Management of Renal Cell Carcinoma With Intra-atrial Tumour Thrombus: A Case Report.

Renal cell cancer (RCC) is at times associated with intravascular tumour thrombus (TT), which in rare cases can extend to the right atrium. The management of RCC with intravascular tumour thrombus is complex and requires a multidisciplinary approach involving urologists, vascular surgeons, and cardiologists. The pre-operative workup is extensive and includes imaging studies to determine the extent of the tumour thrombus and assess the patient's overall health status. Here, we present a case report detailing the operative and perioperative management of a patient presenting with renal cell cancer and intravascular TT.

Sutureless vs. rapid-deployment valve: a systemic review and meta-analysis for a direct comparison of intraoperative performance and clinical outcomes.

Background: Sutureless and rapid-deployment valves are bioprostheses anchoring within the aortic annulus with few sutures, and they act as a hybrid of conventional surgical and transcatheter valves under aortic valve replacement. Considering that the 3F Enable valve is now off-market, the only two sutureless and rapid-deployment valves available on the world marketplace are the Perceval and Intuity valves. However, a direct comparison of the function of these two valves eludes researchers. Purpose: Against this background, we performed this systematic review and meta-analysis comparing the intraoperative performance and early clinical outcomes between the Perceval valve and the Intuity valve under sutureless and rapid-deployment aortic valve replacement. Methods: We systematically searched electronic databases through PubMed/MEDLINE, OvidWeb, Web of Science, and Cochrane Central Register of Controlled Trials (from the establishment of the database to November 17, 2022, without language restriction) for studies comparing the sutureless valve (the Perceval) and the rapid-deployment valve (the Intuity) under aortic valve replacement. Our primary outcomes were early mortality and postoperative transvalvular pressure gradients. The secondary outcomes were defined to include aortic cross-clamp and cardiopulmonary bypass time, paravalvular leak (any paravalvular leak, moderate-to-severe paravalvular leak) after aortic valve replacement, need for pacemaker implantation, postoperative neurological events (stroke), and intensive care unit stay. Results: This meta-analysis included ten non-randomized trials with 3,526 patients enrolled (sutureless group = 1,772 and rapid-deployment group = 1,754). Quality assessments were performed, with the mean scores of the studies reading 6.90 (SD = 0.99) out of 9 according to the Newcastle-Ottawa Scale. Compared with rapid-deployment aortic valve replacement, sutureless aortic valve replacement was associated with higher mean and peak transvalvular pressure gradients postoperatively. In contrast, aortic cross-clamp and cardiopulmonary time were needed less in sutureless aortic valve replacement vs. rapid-deployment aortic valve replacement. There was no evidence of significant publication bias observed by the funnel plot and Egger's test. Conclusions: For postoperative hemodynamics, sutureless aortic valve replacement was associated with increased mean and peak transvalvular pressure gradients compared with rapid-deployment aortic valve replacement. In sharp contrast, sutureless aortic valve replacement significantly reduced the amount of time needed for fixing the aortic cross-clamp and the cardiopulmonary bypass procedure. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022343884.

A new surgical technique for left atrial reduction in giant left atrium.

Objective: The study objective was to evaluate the safety and clinical and echocardiographic outcomes of a new surgical technique in adult patients diagnosed with a giant left atrium. Methods: We analyzed a cohort of patients who underwent left atrium reduction surgery between January 2016 and June 2020 performed by a specialized surgical team in 2 national reference centers in Lima, Peru. We assessed the major adverse valvular-related events and the New York Heart Association functional class as primary clinical outcomes. Also, our primary echocardiographic endings were the diameter, area, and volume of the left atrium. We assessed these variables at 3 time periods: baseline (t0), perioperative period (t1), and extended follow-up (t2: 12 ± 3.4 months). We carried out descriptive and bivariate exploratory statistical analysis for dependent measures. Results: We included 17 patients, 70.6% of whom were women. Rheumatic mitral valve disease (76.5%) was the main etiology. We performed 14 (82.4%) mitral valve replacements and 3 repairs. Major adverse valvular-related events occurred in 1 patient (5.9%) (hemorrhagic stroke) at t1. A significant reduction in the size of the left atrium was observed: diameter (77 mm vs 48 mm, P < .001), area (75 cm2 vs 31 cm2, P < .001), and volume (332 cm3 vs 90 cm3, P < .001). Compared with t0 and t1, these echocardiographic findings remained without significant changes during t2. Conclusions: Our surgical left atrium reduction technique was associated with improved clinical functionality and reduced left atrium measures in patients with a giant left atrium undergoing mitral valve surgery.

