Perceval-S over time. Clinical outcomes after ten years of usage.

BACKGROUND: Perceval-S has become a reliable and commonly used option in surgical aortic valve replacement (AVR) since its first implantation in humans 15 years ago. Despite the fact that this aortic valve has been proven efficient enough in the short and mid-term period, there is still lack of evidence for the long-term outcomes. MATERIALS AND METHODS: This is an observational retrospective study in a high-volume cardiovascular center. Pertinent data were collected for all the patients in whom Perceval-S was implanted from 2013 to 2020. RESULTS: The total number of patients was 205 with a mean age 76.4 years. Mean survival time was 5.5 years (SE = 0.26). The overall survival probability of patients undergoing aortic valve replacement with Perceval-S at 6 months was 91.0% (Standard Error SE = 2.0%), at one year 88.4% (SE = 2.3%) and at 5-years 64.8% (SE = 4.4%). A detrimental cardiac event leading to death was the probable cause of death in 35 patients (55.6%). The initiation of Transcatheter Aortic Valve Replacement (TAVR) program in our center in 2017 was associated with a decline in the number of very high-risk patients treated with sutureless bioprosthesis. This fact is demonstrated by the significant shift towards lower surgical risk cases, as median Euroscore II was reduced from 5,550 in 2016 to 3,390 in 2020. Mini sternotomy was implemented in 79,5% of cases favoring less invasive approach. Low incidence of reinterventions, patient prosthesis mismatch and structural valve degeneration was detected. CONCLUSIONS: The survival rate after aortic valve replacement with implantation of Perceval-S is satisfactory in the long-term follow-up. Cases of bioprosthesis dysfunction were limited. Mini sternotomy was used in the majority of cases. TAVR initiation program impacted on the proportion of patients treated with Perceval-S with reduction of high-risk patients submitted to surgery.

Delayed simultaneous aortoesophageal and aortobronchial fistulae post thoracic endovascular aortic repair (TEVAR).

Aortoesophageal and aortobronchial fistulae after thoracic endovascular aortic repair (TEVAR) are rare and life-threatening conditions. No clear guidance exists in the literature for the optimal therapeutic management of such cases. This case demonstrates a delayed simultaneous aortoesophageal and aortobronchial fistulae treated conservatively with culture-guided antibiotic therapy and combined endovascular management.

Intraoperative accurate assessment of septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM).

Surgical restoration of the left ventricular outflow tract (LVOT) is necessary for patients suffering from hypertrophic obstructive cardiomyopathy (HOCM), when symptoms are present despite the administration of medical treatment. One point of great significance during the procedure is the evaluation of the LVOT gradient after completion of septal myectomy. Most physicians choose to measure this value by transesophageal echocardiography (TEE) in combination with the direct measurement with the use of needles inserted into the aorta and left ventricle. In this article, we present the implementation of a new technique to estimate the peak-to-peak pressure gradient between the left ventricle and the aorta intraoperatively using a single double lumen central venous catheter inserted through the antegrade cardioplegia cannulation site across the aortic valve into the left ventricle.

A Case of a Large Cephalic Vein Aneurysm.

Vein aneurysms represent a rare clinical entity with a wide range of clinical symptoms. We present a case of a 67-year-old male who presented with a large, bluish, easily compressible, soft tissue mass in the lateral side of his forearm, which was mildly tender and it had been worsening during the last year. A color duplex ultrasound revealed local venous dilatation of the cephalic vein, measuring 6.3 × 3.2 cm. The patient was operated under local anesthesia and the lesion was removed. Histology showed thinning of the inner and middle layers of the cephalic vein and incipient replacement of the outer layer by acellular fibrous tissue with progressive decrease of elastic, smooth muscle and collagen fibers of the inner and middle layers, compatible with an aneurysm of the cephalic vein. Large cephalic vein aneurysms might cause nerve compression and require surgical removal before permanent neurological defect occurs.

Oesophageal necrosis after thoracic endovascular aortic repair: a minimally invasive endovascular approach-a dramatic complication.

