Optimal Management of Patients Treated With Minimally Invasive Cardiac Surgery in the Era of Enhanced Recovery After Surgery and Fast-Track Protocols: A Narrative Review.

OBJECTIVES: Use of minimally invasive cardiac surgery (MICS) is increasing, but to exert its maximum effect on patient outcomes, MICS must be coupled with improved perioperative management, including the Enhanced Recovery after Surgery (ERAS) and fast-track protocols. This study aimed to evaluate the impact of ERAS and fast track in this context. DESIGN: NARRATIVE REVIEW: The authors performed a narrative review that included patients treated with MICS and patients treated with the ERAS/fast-track protocols in the MEDLINE/PubMed database. The keywords ERAS and fast-track were combined with the following key words: minimally invasive cardiac surgery OR robotic cardiac surgery OR minimally invasive mitral surgery OR minimally invasive aortic surgery. RESULTS: Overall, the authors selected six studies in which either the ERAS or fast-track protocol was applied. The reported adherence to ERAS protocols was high, and neither protocol-related complications nor in-hospital mortality occurred. Patients managed based on ERAS had significantly lower postoperative pain scores, fewer rates of blood transfusions, and shorter hospital and intensive care unit stays compared with those who received standard management. All ERAS patients were managed safely, with early extubation. Similarly, fast-track cardiac surgery, with immediate postprocedure extubation and early transfer to the ward, was shown to be safe, with no increased morbidity or mortality. CONCLUSION: Use of standardized ERAS and fast-track protocols seems to be feasible and safe in the context of MICS, with improved outcomes. Both ERAS and fast track allow for a faster return to full functional status while minimizing perioperative complications.

Early prediction of hypocalcemia following thyroid surgery. A prospective randomized clinical trial.

PURPOSE: The aim of this randomized-controlled trial was to validate the results of a previous prospective single-cohort observational study conducted in the same surgical unit regarding the use of concomitant intact parathyroid hormone (iPTH) and serum calcium measurement in predicting hypocalcemia after total thyroidectomy. METHODS: From January 2014 to January 2015, 150 patients underwent total thyroidectomy in our department and were randomized into two groups. The experimental group was submitted to iPTH assay 6 h after surgery while the control group was submitted to a daily assay of serum calcium and phosphorus. Sensitivity and specificity of different serum measurements have been calculated using the receiver-operator characteristics (ROC) curve. RESULTS: The prevalence of hypocalcemia was 14.25% in both groups. The assay of iPTH 6 h after surgery combined with the serum calcium assay 24 h after surgery yielded the highest diagnostic accuracy in predicting hypocalcemia using ROC curves, with 100% sensitivity and 100% specificity. CONCLUSIONS: According to our previous study, the combined measurement of iPTH 6 h after surgery and of serum calcium 24 h after surgery are highly predictive of early postoperative hypocalcemia. These results are important in selecting the patients eligible for early discharge and those who need calcium and vitamin D supplementation.

Takotsubo cardiomyopathy after minimally invasive mitral valve surgery: clinical case and review.

A sudden, unexpected, reversible, severe left ventricular dysfunction, mimicking an acute myocardial infarction without demonstrable obstructive coronary artery stenosis, was first recognized in Japan in 1990 and originally termed takotsubo cardiomyopathy. In 2006, the American Heart Association included takotsubo cardiomyopathy into its classification of primary acquired cardiomyopathy. The true incidence of takotsubo cardiomyopathy in the community is difficult to estimate. In fact, despite an increasing awareness, this syndrome has to date been under-recognized and misdiagnosed, mainly because of the transitory natures of its clinical and instrumental features. The study aim was to investigate the association between the occurrence of takotsubo cardiomyopathy and emotional or physical stressors, as described also in the setting of various surgical procedures. The case is also described of a 77-year-old woman who suffered a transient left ventricular dysfunction soon after cardiac surgery for valvular disease and epicardial cryoablation of atrial fibrillation.