Donation after circulatory death heart transplantation using normothermic regional perfusion:The NYU Protocol.

Objective: This study aimed to evaluate the impact of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion on the metabolic milieu of donation after cardiac death organ donors before transplantation. Methods: Local donation after cardiac death donor offers are assessed for suitability and willingness to participate. Withdrawal of life-sustaining therapy is performed in the operating room. After declaration of circulatory death and a 5-minute observation period, the cardiac team performs a median sternotomy, ligation of the aortic arch vessels, and initiation of thoraco-abdominal normothermic regional perfusion via central cardiopulmonary bypass at 37 °C. Three sodium chloride zero balance ultrafiltration bags containing 50 mEq sodium bicarbonate and 0.5 g calcium carbonate are infused. Arterial blood gas measurements are obtained every 15 minutes after every zero balance ultrafiltration bag is infused, and blood is transfused as needed to maintain hemoglobin greater than 8 mg/dL. Cardiopulmonary bypass is weaned with concurrent hemodynamic and transesophageal echocardiogram evaluation of the donor heart. The remainder of the procurement, including the abdominal organs, proceeds in a similar controlled fashion as is performed for a standard donation after brain death donor. Results: Between January 2020 and May 2022, 18 donation after cardiac death transplants using the thoraco-abdominal normothermic regional perfusion protocol were performed at our institution. The median donor age was 42.5 years (range, 20-51 years), and 88.9% (16/18) were male. The mean total donor cardiopulmonary bypass time was 88.8 ± 51.8 minutes. At the beginning of cardiopulmonary bypass, the average donor lactate was 9.4 ± 1.5 mmol/L compared with an average final lactate of 5.3 ± 2.7 mmol/L (P<.0001). The average beginning potassium was 6.5 ± 1.8 mmol/L compared with an average end potassium of 4.2 ± 0.4 mmol/L (P<.0001) . The average beginning hemoglobin was 6.8 ± 0.7 g/dL, and the average end hemoglobin was 8.2 ± 1.3 g/dL (P<.001) . On average, donation after cardiac death donors received transfusions of 2.3 ± 1.5 units of packed red blood cells. Of the 18 donors who underwent normothermic regional perfusion, all hearts were deemed suitable for recovery and successfully transplanted, a yield of 100%. Other organs successfully recovered and transplanted include kidneys (80.6% yield), livers (66.7% yield), and bilateral lungs (27.8% yield). Conclusions: The use of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion is a burgeoning option for improving the quality of organs from donation after cardiac death donors. Meticulous intraoperative management of donation after cardiac death donors with a specific focus on improving their metabolic milieu may lead to improved graft function in transplant recipients.

Symptomatic uterine leiomyomatosis with intracaval and intracardiac invasion: Video case report.