There are few cases in the literature reporting dysphagia caused by oesophageal compression by the aorta due to acute or chronic aortic pathology. This type of dysphagia is called dysphagia aortica. Thoracic endovascular aortic repair is nowadays the treatment of choice for anatomically suitable patients experiencing complicated Type B aortic dissection. Oesophageal necrosis is a rare but fatal complication following thoracic endovascular aortic repair. Extrinsic oesophageal compression by the thrombosed aneurysmal sac, a mediastinal haematoma or extensive thrombosis in the false lumen of a dissected aorta and acute vascular occlusion of the oesophageal supply are possible mechanisms. When oesophageal necrosis is suspected, endoscopic examination and computed tomography imaging should be performed repeatedly. Oesophagoscopy will confirm the diagnosis revealing a black, diffusely necrotic and ulcerated oesophageal mucosa. It is critical to intervene before full-thickness oesophageal wall necrosis and mediastinitis occur. Guidelines are absent because of the rarity of this complication. Moreover, lack of a large series does not permit the establishment of guidelines either. However, oesophagectomy of the impaired oesophagus is the only chance for survival. Unfortunately, survival rates are disappointing. Prevention and awareness is the cornerstone of success. Early endoscopic examination when oesophageal necrosis is suspected due to even minimal symptoms will detect this fatal menace on time.

Endovascular stent grafting for ascending aorta diseases.

OBJECTIVE: Conventional open surgery encompassing cardiopulmonary bypass has been traditionally used for the treatment of ascending aorta diseases. However, more than one in five of these patients will be finally considered unfit for open repair. We conducted a systematic review and meta-analysis to investigate the role of thoracic endovascular aortic repair (TEVAR) for aortic diseases limited to the ascending aorta. METHODS: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We investigated patients' baseline characteristics along with early (30 days/in-hospital stay) and late (beyond 30 days/in-hospital stay) outcomes after TEVAR limited to the ascending aorta and not involving the arch vessels. Separate analyses for case reports and case series were conducted, and pooled proportions with 95% confidence intervals (CIs) of outcome rates were calculated. RESULTS: Approximately 67% of the patients had a prior cardiac operation. TEVAR was performed mainly for acute or chronic Stanford type A dissection (49%) or pseudoaneurysm (28%). The device was usually delivered through the femoral artery (67%), and rapid ventricular pacing was used in nearly half of the patients. Technical success of the method was 95.5% (95% CI, 87.8-99.8). Among the early outcomes, conversion to open repair was 0.7% (95% CI, 0.1-4.8), whereas mortality was 2.9% (95% CI, 0.02-8.6). We estimated a pooled rate of 1.8% (95% CI, 0.1-7.0) for neurologic events (stroke or transient ischemic attack) and 0.8% (95% CI, 0.1-5.6) for myocardial infarction. Late endoleak was recorded in 16.4% (95% CI, 8.2-26.0), and 4.4% (95% CI, 0.1-12.4) of the population died in the postoperative period. Finally, reoperation was recorded in 8.9% (95% CI, 3.1-16.4) of the study sample. CONCLUSIONS: TEVAR in the ascending aorta seems to be safe and feasible for selected patients with various aortic diseases, although larger studies are required.

Perioperative neutrophil to lymphocyte ratio as a predictor of poor cardiac surgery patient outcomes.

