between May 2019 and October 2020, 21 patients with different aortic pathologies were prospectively recruited and retrospectively analyzed. Important clinical and device-related outcomes were evaluated. The endpoints included short-term survival, technical success, access failures, major vascular and clinical complications, endoleaks, and hospital stay. RESULTS: The commonest indication of stenting was penetrating aortic ulcers (28.6%) and six (28.6%) patients had emergency stenting performed for aortic transection or rupture. 30 days of survival postprocedure was recorded and complete. There were no major vascular complications. Deployment accuracy was 100%, and the technical success rate was 94.7% (18/19) with one patient having a Type 2 endoleak on follow-up imaging. No neurological complications were noted. The mean operative time was 95 ± 73.6 min and the mean fluoroscopy time was 16.2 ± 10.8 min. Mean hospital stay for elective zone 2, 3, and 4 stenting was 5.3 ± 3.8 days, and only one patient postzone 1 thoracic endovascular aortic repair required a brief (0.5 days) ICU stay. All procedures were performed via the percutaneous transfemoral route with 100% success in percutaneous closure. CONCLUSION: This first reported Asian case series demonstrated versatility, safety, and efficacy of the Valiant NavionTM stent in Asian patients with different aortic pathologies.

Total Aortic Arch Replacement and Frozen Elephant Trunk.

Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement and frozen elephant trunk had evolved over last decades with promising mid-term outcomes. We evaluate our mid-term outcomes on total arch replacement with frozen elephant trunk and the role of timely second staged interventions. Between August 2014 and April 2020, 41 patients with aortic arch pathologies underwent total arch replacement with frozen elephant trunk with Thoraflex-Hybrid-Plexus device (Vascutek, Inchinnan, Scotland). Patients' perioperative, clinical and radiological outcomes were reviewed. Post discharge survival (n = 37) at 3 year was 100%. Overall survival of 85.3% over a median follow up of 3.3 years, inpatient mortality of 9.8%. Distribution of aortic pathologies with acute type A dissection or intramural hematoma (n = 15, 36.6%), thoracic aortic aneurysm, including arch and descending aortic aneurysm (n = 9, 22%) and chronic aortic dissection including chronic type A and type B dissections (n = 13, 31.7%). Mean operative, circulatory arrest, and antegrade cerebral perfusion time were 417 ± 121 minutes, 89 ± 28 minutes, and 154 ± 43 minutes, respectively. Second stage procedures were performed in 32% and distal stent graft induced new entry was observed in 19% of patients. We reported an Asian series of Thoraflex with outstanding midterm clinical outcomes, given descending aortic pathologies were tackled with a timely second stage interventions. The observation of aortic remodeling and distal stent graft induced new entry requires further investigations.

Short term clinical outcomes and analysis of risk factors for pacemaker implantation: a single center experience of self-expandable TAVI valves.

OBJECTIVES: Transcatheter aortic valve implantation is a recognized treatment for patients with severe aortic stenosis at all risk groups. However, permanent pacemaker rates remain high for self expandable transcatheter valves and permanent pacemaker implantation has been associated with increased morbidity. In this analysis we aim to evaluate short term clinical outcomes post self expandable transcatheter aortic valve implantation and determine risk factors for permanent pacemaker implantation. METHODS: 88 patients with severe aortic stenosis with transcatheter aortic valve implantation performed between the year 2016-2018 were retrospectively analyzed. Outcomes of interest included 1- year all cause mortality, 30-day major adverse cardiovascular events, permanent pacemaker and paravalvular leak rates. Survival analysis was performed with Kaplan Meier analysis and risk factors for survival and permanent pacemaker rates were identified with log rank test and regression analysis. RESULTS: The mean age of the cohort was 80.3 +/- 6.9 years. The mean STS score was 9.25. The 30 day all-cause mortality was 5.7% and 1-year all cause mortality was 16.7%. 80 patients had transfemoral transcatheter aortic valve implantation, and a majority of the patients (85.2%) were implanted with Corevalve Evolut R device. The device success rate was 88.6%. Multivariate analysis identified concomitant severe coronary artery disease (OR = 18.2 +/- 0.9; P = 0.002), pre transcatheter aortic valve implantation atrial fibrillation (OR = 8.6 +/- 0.91; P = 0.02) and post procedural disabling stroke (OR = 32.6 +/- 1.35; P = 0.01) as risk factors for 1-year mortality. The 30-day pacemaker rate was 17.6%. The presence of right bundle branch block (OR 11.1 +/- 0.86; P = 0.005), non-coronary cusp implantation depth (OR = 1.34 +/- 0.15; P = 0.05) and a non coronary cusp implantation depth / membranous septal length ratio of more than 50% were associated with post procedural pacemaker implantation (OR = 29.9 +/- 1.72; P = 0.05). Among the 15 patients with post procedural pacemaker implantation, 40% were found to be non-pacemaker dependent at 1 year. CONCLUSION: Short term outcomes of transcatheter aortic valve implantation in severe aortic stenosis patients are promising. Pacemaker rates remain high. More studies are needed to evaluate the factors that influence pacemaker rates and dependence to further improve transcatheter aortic valve implantation outcomes.