Late Iatrogenic Coronary Sinus Hematoma During Cardiac Surgery.

Retrograde cardioplegia is commonly used in cardiac surgery to induce cardioplegic arrest. However, this method could be potentially associated with coronary sinus injuries, which can be fatal or extremely difficult to manage. This report describes the conservative management of an iatrogenic coronary sinus hematoma by daily transthoracic echocardiography and weekly computed tomography follow-up. (Level of Difficulty: Intermediate.).

Partially Resorbable Mesh Inclusion between Dissected Layers during Surgical Repair of Aortic Dissection.

Surgical management of aortic dissection is technically challenging for different reasons. Reapproximation of dissected layers because of fragility of the dissected aortic wall layers is of major concern. Many techniques have been described to restore the integrity of aortic wall. Inclusion of a partially resorbable mesh fixed with glue, between the dissected layers, may be a simple and effective method for providing a secure and viable end-to-end anastomosis between aortic stump and a Dacron graft.

Direct proximal right subclavian artery cannulation during surgery of the thoracic aorta.

OBJECTIVE: To evaluate outcomes of single sternum access for right subclavian artery cannulation without infraclavicular incision in surgery of the thoracic aorta. METHODS: Between January 2015 and December 2019, 44 consecutive patients underwent surgery of the thoracic aorta with cannulation of the right subclavian artery, after sternotomy and before pericardiotomy, through a direct percutaneous cannula with a single access without additional infraclavicular skin incision. The indication for surgery was type A acute aortic dissection in 29 patients (65.9%), proximal aortic aneurysm in 11 (25%), and aneurysm of the aortic arch in 4 (9%). Operative procedures were replacement of the ascending aorta in 23 patients, Bentall procedure in 10, hemiarch replacement in 6, and total arch replacement in 5. The mean cardiopulmonary bypass (CPB) and cross-clamp times were 185 ± 62 minutes and 138 ± 41 minutes, respectively. RESULTS: The in-hospital mortality rate was 6.8%. Permanent neurologic dysfunction occurred in 3 patients (6.8%) and temporary neurologic dysfunction occurred in 4 patients (9.0%). There were no vascular complications related to this technique. No lesions to the vagus and recurrent laryngeal nerves have been reported. CONCLUSIONS: In our experience, a single sternum access for right subclavian artery cannulation avoids the risk and complications of an infraclavicular incision required for axillary artery cannulation. This technique is safe and represent a valid option for CBP and antegrade cerebral perfusion during surgery of the thoracic aorta.

Extracorporeal membrane oxygenation as a "bridge to recovery" in a case of myotomy for myocardial bridge complicated by biventricular dysfunction.

The incidence of cardiac dysfunction after routine cardiac surgical procedures is quite high (3-5%), but the majority of patients improve using inotropic drugs or intraaortic balloon counterpulsation. However, approximately 1% of these patients do not benefit from using these supports, and they need more invasive strategies, such as ventricular assist devices. Extracorporeal membrane oxygenation (ECMO) is one of them, and it offers biventricular support, can be managed very easily and is one of the cheapest devices. We describe our experience with ECMO in a case of postocardiotomy failure after myotomy for myocardial bridge. Because of failure of medical therapy, we decided to perform surgical myotomy of the bridge and coronary artery bypass grafting of the LAD with the left internal mammary artery. Many episodes of ventricular fibrillation occurred with quick worsening of biventricular function requiring extracorporeal membrane oxygenation (ECMO) support. The pump flow was maintained at about 1.8-2 l/m(2) (about 80% of the ideal flow) in order to reduce cardiac work offering a more rapid recovery of cardiac function. ECMO support was slowly reduced because EKG progressively improved and the hemodynamic parameters were stable. ECMO was interrupted in the 4th postoperative day when mean pressure was >90 mmHg and organ perfusion was adequate. The particularity of our case was the complicated management of MB: it is very uncommon that myotomy of the LAD results in biventricular dysfunction. Our experience confirms that benign pathologies such as MB may hide life-threatening complications and that ECMO support is the simplest solution in case of biventricular dysfunction.