PURPOSE: The purpose of the present study was to investigate the association between the perioperative neutrophil to lymphocyte ratio (NLR) and cardiac surgery patient outcomes. PATIENTS AND METHODS: A retrospective cohort study of 145 patients who underwent cardiac surgery in a tertiary hospital of Athens, Greece, from January to March 2015, was conducted. By using a structured short questionnaire, this study reviewed the electronic hospital database and the medical and nursing patient records for data collection purposes. The statistical significance was two-tailed, and p-values <0.05 were considered significant. The statistical analysis was performed with Mann-Whitney U test and Spearman's correlation coefficient, by using the Statistical Package for Social Sciences software (IBM SPSS 21.0 for Windows). RESULTS: The increased preoperative levels of NLR were associated with significantly higher mortality, both in-hospital (p=0.001) and 30-day (p=0.002), prolonged postoperative hospital length of stay (LOS), both in the cardiac intensive care unit (ICU) (p=0.002), and in-hospital (p=0.018), and likewise with delayed tracheal extubation (p≤0.001). Furthermore, patients with elevated NLR during the second postoperative day had significantly higher in-hospital mortality (p=0.018), increased incidence of pneumonia (p=0.022), higher probability of readmission to the ICU (p=0.002), prolonged ICU LOS (p≤0.001), and delayed tracheal extubation (p≤0.001). CONCLUSION: Increased perioperative NLR seems to be associated with significantly higher mortality and morbidity in cardiac surgery patients. At the same time, NLR is a significant and inexpensive biomarker for the early identification of patients at high risk for complications. In addition, NLR levels could lead clinicians to perform measures for the optimal therapeutic patient approach.

Is axillary superior to femoral artery cannulation for acute type A aortic dissection surgery?

A best evidence topic was written according to a structured protocol. The question addressed was whether axillary artery cannulation (AXC) is superior to femoral artery cannulation (FAC) in patients undergoing surgical repair of acute type A aortic dissection. A total of 90 studies were identified using the reported search, of which 10 represented the best evidence to answer the clinical question. There were nine retrospective studies and one meta-analysis. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Four papers, including the meta-analysis, reported significantly increased mortality in patients undergoing surgery with FAC. From these, two papers, again including the meta-analysis, reported also significantly increased neurological dysfunction, and another one demonstrated significantly increased incidence of postoperative bleeding and sternal infections in this same group of patients. Two more studies reported decreased mortality, malperfusion and neurological complications in patients undergoing surgical repair with AXC, but no statistical analysis was performed. Three reports comparing AXC and FAC found no difference between the two groups in terms of operative mortality and major complications, while another one demonstrated increased incidence of postoperative mortality in patients undergoing surgery with AXC, most likely due to the presence of malperfusion of one or more organs preoperatively in those who died. Patients undergoing repair of type A aortic dissection may benefit from AXC, whenever this is technically feasible. Most reports show that inflow perfusion through the axillary artery will reduce overall mortality, and neurological and malperfusion complications when compared with FAC. However, it needs to be stressed that, in three reports, the superiority of AXC over FAC might be attributed to the fact that patients in the latter group were critically ill in haemodynamic collapse. Nevertheless, this indicates that the femoral artery remains a bailout option in the emergency situation when institution of cardiopulmonary bypass is required rapidly.

Perioperative prostate specific antigen levels among coronary artery bypass grafting patients: Does extracorporeal circulation and body temperature induce prostate specific antigen levels alterations?

PURPOSE: The purpose of this study is to compare the perioperative total prostate specific antigen (tPSA) levels among coronary artery bypass grafting (CABG) patients with and without extracorporeal circulation (ECC), to investigate the changes overtime of tPSA in each group separately and to determine the effect of body core temperature on tPSA levels. MATERIALS AND METHODS: A prospective study was conducted. Our sample was allocated to: (a) Seven patients who underwent off pump CABG (Group I) and (b) 16 CABG patients with ECC (Group II). The levels of tPSA were measured preoperatively (baseline), intra-operatively and at the 4(th) postoperative day. We compared the two groups on their tPSA levels and we investigated the changes of tPSA overtime in each group separately. RESULTS: Intra-operative serum samples were obtained in significantly lower body temperature in patients of Group II than in those of Group I (31°C vs. 36.9°C, P < 0.001). In each group separately, postoperative tPSA levels were increased significantly compared to the baseline values (2.55 ng/ml vs. 0.39 ng/ml for Group I, P = 0.005 and 4.36 ng/ml vs. 0.77 for Group II, P < 0.001). CABG patients with ECC had significantly lower intra-operative tPSA levels than the baseline values (0.67 ng/ml vs. 0.77 ng/ml, P = 0.008). We did not observe significant differences of tPSA levels between the two groups. CONCLUSIONS: CABG surgery affects similarly the perioperative tPSA independently the involvement of ECC. Although all patients had significantly higher early postoperative tPSA levels, only those who underwent CABG with ECC had exceeded normal values and significantly decreased intra-operative tPSA. Hypothermia seems to be the causal factor of tPSA reduction.

