Topical skin adhesive PRINEO as the ideal wound closure system in cardiac surgery to limit surgical site infection.

OBJECTIVE: Surgical site infections (SSIs) are a major source of morbidity after cardiac surgery, involving prolonged hospitalisation. Among the numerous techniques of skin closure and dressings available, the optimal method remains undetermined. The DERMABOND-PRINEO (PRINEO) (PRINEO, Ethicon, J&J) is the only skin closure system which combines a topical skin adhesive with a mesh. Other surgical disciplines have highlighted remarkable results with PRINEO. The aim of this study was to evaluate the effects of PRINEO, used as the final layer in sternotomy closure, in the incidence of postoperative SSIs. METHOD: This was a retrospective single-centre cohort study including adult patients who underwent cardiac surgery between January 2015 and December 2018. Patients who had undergone heart transplantation or ventricular assist surgery were excluded. Included patients were divided into two groups depending on the type of post-operative wound care technique used. Group 1 consisted of patients who had their sternotomy closed with a standard dressing and group 2 consisted of patients who were treated with PRINEO. The primary endpoint of our study was the occurrence of SSIs and secondary outcomes were the length of hospitalisation and mortality. RESULTS: A total of 1603 patients were reviewed with the occurrence of 44 SSIs. Both groups were homogeneous in terms of risk factors. The incidence of SSIs was significantly lower in group 2 (PRINEO) than in group 1 (standard dressing) (n=29, 3.8% vs n=15, 1.8%, respectively; p=0.042). However, there was no significant difference in the duration of hospitalisation and mortality. CONCLUSION: In our practice, PRINEO has proven to be a safe wound closure system after sternotomy, with a reduced SSI rate compared to conventional wound care techniques.

Usefulness of postoperative high-sensitive troponin T measurement and implications for defining type 5 infarction.

BACKGROUND AND AIM OF THE STUDY: Guidelines indicate for type 5 myocardial infarction (MI) that postoperative troponin need not be exclusively ischemic but may also be caused by epicardial injury. Complexity arises from the introduction of high-sensitive troponin. This study attempts to contribute to the understanding of postoperative high-sensitive cardiac troponin T (hs-cTnT) increase. METHODS: The median enzyme increase of different cardiac operations was compared. Linear regression analyses were used to determine correlations between enzyme rise and independent parameters. Receiver-operating characteristics (ROC) served to evaluate the discriminatory power of enzyme rise in detecting ischemia and to determine possible thresholds. RESULTS: Among 400 patients, 2.8% had intervention-related ischemia analogous to type 5 MI definition. The median postoperative hs-cTnT/creatine kinase myocardial band (CK-MB) increase varied according to types of surgery, with highest increase after mitral valve and lowest after off-pump coronary surgery. After ruling out patients with preoperatively elevated hs-cTnT, regression analysis confirmed Maze procedure (p < .001), intra-pericardial defibrillation (p = .002), emergency intervention (p = .01), blood transfusions (p = .02), and cardiopulmonary bypass time (p = .03) as significant factors associated with hs-cTnT increase. In addition, CK-MB increase was associated with mortality (p = .002). ROC confirmed good discriminatory power for hs-cTnT and CK-MB with ischemia-indicating thresholds of 1705.5 ng/L (hs-cTnT) and 113 U/L (CK-MB) considering different types of operations. CONCLUSIONS: The Influence of the type of surgery and intervention-related parameters on hs-cTnT increase was confirmed. Potential thresholds indicating perioperative ischemia appear to be significantly elevated for high sensitive markers.

Implantation of a HeartMate 3 in a 13-Year-Old Child with Dilated Cardiomyopathy.

Left ventricular assist device is a well-established therapy in heart failure adults, but less in children. A 13-year-old-boy with severe left ventricular dysfunction did not improve under medical treatment. A HeartMate 3 (HM3) was implanted as a bridge to transplantation. Despite the size limitation, the HM3 shows promising results and our case supports its feasibility in children.

Trifecta and Carpentier Edwards aortic bioprostheses: Comparison of six years follow-up outcomes.