Safety and effectiveness of low dosing of double antiplatelet therapy during long-term left ventricular support with the INCOR system.

Adverse events due to anticoagulation and antiplatelet therapy during left ventricular assistance device (LVAD) support are very common, and every effort must be made to reduce their impact. We report our experience using a low dose of double antiplatelet therapy for patients provided with the INCOR LVAD system as a bridge to transplantation. Twelve patients (10 males, 35-60 years old) with acute or end-stage heart failure were included in this study. The mean follow-up was 10 months (cumulative 4.9 years). For antiplatelet therapy, we use an association of variable doses of aspirin and clopidogrel. The use of a platelet aggregation test (PAT) allows reducing the dose of the drugs to the minimum needed. The primary end point was to check the safety of the therapy, analyzing the incidence of major and minor bleeding complications. The secondary end point was to check the effectiveness of the therapy, evaluating the incidence of major and minor thromboembolic events. We had three (25%) cases of early postoperative mediastinal bleeding. On the contrary, no episodes of major bleeding occurred during the follow-up period. The rate of minor bleeding complications was low: 0.2 events per patient/year. The rate of major and minor thromboembolic events was acceptable (respectively 0.09 and 0.2 per patient/year). During LVAD support, double antiplatelet therapy with a low dose of aspirin and clopidogrel was safe and effective. PAT allows reducing the dose of antiplatelet drugs, avoiding complications related to excessive or insufficient dose administration.

Right subclavian artery cannulation for aortic dissection surgery, without infraclavicular incision.

The choice of arterial cannulation strategy for acute type A dissection surgery remains a controversial  issue and a subject of great debate because of its impact on clinical outcomes. A review of retrospective studies shows that surgeons are tending to switch from a retrograde to an antegrade perfusion strategy. Innominate artery cannulation has a number of advantages when compared to other cannulation techniques; however when the vessel is dissected, the proximal right subclavian artery can be used for arterial return. Also, because cannulation of the right subclavian artery does not require a second surgical incision in addition to median sternotomy, this decreases the number of incision sites and further simplifies the procedure.

Percutaneous or Side-Arm Graft Right Subclavian Artery Cannulation via Median Sternotomy.

Several cannulation sites alternative to the ascending aorta, such as femoral, right axillary, carotid, innominate artery, and, less commonly, apical sites, have been proposed. Cannulation of the right subclavian artery, through sternotomy, is one possible means of establishing cardiopulmonary bypass, hence avoiding a second surgical incision. In our experience, cardiopulmonary bypass flow was adequate and circulatory arrest with antegrade cerebral perfusion was successfully performed in all cases. There was no in-hospital mortality.

One-stage transmediastinal surgical approach for extensive aortic pathology.

"One-stage" transmediastinal replacement of the thoracic aorta provides an alternative treatment to single or multiple stage hybrid procedures for patients with ascending, arch, and descending thoracic aorta aneurysm. The patient is placed on bypass and cooled. During circulatory arrest, after surgical treatment of the aortic valve and root where appropriate, the entire ascending aorta is excised and the transverse arch is opened longitudinally. The heart is retracted cephalad and the left pleural cavity is entered longitudinally. The descending aorta is exposed through the posterior pericardium and opened transversely. After supra-aortic vessel reimplantation, a quadrifurcated Dacron graft is pulled into thorax behind the left lung, towards the hilum, and anastomosed to the descending thoracic aorta in an end-to-end fashion at the level of the transverse aortotomy. This anastomosis effectively seals the descending thoracic aorta. A Dacron patch is used also to close the upper descending aorta. The proximal graft is then sewn to the ascending aorta. The patient is rewarmed and weaned from cardiopulmonary bypass.