Background: Fibroid is the most prevalent benign tumor of the female genital tract. Intravenous and intracardiac leiomyomatosis (IVL and ICLM, respectively) are rare complications that present with symptoms of pulmonary thromboembolism and heart failure and whose etiology, despite controversial, is a direct vascular invasion by a primary uterine leiomyoma. Case presentation: We present the case of a 31-year-old female patient with a previous history of pelvic pain and dysmenorrhea, whose ultrasound showed an enlarged and heterogeneous uterus. Complete hysterectomy was performed, and the anatomopathological examination showed leiomyomas without evidence of malignancy. One month later, the patient manifested dyspnea and chest pain. A neoplastic thrombus was identified, extending from the inferior vena cava to the right atrium, for which we proceeded with cavo-atrial thrombectomy under Normothermic Cardiopulmonary Bypass (CPB) with Warm Blood Cardioplegia (WBC). A metastatic lung injury of non-malignant histology was also detected. Discussion: Uterine leiomyoma is a very common benign tumor of the female genital tract. IVL with ICLM are rare and difficult-to-treat complications, whose etiology is a direct vascular invasion by a primary uterine leiomyoma, although it is still controversial. The incidence of ICLM is 10 to 30% of IVL cases. The main symptoms of ICLM are dyspnea, syncope, edema of the lower extremities and palpitations. Treatment is based on complete surgical removal of the tumor thrombus. Studies demonstrated that the one-stage procedure is safer from the patient's perspective and that CPB with WBC reduced intraoperative blood loss and total operative time, ensuring a less traumatic postoperative. Conclusions: Most patients with uterine leiomyoma are asymptomatic and acute complications are rare. In ICLM clinical manifestations are related to heart failure and flow obstruction. Because of the severity of the condition and the curative potential of treatment, surgery is morbid but highly recommended. The use of CPB with WBC improved the postoperative period and increased the patient's quality of life.

1-Year Patency of Biorestorative Polymeric Coronary Artery Bypass Grafts in an Ovine Model.

Many attempts have been made to inhibit or counteract saphenous vein graft (SVG) failure modes; however, only external support for SVGs has gained momentum in clinical utility. This study revealed the feasibility of implantation, and showed good patency out to 12 months of the novel biorestorative graft, in a challenging ovine coronary artery bypass graft model. This finding could trigger the first-in-man trial of using the novel material instead of SVG. We believe that, eventually, this novel biorestorative bypass graft can be one of the options for coronary artery bypass graft patients who have difficulty harvesting SVG.

Single-port robotic transcervical long-segment thoracic tracheal reconstruction: Cadaveric proof-of-concept study.

Objective: Slide tracheoplasty is the standard technique to repair congenital long-segment tracheal stenosis. This operation most commonly requires median sternotomy, which has drawbacks in young children. We hypothesized that a transcervical approach without sternotomy would be feasible if done with a single-port robotic system. Methods: This proof-of concept study was performed in 2 small adult cadavers using a single-port robotic surgical system via a small neck incision. Relevant information, including operative time and details of operative technique, were recorded. Results: Long-segment slide tracheoplasty was completed successfully in 2 cadavers using a small neck incision and a single-port robotic surgical system. Strengths and pitfalls of the technique were identified, including technical refinements from the first attempt to the second. Operative time for robotic mobilization, incision, and anastomosis of the trachea was comparable to standard open approaches. Conclusions: Small-incision transcervical slide tracheoplasty, assisted by a single-port surgical robotic system, is feasible in a human cadaver. More work is needed to determine safety and applicability in live patients, particularly in children.

Surgical Salvage of Annular Rupture After Transcatheter Aortic Valve Implantation by Conversion Into Annular Enlargement.

We describe an 88-year-old woman who experienced annular rupture during transcatheter aortic valve replacement despite preventative measures. She underwent Y incision and rectangular patch for the double purpose of repairing the rupture and enlarging the aortic root. We highlight the heart team's role in confronting this potentially catastrophic complication. (Level of Difficulty: Advanced.).

Coronary Sinus Rupture Due to Blunt Cardiac Trauma.

We present a very rare case of devastating blunt cardiac trauma with large right atrial rupture, contusion of the right atrioventricular groove, and coronary sinus tear. Surgical repair was successfully performed by urgently establishing cardiopulmonary bypass via the femoral vein and artery simultaneously with a median sternotomy. (Level of Difficulty: Intermediate.).

Five-minute test to prevent postcardiotomy reexploration.