BACKGROUND: To compare mid-term clinical outcomes and hemodynamic performance of the stented pericardial Trifecta bioprosthesis for surgical aortic valve replacement (AVR) with a technically comparable commonly used surgical bioprosthesis. METHODS: Data from consecutive patients implanted with the TF or the Carpentier Edwards Magna Ease valve were retrospectively analyzed. Primary analysis was performed on a propensity score-matched cohort. Primary endpoints included the composite of death or reoperation and structural valve deterioration. The comparison also included echocardiographic assessments at one-week post-AVR and at the last documented follow-up. RESULTS: Two propensity score-matched groups of 170 patients each were identified from the overall population (n = 486). Incidence of postoperative mortality (2.9% vs. 7.1%, respectively, p = 0.08), and patient prosthesis mismatch (1.2% and 2.4%, p = 0.41) were similar. At mean follow-up of 5.84 (Trifecta) and 6.1 (Carpentier Edwards) years, the incidence of all-cause death/reoperation (15.3% vs. 15.9%, p = 0.88 for Trifecta and Carpentier Edwards, respectively) and structural valve disease (1.8% vs. 2.9%, p = 0.47) were similar. Overall, postoperative mean transvalvular pressure gradients were significantly lower in the Trifecta group than in the Carpentier Edwards group (7.7 ± 3.3 vs. 11.3 ± 3.6 mmHg, p < 0.01). Mean transvalvular gradient remained significantly lower through the last follow-up for small-sized Trifecta valves (19/21 mm; 10.5 ± 4.2 vs. 13.8 ± 5.9 mmHg, p = 0.039) but not for larger valves (10.3 ± 4.8 vs. 9.4 ± 3.5 mmHg, p = 0.31). CONCLUSION: The Trifecta valve is a valuable alternative to the Carpentier Edwards valve in terms of safety, hemodynamic performance, and mid-term durability. Smaller-sized valves provide additional clinical benefits, given their persistent hemodynamic advantages through mid-term follow-up.

Complete atrioventricular septal defect: Modified 2-patch technique.

Complete atrioventricular septal defect is a common congenital malformation. Various surgical corrections coexist. This video tutorial describes a correction that preserves the height of the leaflets by splitting both the anterior and the posterior bridging leaflets and using two patches to close the ventricular septal defect and the atrial septal defect separately.

Extracorporeal cardiopulmonary resuscitation for severe chloroquine intoxication in a child - a case report.

BACKGROUND: Chloroquine use has increased worldwide recently in the setting of experimental treatment for the novel coronavirus disease (Covid-19). Nevertheless, in case of chloroquine intoxication, it can be life threatening, with cardiac arrest, due to its cardiac toxicity. CASE PRESENTATION: This case study reports on a 14-years-old girl who presented in cardiac arrest after an uncommon suicide attempt by ingesting 3 g of chloroquine. After 66 min of cardio-pulmonary resuscitation (CPR), extracorporeal cardiopulmonary resuscitation (ECPR) was initiated, allowing cardiac function to recover. CONCLUSIONS: Chloroquine intoxication is a rare but serious condition due to its cardiac toxicity. Use of ECPR in this case of transient toxicity allowed a favorable evolution with little neurological impairment.

Type A aortic dissection in aneurysms having modelled pre-dissection maximum diameter below 45 mm: should we implement current guidelines to improve the survival benefit of prophylactic surgery?

OBJECTIVES: Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. METHODS: All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). RESULTS: Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort's mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). CONCLUSIONS: TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.

Case report: early aortic valve degeneration associated with interstitial deletion of chromosome 2-46,XX,del (2)(q31.3; q32.2).

BACKGROUND: Interstitial deletions within the long arm of chromosome 2, involving the 2q31q33 region, are rare but are known to be associated with delays in development, behavioral problems, facial dysmorphism and various hand/foot anomalies. CASE PRESENTATION: Here, we describe a case with an interstitial 2q31.3.q32.2 deletion, presenting the previously described phenotype, exhibiting fibromyxoid degeneration of the aortic valve in addition to previously described clinical features. CONCLUSION: Interstitial deletion in chromosome 2q31.2q32.3 might be associated to a fibromyxoid degeneration of valvular leaflets generating regurgitation. Patients diagnosed with this mutation may require investigation to rule out a valvular disease.

Cylinder mitral and tricuspid valve replacement in neonates and small children.

OBJECTIVES: Atrioventricular valve replacement in small children is associated with high morbidity and mortality. There are no prostheses available with a diameter ˂15 mm. This study reports our initial experience with a cylinder valve for mitral and tricuspid valve replacement in infants and small children. METHODS: Our cylinder valve was hand-made for patients requiring atrioventricuclar valve replacement with an annulus of <15 mm. A 12-mm Contegra valve was prepared and placed inside a 14-mm Gore-Tex tube graft and sutured on both extremities. RESULTS: Eight patients were included, with a median age of 6.9 months (range 1 day to 38 months). Four had mitral and 4 had tricuspid valve replacement. All implants were technically successful, with no significant regurgitation, no stenosis and no left ventricular outflow tract obstruction. There were 3 early deaths from low cardiac output, in patients with significant associated lesions (severe neonatal Ebstein's, pulmonary artery-intact ventricular septum, biventricular conversion from Norwood stage 1). Two patients required early reintervention: 1 for balloon dilatation for stenosis and 1 for reoperation for paravalvular leak. During follow-up, 2 patients had mitral valve replacement with a 16-mm mechanical valve at 9 and 20 months from the cylinder valve implantation. The remaining 2 patients are alive and well 2 years and 2 months after the procedure. CONCLUSIONS: Cylinder valve replacement of atrioventricular valves was feasible without any technical issues. It was successful in getting out of a difficult situation and allows for somatic growth and implantation of a reasonably-sized mechanical prosthesis on the annulus.