New ultrasonic device for internal thoracic artery harvesting.

The internal thoracic artery skeletonization method typically involves careful dissection with electrocautery. However, skeletonization using harmonic technology is safer than the conventional method. Ultrasonic shears may be faster than traditional methods, and may optimize the quality of skeletonized grafts during harvesting, preserving their functional and structural conduit integrity, and facilitating harvesting of the bilateral internal thoracic artery. This tutorial shows in detail the skeletonization harvest technique, using Ethicon's harmonic shears (Ethicon Endo-Surgery©, CVD, Cincinnati, OH, USA) Our results, using this technique, showed no harvesting damage and excellent graft quality as evaluated intraoperatively.

Syncope with Surprise: An Unexpected Finding of Huge Gastric Diverticulum.

A gastric diverticulum is a pouch protruding from the gastric wall. The vague long clinical history ranging between dyspepsia, postprandial fullness, and upper gastrointestinal bleeding makes this condition a diagnostic challenge. We present a case of large gastric diverticulum that has been diagnosed during clinical investigations for suspected cardiovascular issues in a patient admitted at the medical ward for syncope. A 51-year-old man presented to the medical department due to a syncopal episode occurring while he was resting on the beach after having his lunch, with concomitant vague epimesogastric gravative pain without any other symptom. A diagnosis of neuromediated syncopal episode was made by the cardiologist. Due to the referred epimesogastric pain, an abdominal ultrasound scan was carried out, showing perisplenic fluid. A CT scan of the abdomen was performed to exclude splenic lesions. The CT scan revealed a large diverticulum protruding from the gastric fundus. The upper gastrointestinal endoscopy visualized a large diverticular neck situated in the posterior wall of the gastric fundus, partially filled by undigested food. The patient underwent surgery, with an uneventful postoperative course. Histologic examination showed a full-thickness stomach specimen, indicative of a congenital diverticulum. At the 2nd month of follow-up, the patient was asymptomatic.

Hybrid repair of aortic arch aneurysm in high-risk patients.

OBJECTIVES: Morbidity and mortality after conventional surgery of aortic arch aneurysms remain high. Alternative techniques are the subject of this report. METHODS AND RESULTS: Open surgery requires cardiopulmonary bypass and hypothermic circulatory arrest. Thoracic endovascular aneurysm repair has a less invasive therapeutic alternative. The number of high-risk patients has considerably increased over the past decade. The proximity of the aneurysm to the supraaortic vessels makes it difficult to achieve a satisfactory proximal landing zone for endovascular stenting. Two methods have been proposed to address this issue: branched stent grafts and extraanatomic bypass, defined as a hybrid approach, which combines aortic debranching and endovascular procedures. Experience with hybrid repair is limited. Today there are no formal guidelines for the management of aortic arch aneurysm in high-risk patients. CONCLUSION: Hybrid repair of aortic arch aneurysm in high-risk patients is a feasible and safer option.

Endoscopic Saphenous harvesting with an Open CO2 System (ESOS) trial for coronary artery bypass grafting surgery: study protocol for a randomized controlled trial.