Objective: To evaluate the effectiveness of the 5-minute test (FMT), developed to record the amount of pericardial bleeding in patients undergoing general cardiac surgery, and determine the relationship between this test and postcardiotomy bleeding. Methods: The medical records of 573 patients who underwent adult cardiac surgery between January 2016 and December 2019 were reviewed retrospectively. Patients were divided into 2 groups: the FMT group included patients who underwent general cardiac surgery between January 2018 and December 2019 (n = 278), and the control group included patients who underwent general cardiac surgery between January 2016 and December 2017 (n = 295). The postcardiotomy reexploration rate due to intrapericardial bleeding or cardiac tamponade within 1 week after surgery and the amount of bleeding until 2 days after surgery were compared. The FMT procedure involved counting the amount of bleeding by packing 4 to 6 surgical gauze sheets for 5 minutes. Sternal closure was performed when the amount of blood measured by the FMT was <100 g. Results: Compared with the control group, the FMT group had a significantly lower incidence of postcardiotomy reexploration (1.5% vs 5.7%; P = .007) and a reduced amount of bleeding after cardiac surgery (median, 1165 mL [interquartile range (IQR), 756.2-1743.8 mL] versus 1440 mL [IQR, 825.0-2130.0 mL]; P = .005). There was a significant positive correlation between the FMT gauze sheet weight and postcardiotomy bleeding (r = 0.322; P < .001). Conclusions: The FMT is an objective and effective tool for estimating postoperative bleeding during cardiac surgery that can prevent postcardiotomy reexploration and reduce the amount of postcardiotomy bleeding.

Report of Accidental Anchoring of an Impella Device to a Perceval Bioprosthesis in a Patient.

We herein report a case in which we encountered complications when placing an Impella CP ventricular assist device (catheter-based ventricular assist device) in a patient with a Perceval bioprosthetic valve (sutureless valve). Specifically, the catheter-based ventricular assist device became anchored to the sutureless valve and needed to be removed under cardiopulmonary bypass. (Level of Difficulty: Advanced.).

Coronary Artery Aneurysm Rupture in a Patient With Polyarteritis Nodosa.

We present the case of a 42-year-old male patient with ST-segment elevation myocardial infarction and pericardial effusion due to rupture of the left anterior descending artery most likely secondary to polyarteritis nodosa. Successful surgery was performed under cardiopulmonary bypass using antegrade and retrograde cardioplegia combined. (Level of Difficulty: Intermediate.).

Unilateral versus bilateral antegrade cerebral perfusion during surgical repair for patients with acute type A aortic dissection.

Objectives: To compare unilateral versus bilateral antegrade cerebral perfusion (ACP) techniques on cerebral protection during acute type A aortic dissection repair. Methods: Using an institutional database, we retrospectively reviewed patients who underwent acute type A aortic dissection repair with selective ACP techniques from October 2008 to December 2019. Primary end point was the detection of neurologic dysfunctions. The secondary end point was mortality. For baseline adjustment, the propensity score matching method was used. Multivariable logistic regression analysis was performed to determine the predictor of neurologic events. Results: Among 522 patients (aged 62.0 ± 14.9 years; 45.7% women), unilateral and bilateral ACP techniques were used in 357 (64.7%) and 165 (35.3%) patients, respectively. Transient (19.6% vs 21.2%; P = .65) and permanent (7.0% vs 10.3%; P = .70) neurologic dysfunction rates were not significantly different in patients with unilateral versus bilateral ACP, respectively. Observed mortality rate was higher in the patients with bilateral ACP (hazard ratio, 2.05; 95% CI, 1.33-3.14; P = .001). Propensity-score matching yielded 94 pairs of patients. In matched analysis, bilateral ACP did not significantly lower the risks for transient (odds ratio, 0.87; 95% CI, 0.42-1.81; P = .71) and permanent (odds ratio, 1.42; 95% CI, 0.55-3.85; P = .47) neurologic dysfunction or death (hazard ratio, 1.65; 95% CI, 0.87-3.15; P = .13). In the multivariable analysis, the ACP technique was not significantly associated with perioperative neurologic deficit. Conclusions: Despite additional supply, the patients undergoing bilateral ACP during acute type A aortic dissection repair did not have superior outcomes in neurologic and death events compared with the patients undergoing unilateral ACP.

Intravenous landiolol for the prevention of atrial fibrillation after aortic root, ascending aorta, and aortic arch surgery: A propensity score-matched analysis.