Heart procurement in a multi-organ donor.

The first orthotopic heart transplant was performed in 1967. Following on from this achievement, the first major evolution in heart transplantation was the transition from biatrial anastomosis to separate caval anastomoses, in 1991. Various strategies for myocardial protection have been used for this. This video tutorial describes heart procurement for a bicaval anastomosis technique in a case of multi-organ procurement.

Muscle-sparing aortic coarctation repair.

OBJECTIVE: Surgery for aortic coarctation repair provides excellent hemodynamic results but may be complicated by musculoskeletal issues. The purpose of the study was to determine the midterm results of a muscle-sparing surgical approach to aortic coarctation repair, with special emphasis on the repair and on the musculoskeletal changes associated with a posterior thoracotomy. METHODS: We included all children with aortic coarctation operated on with our minimally invasive approach between June 2002 and October 2004, with a follow-up of ≥4.5 years. Patients were assessed clinically and echocardiographically. The spine, left chest, and shoulder were assessed clinically and radiographically. RESULTS: Thirty-one children were included. The age at operation ranged from 1 day to 15 months and weight ranged from 980 g to 10 kg. All patients underwent an extended end-to-end anastomosis coarctation repair through a minimal (n = 19) or total-muscle sparing (n = 12) or extrapleural (n = 18) approach. Five patients had an additional enlargement procedure on the aortic arch. 27 patients had no residual or recurrent gradient. Four patients exhibited restenosis, for which 1 underwent a percutaneous angioplasty and 2 underwent surgical reintervention. All patients were free of hypertension. One patient had borderline values. The musculoskeletal assessment was normal in all but 3 patients. Two patients who underwent other subsequent thoracic surgeries developed thoracogenic scoliosis of moderate severity. A third patient had a left winged scapula. No rib fusion or intercostal space enlargement was found. CONCLUSIONS: Compared with a conventional approach, our minimally invasive surgical approach led to excellent musculoskeletal outcomes without compromising the hemodynamic results.

Pediatric Orthotopic Heart Transplantation.

Since the first pediatric orthotopic heart transplant was performed by Dr Adrian Krantowicz in 1967, just days after the first ever human transplant by Dr Christiaan Barnard, the technique for orthotopic heart transplantation has evolved from biatrial anastomosis to separate caval anastomoses, leaving the right atrium intact. In this video tutorial, we present our technique for standard orthotopic heart transplantation in children.

Giant coronary aneurysms producing chest pain.

BACKGROUND: Coronary artery aneurysms (CAA) are defined as localized coronary artery dilations more than 1.5 times the diameter of the adjacent segments [1]. Giant coronary aneurysms (GCAA) are unusual and aneurysms on the left side are even rarer. Mechanisms are unclear, but seem predominated by atherosclerosis. Until now, management of giant coronary aneurysm is still unclear. CASE PRESENTATION: A 62-year-old man, presented a 4-month history of progressive chest pain aggravated by physical CAAs: 3 on the right coronary artery (RCA), including a giant one, and one on the intermediate branch. Intraoperatively, we found two proximal RCA CAAs of 2 cm each, a 6 cm distal RCA CAA partially thrombosed, and a 3 cm CAA on the intermediate branch. The two largest CAAs were resected and two saphenous graft bypasses were performed. CONCLUSIONS: Treatment options include medical treatment (antiaggregation, anticoagulation), percutaneous coronary angioplasty and surgery. Results of observational or conservative management in the few cases of GCAA described in literature, appear to have poor results. Surgery is a good option with low operative risk, especially in giant coronary aneurysms.

18-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography to Guide Aortic Arch Replacement in Relapsing Polychondritis.

Relapsing polychondritis (RP) is a rare progressive autoimmune disease. The cardiovascular system is rarely involved. The authors report the case of a young woman with RP aortic arch aneurysm and symptomatic cerebral vessels stenosis. A positron emission tomography-computed tomography (PET-CT) indicated areas with activity and guided the surgery. Aortic arch with proximal vessels was successfully replaced. The PET-CT may be useful to assess the risks and determine healthy zones for potential anastomotic sites.