BACKGROUND: In coronary artery bypass grafting surgery, arterial conduits are preferred because of more favourable long-term patency and outcome. Anyway the greater saphenous vein continues to be the most commonly used bypass conduit. Minimally invasive endoscopic saphenous vein harvesting is increasingly being investigated in order to reduce the morbidity associated with conventional open vein harvesting, includes postoperative leg wound complications, pain and patient satisfaction. However, to date the short and the long-term benefits of the endoscopic technique remain controversial. This study provides an interesting opportunity to address this gap in the literature. METHODS/DESIGN: Endoscopic Saphenous harvesting with an Open CO2 System trial includes two parallel vein harvesting arms in coronary artery bypass grafting surgery. It is an interventional, single centre, prospective, randomized, safety/efficacy, cost/effectiveness study, in adult patients with elective planned and first isolated coronary artery disease. A simple size of 100 patients for each arm will be required to achieve 80% statistical power, with a significant level of 0.05, for detecting most of the formulated hypotheses. A six-weeks leg wound complications rate was assumed to be 20% in the conventional arm and less of 4% in the endoscopic arm. Previously quoted studies suggest a first-year vein-graft failure rate of about 20% with an annual occlusion rate of 1% to 2% in the first six years, with practically no difference between the endoscopic and conventional approaches. Similarly, the results on event-free survival rates for the two arms have barely a 2-3% gap. Assuming a 10% drop-out rate and a 5% cross-over rate, the goal is to enrol 230 patients from a single Italian cardiac surgery centre. DISCUSSION: The goal of this prospective randomized trial is to compare and to test improvement in wound healing, quality of life, safety/efficacy, cost-effectiveness, short and long-term outcomes and vein-graft patency after endoscopic open CO2 harvesting system versus conventional vein harvesting.The expected results are of high clinical relevance and will show the safety/efficacy or non-inferiority of one treatment approach in terms of vein harvesting for coronary artery bypass grafting surgery. TRIAL REGISTRATION: www.clinicalTrials.gov NCT01121341.

Mesothelial cyst of the pericardium, absent on earlier computed tomography.

Pericardial cysts are benign intrathoracic lesions that are considered to be congenital. They are usually found incidentally upon chest radiography and typically cause few symptoms. Their true incidence is unknown. Herein, we describe the case of a 41-year-old man who, over nearly a decade, had undergone frequent hospital admissions for fever and thoracic pain. Computed tomography had shown no evidence of any intrathoracic mass. He was admitted to the hospital with fever, chest pain, tachycardia, dyspnea, and cough. The symptoms persisted despite medical therapy. Computed tomography revealed a pericardial cyst on the right side of the anterior mediastinum, near the confluence of the brachiocephalic vein and the superior vena cava and very close to the ascending aorta. The mass compressed the right main bronchus. Due to the cyst's unusual location and the ineffectiveness of medical therapy, we excised the tumor via median sternotomy. We found a large (7 x 4-cm), well-circumscribed, unilocular cyst, which unexpectedly involved the outside pericardial surface and the phrenic nerve. Histopathologic examination confirmed that the lesion was a simple mesothelial cyst of the pericardium. After the surgery, the patient's fever and chest pain resolved. We know of no other report of a pericardial cyst that had gone undetected upon earlier computed tomography. We believe that surgical treatment of pericardial cysts should be reserved for patients who have severe symptoms due to complications, or when diagnosis is uncertain and malignancy is suspected.

Unexpected long durability of a low-profile porcine Liotta bioprosthesis in mitral position.

We report a case in which replacement of a low-profile porcine Liotta bioprosthesis was required 21 years after initial implantation. The patient underwent mitral valve replacement with a 28-mm Liotta bioprosthesis in 1985 for mitral stenosis. Twenty-one years later, severe mitral regurgitation was detected at echocardiography and mitral valve reoperation combined with tricuspid annuloplasty was successfully performed. Focal perforation of two cusps with consequent intravalvular leak on bioprosthesis was found. This is the longest durability report for a Liotta bioprosthesis in mitral position.

Patent foramen ovale and ascending aortic aneurysm with platypnea-orthodeoxia syndrome.

Platypnea-orthodeoxia is a rare syndrome characterized by dyspnea induced by the upright position and relieved by supine position and an arterial deoxygenation increased by the upright position which improves during recumbency. Several anatomical factors that can alter the atrial anatomy and facilitate shunting through an interatrial defect have been related with this syndrome. In many cases, this syndrome has been associated with patent foramen ovale and right-to-left shunt. Rarely platypnea-orthodeoxia syndrome has been described associated with an aortic aneurysm too. We present a case of platypnea-orthodeoxia syndrome in a 76-year-old Italian man with patent foramen ovale and ascending aortic aneurysm.