Objective: Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased mortality. The efficacy of landiolol hydrochloride for POAF prevention after coronary artery bypass grafting procedure and valve surgery has been reported. However, little evidence is available on its role in POAF prevention after aortic root, ascending aorta, and aortic arch surgery. This study aimed to determine the association between intravenous landiolol and the incidence of POAF after these aortic surgeries. Methods: We included 358 consecutive adult patients without preoperative atrial fibrillation who underwent aortic root, ascending aorta, and aortic arch surgery between January 1, 2011, and December 31, 2018, at our institution. The therapeutic influence of landiolol in preventing POAF was estimated by propensity score-matched analysis (n = 222). The primary end point was the incidence of POAF within 72 hours after surgery. The secondary end points included adverse clinical events such as 30-day mortality and symptomatic cerebral infarction. Results: The median age of the cohort was 72 years, 68.5% were men, and 46.4% received postoperative oral or transdermal ß-blockers. After minimizing differences in patient background by propensity score matching, the incidence of POAF in the landiolol group was significantly lower than that in the reference group (18.9% vs 38.7%; P = .002). Landiolol use was associated with reduced incidence of POAF (odds ratio, 0.39; 95% CI, 0.21 to -0.72; P = .003). There were no significant differences in secondary end points. Conclusions: Intravenous landiolol was associated with a lower incidence of POAF after aortic root, ascending aorta, and aortic arch surgery.

An automated line-clearing chest tube system after cardiac surgery.

Objective: To complete the first in-human study of the automated line clearance Thoraguard chest tube system. The study focuses on the viability and efficacy of the device in comparison with conventional models as well as secondary matters such as patient experience and ease of use. Methods: This was a single-center, prospective, open-label study involving adult patients (n = 27) who underwent nonemergent, first-time, cardiac surgery. Patients received automated clearance chest tubes for surgical drainage in both the mediastinal and pleural spaces. The control group was retrospective (n = 80); individuals received conventional chest tubes placed and secured in locations determined at the surgeon's discretion. Results: The automated-clearance tubes exhibited a similar drainage profile at 1, 3, 6, 12, and 24 hours compared with the conventional chest tubes. The final output at the time of tube removal was also similar (1150 [750-1590] vs 1289 [766.3-1890] mL, respectively, P = .76). The number of patients readmitted for drainage of an effusion was similar in both groups (1/27 [3.7%] vs 3/80 [3.75%], P > .99). Conclusions: This study has shown that the Centese Thoraguard chest tube system is a viable option for surgical chest drainage and effective when used in routine cardiac surgery operations.

Percutaneous versus open surgical cannulation for minimal invasive cardiac surgery; immediate postprocedural outcome analysis.

Objectives: Open surgical cannulation (SC) is traditionally used for cardiopulmonary bypass cannulation in minimally invasive cardiac surgery (MICS). The percutaneous cannulation (PC) technique using arterial closure devices has also been used in select centers. The aim of this study was to compare outcomes between patients undergoing the PC or SC approach, with a particular focus on cannulation-related groin complications. Methods: A retrospective analysis of patients undergoing MICS at our institution between January 2018 and April 2022 was performed. Starting from June 2020, 3 surgeons at our institution started using the PC approach. For patients in the PC group, a primary suture-based technique (ProGlide) complemented by a small-sized plug-based closure device (AngioSeal) was used. The primary end point of the study was groin complications following the procedures. Results: A total of 524 patients underwent MICS through a right lateral minithoracotomy during the study time period. Of these, 88 patients (17%) were cannulated using PC approach and 436 (83%) using SC approach. The total number of cannulation-related groin complications was greater in the SC group (4% vs 0%, P = .05). Propensity score matching resulted in 2 comparable groups, with 172 patients in the SC group and 86 patients in the PC group. The number of groin complications remained greater in the SC group (P = .05). In-hospital mortality was comparable between groups (1% PC vs 0% SC, P = .3). Conclusions: The PC approach is a safe cannulation technique for patients undergoing MICS. It minimizes postoperative groin complications with no obvious negative impact on outcomes.

Transfusion-Related Renal Dysfunction After Cardiac Surgery: The Role of Myeloid-Related Protein_14 in Neutrophil-Mediated Tubular Damage.