En bloc transdiaphragmatic lung resection for locally advanced hepatocellular carcinoma: a case report.

A 56-year-old man presented with an 11-cm hepatocellular carcinoma (HCC) at segment 7 of liver. To induce left liver hypertrophy, a sequential transarterial chemoembolization (TACE) and portal vein embolization before right hepatectomy were adopted. However, the tumor further increased in size despite TACE and invaded through the diaphragm to the right lung base. Anterior approach right hepatectomy with en bloc wedge resection of the involved right lower lobe of lung by endovascular staplers via transdiaphragmatic approach was performed. The diaphragmatic defect was closed with Goretex mesh. Patient made an uneventful recovery. Pathology confirmed a 12.5 cm poorly differentiated HCC invading through diaphragm to lung. During follow-up, patient developed a 6 cm recurrence at left lung base 17 months after surgery for which he received sorafenib therapy. However, the lung mass further increased in size with new liver recurrence at segment 3 despite treatment. He succumbed 2 years and 3 months after surgery.

Management of acute type A intramural hematoma: upfront surgery or individualized approach? A retrospective analysis and meta-analysis.

BACKGROUND: Management of acute type A intramural hematoma (IMH) is a controversial topic. In our study, we aim to analyze the survival outcomes in local patients with acute type A IMH and a meta-analysis on survival in type A IMH treated medically versus surgically was performed. METHODS: From 2014 to 2019, 65 patients with acute type A IMH were selected for analysis. Primary outcome of interest was 1 year all cause survival. The rate of aortic-related events in the medical group was evaluated. PubMed and Embase were searched for meta-analysis. RESULTS: The mean age of our cohort was 61.7±9.7 years. Of the 65 patients, 40% had emergency operation. Overall 1-year survival was 96.9%. The 1-year survival was 94.9% for the medical group. 46.2% of the medical group required aortic intervention at a mean duration of 191±168 days. Maximal aortic diameter (MAD) ≥45 mm was predictive of aortic-related events in the medical group (OR: 7.0; 95% CI, 1.7-29.4; P=0.008). For the meta-analysis, 21 studies were identified, and 900 patients were included. Emergent surgery was associated with improved survival in type A IMH (OR: 0.76; 95% CI, 0.29-1.97, P=0.58; I2=27%). CONCLUSIONS: The 1-year survival after type A IMH was promising, regardless of approach. The conservative-first approach was found to be safe & feasible, and upfront surgery remained the management of choice in general. Patients with MAD ≥45 mm was associated with subsequent aortic intervention in the medical-first group.

10-year outcomes post coronary artery bypass grafting in Asian patients with ischemic cardiomyopathy: a comprehensive analysis of survival and cardiac performance.

BACKGROUND: Coronary artery bypass grafting (CABG) is the standard of care for patients with ischemic cardiomyopathy (ICM). Despite recent evidence supporting the role of CABG, long term outcomes for patients with ICM remain poor and 10-year results post CABG in ICM patients are under-reported, especially among Asians. Uncertainty on whether CABG improves cardiac performance and survival in the long term remains. In this study, we aim to analyze 10-year results concerning cardiac performance and survival post CABG in Asian patients with left ventricular ejection fraction (LVEF) ≤35% and predominant heart failure symptoms, and identify perioperative risk factors affecting long term survival and cardiac function. METHODS: Thirty-six patients with LVEF <35% who had CABG performed between the year 2006-2009 were selected from local hospital records for retrospective analysis. Outcomes of interest included post-operative cardiac symptoms, LVEF & 10-year all-cause and cardiac-event free survival. Survival analysis was performed using Kaplan Meier analysis, and predictive factors were identified with log- rank test and logistic regression analysis. RESULTS: The mean age of the cohort was 62.9±9.9 years. Operative mortality within 30 days was 5.6%. The 10-year all-cause mortality rate was 55.6%. The mean duration of survival was 105.9±8.3 months. Of the patients who did not survive till 10 years, 65.0% died of cardiac-related causes, with non-ST elevation myocardial infarction being the commonest cause. CABG improved LVEF (24.9% to 32.2%; P<0.001) and 66.7% of patients remained with impaired LVEF ≤35% post CABG. Post op NYHA class 3-4 symptoms (OR: 6.3; P=0.012) was the only predictive factor for 10 year all-cause mortality and post op LVEF improvement ≥5% (OR: 5.8; 95% CI, 1.1-29.9; P=0.036) was associated with improvement in NYHA class. Completeness of revascularization and viability of myocardium were not predictive of survival or changes in LVEF or NYHA class. CONCLUSIONS: The 10-year survival rates of Asian patients with ICM were similarly disappointing as its counterparts in the west. A majority of patients still suffered from cardiac-event related deaths. Post CABG NYHA class was found to be important in determining success and adequacy of treatment in patients with ICM and improvement in LVEF ≥5% was predictive of improvement of symptoms. Neither completeness of revascularization or presence of myocardial viability had any impact on survival in our patient cohort.