Acute peri-operative coronary subclavian steal syndrome: A diagnostic and treatment challenge.

The coronary subclavian steal syndrome (CSSS) generally occurs during follow up after coronary surgery. The case demonstrates an immediate peri-operative CSSS followed by myocardial infarction, notwithstanding a preoperative computed tomography scan quantifying subclavian artery calcifications as non-stenosing, and a subjective patent blood flow through the transected left internal mammary artery (LIMA). Blood flow inversion in the LIMA to anterior descending artery (LAD) bypass was detected by transit time flow measurement (TTFM). Following an elective brachiocephalic bypass a complementary, emergent subclavian bypass was performed, which restored antegrade LIMA flow, as confirmed by TTFM and angiography, but the patient suffered a peri-operative myocardial infarction. Reports about elective, concomitant subclavian and coronary surgery for sub-acute CSSS, allowing diagnostic investigations, have been published; however this case demonstrates diagnostic and treatment challenges in acute CSSS and emphasizes the role of peri-operative TTFM. .

Muscle-sparing extrapleural repair of neonatal aortic coarctation.

The goal of surgical treatment of aortic coarctation is to relieve the pressure gradient on the aorta and to allow for subsequent growth of the repaired aorta. In this regard, coarctation resection and extended end-to-end anastomosis has become the surgical gold standard. Early and long-term results have been reported to be excellent. In this tutorial, we present our technique for correction of aortic coarctation using a muscle-sparing, extrapleural approach.

HeartMate 3 implantation via left antero-lateral thoracotomy to avoid resternotomy in high risk patients.

Left ventricular assist devices (LVADs) are currently the best alternative to cardiac transplantation for patients with end-stage heart failure (HF) as a bridge to transplant or to decision, or as destination therapy. Full median sternotomy or minimally invasive techniques are the more standard approaches used at present.  LVADs are usually implanted between the left ventricle apex and the ascending aorta. An implantation through a left thoracotomy with an outflow graft connected to the descending aorta is much less performed nowadays due to the longer times to extubation, higher incidence of postoperative pain, and poorer hemodynamics in the ascending aorta, which may lead to thrombosis. However, some patients present a prohibitive risk for a medial approach. Also, many patients with a VAD will require future transplantation, and avoiding a sternotomy or crossing the mediastinum with the outflow graft can reduce the risks of the subsequent procedure in these patients. Various options for implantation may be used. Our described approach consists of implanting the left VAD (LVAD) via a left lateral thoracotomy and anastomosing the outflow graft to the descending aorta.

A safe and reproducible method to correct a d-transposition of the great arteries with the usual (type A) coronary artery pattern.

The success of the arterial switch operation mostly depends on the proper relocation of the coronary arteries. This involves more than the simple suturing of the coronary cuff to the neo-aortic root, it also involves the preparation of the landing zone and the correct mobilisation of the primary coronary branches. In this tutorial, we present our technique for correction of a dextro-transposition of the great arteries with a normal, type A, coronary artery pattern.

Low pacemaker incidence with continuous-sutured valves: a retrospective analysis.

Background Permanent pacemaker implantation after surgical aortic valve replacement depends on patient selection and risk factors for conduction disorders. We aimed to identify risk criteria and obtain a selected group comparable to patients assigned to transcatheter aortic valve implantation. Methods Isolated sutured aortic valve replacements in 994 patients treated from 2007 to 2015 were reviewed. Demographics, hospital stay, preexisting conduction disorders, surgical technique, and etiology in patients with and without permanent pacemaker implantation were compared. Reported outcomes after transcatheter aortic valve implantation were compared with those of a subgroup including only degenerative valve disease and first redo. Results The incidence of permanent pacemaker implantation was 2.9%. Longer hospital stay ( p = 0.01), preexisting rhythm disorders ( p < 0.001), complex prosthetic endocarditis ( p = 0.01), and complex redo ( p < 0.001) were associated with permanent pacemaker implantation. Although prostheses were sutured with continuous monofilament in the majority of cases (86%), interrupted pledgetted sutures were used more often in the pacemaker group ( p = 0.002). In the subgroup analysis, the incidence of permanent pacemaker implantation was 2%; preexisting rhythm disorders and the suture technique were still major risk factors. Conclusion Permanent pacemaker implantation depends on etiology, preexisting rhythm disorders, and suture technique, and the 2% incidence compares favorably with the reported 5- to 10-fold higher incidence after transcatheter aortic valve implantation. Cost analysis should take this into account. Often dismissed as minor complication, permanent pacemaker implantation increases the risks of endocarditis, impaired myocardial recovery, and higher mortality if associated with prosthesis regurgitation.