Transfusion is a specific cause of acute kidney injury (AKI) after cardiac surgery. Whether there is an association between the composition of blood products and the onset of AKI is unknown. The present study suggests that the transfusion of packed red blood cells containing a high amount of myeloid-related protein 14 (MRP_14) could increase the incidence of AKI after cardiac surgery. In a mouse model, MRP_14 increased the influx of neutrophils in the kidney after ischemia-reperfusion and their ability to damage tubular cells. Higher concentrations of MRP_14 were found in packed red blood cells from female donors or prepared by whole blood filtration.

Aortic and arch branch vessel cannulation in acute type A aortic dissection repair.

Objective: To evaluate central aortic cannulation and arch branch vessel (ABV) cannulation in acute type A aortic dissection repair. Methods: From 2015 to April 2020, 298 patients underwent open repair of an acute type A aortic dissection. Patients undergoing femoral cannulation for cardiopulmonary bypass (n = 34) were excluded. Patients were then divided based on initial cannulation for cardiopulmonary bypass into central aortic cannulation (n = 72) and ABV cannulation (n = 192) groups. ABV sites included cannulation of the axillary, innominate, right/left common carotid, and intrathoracic right subclavian arteries. Results: The aortic cannulation group was younger (59 vs 62 years; P = .02), more likely to be men (76% vs 60%; P = .02), and had more peripheral vascular disease (60% vs 37%; P = .0009). ABV dissection was similar between central and ABV cannulation groups (53% vs 60%; P = .51). The aortic cannulation group underwent less aggressive arch replacement, had shorter cardiopulmonary bypass times (200 vs 222 minutes; P = .01), less utilization of antegrade cerebral perfusion (93% vs 98%; P = .04), and received less blood transfusion (0 vs 1 U; P = .001). Postoperative outcomes were similar between aortic and ABV cannulation groups, including stroke (5.6% vs 5.2%; P = 1.0) and operative mortality (4.2% vs 6.3%; P = .77). In addition, postoperative strokes were similar in location (right-brain, left-brain, or bilateral), etiology (embolic vs hemorrhagic), and presence of permanent deficits. Aortic cannulation was not a risk factor for postoperative stroke (odds ratio, 0.94; P = .91) or operative mortality (odds ratio, 0.70; P = .64). Short-term survival was similar between central and ABV cannulation groups. Conclusions: Both aortic and ABV cannulation were safe and effective cannulation strategies in acute type A aortic dissection repair.

Effect of sarcopenia on hospital stay from post cardiac surgery to discharge.

Background: Cardiovascular surgery in older patients with sarcopenia has high rates of major complications, long hospital stays, readmissions, and discharge transfers. However, the factors that influence the length of hospital stay are unknown. This study aimed was to identify the predictors of the prolonged hospital stay in patients with sarcopenia after cardiovascular surgery. Methods: A total of 192 patients scheduled for cardiac surgery were enrolled in this retrospective observational study. Sarcopenia was diagnosed preoperatively. Clinical data from the preoperative, intraoperative, and perioperative periods were evaluated to determine the factors influencing the length of hospital stay. Results: The sarcopenia and non-sarcopenia groups differed significantly in age; body mass index; renal function; intubation time; transfusion of red blood cells; hospital transfer; and hemoglobin, brain natriuretic peptide, and albumin levels. Sarcopenia was the most significant factor influencing prolonged postoperative hospital stay, as well as prolonged intubation time. In the sarcopenia group, albumin levels and cardiopulmonary bypass time were the significant factors affecting hospital stay. Conclusions: Sarcopenia was the most significant factor associated with prolonged postoperative hospital stay in patients who underwent cardiac surgery. In addition, improving sarcopenia, nutritional status, and shortening cardiopulmonary bypass time appear to shorten the hospital stay in patients with sarcopenia who underwent cardiovascular surgery.

Role of Multimodality Imaging and Preoperative Management in Intrapericardial Paragangliomas: Experience From a Case Series.

Intrapericardial paragangliomas are rare, highly vascular tumors that frequently adhere to adjacent structures and blood vessels, making surgical resection challenging. In this case series, we discuss the role of multimodality imaging and preoperative embolization in the management of 3 patients presenting with intrapericardial paragangliomas. (Level of Difficulty: Advanced.).