Corynebacterium diphtheriae endocarditis with multifocal septic emboli: can prompt diagnosis help avoid surgery?

PATIENT: Male, 23. FINAL DIAGNOSIS: Corynebacterium diphtheriae endocarditis. SYMPTOMS: Abdominal pain • cachexia • diarrhea • fever • vomiting. MEDICATION: -. CLINICAL PROCEDURE: Mitral valve replacement. SPECIALTY: Surgery. OBJECTIVE: Rare disease. BACKGROUND: Although Corynebacterium diphtheriae is well known for causing diphtheria and other respiratory tract infections, in very rare cases it can lead to severe systemic disease. CASE REPORT: This is a case of a previously healthy young man (no prosthetic valve in situ or other known congenital defect), presenting with a Corynebacterium diphtheriae infection leading to endocarditis. The patient reported no I.V. drug use, so it can be assumed that no risk factors for infective endocarditis were present. CONCLUSIONS: This report aims to raise suspicion for this specific infection in order to proceed with the right treatment as soon as possible.

Right heart failure post left ventricular assist device implantation.

Right heart failure (RHF) is a frequent complication following left ventricular assist device (LVAD) implantation. The incidence of RHF complicates 20-50% (range, 9-44%) of cases and is a major factor of postoperative morbidity and mortality. Unfortunately, despite the fact that many risk factors contributing to the development of RHF after LVAD implantation have been identified, it seems to be extremely difficult to avoid them. Prevention of RHF consists of the management of the preload and the afterload of the right ventricle with optimum inotropic support. The administration of vasodilators designed to reduce pulmonary vascular resistance is standard practice in most centers. The surgical attempt of implantation of a right ventricular assist device does not always resolve the problem and is not available in all cardiac surgery centers.

Left ventricular rupture after double valve replacement in a patient with myocarditis due to myasthenia gravis.

Myasthenia gravis is an autoimmune disease characterised by weakness of the skeletal muscles, with remissions and exacerbations due to antibodies acting on the acetylcholine receptors. This leads to the characteristic defect transmission in the neuromuscular junction. Treatment includes anticholinesterase agents, thymectomy, and immunosuppression. Surgical thymectomy can induce remission or improvement, allowing for reduction in the immunosuppressive treatment. The case of an 84-year-old female patient with myasthenia gravis, aortic valve stenosis, mitral valve regurgitation and myocarditis is described. The development of myocarditis was related to inflammatory cell infiltration, and progressive and additive focal cellular necrosis associated with reactive myocardial fibrosis. After replacement of the mitral valve, complications arose when a rupture of the left ventricular posterior wall occurred, which caused massive bleeding and sudden death on the operating table.

Trans-aortic excision of intraventricular lipoma with the assistance of arthroscopic camera.

Cardiac lipomas are extremely rare benign neoplasms of the heart. We report the case of a 64-year-old female complaining of rapidly worsening dyspnea and lower limb edema. Echocardiograms showed a large hyperechoic mass which occupied the left ventricle. The cardiac nuclear magnetic resonance allowed the diagnosis of the left ventricular tumor of lipoma or liposarcoma. The tumor was resected through the ascending aorta, without injuring neither the aortic valve nor the left ventricle. Histological diagnosis showed that the tumor was a lipoma. The patient had an uneventful recovery, with no recurrence two years later.

Left ventricular rupture after double valve replacement in a patient with myocarditis due to myasthenia gravis : case report.

Myasthenia gravis is an autoimmune disease characterised by a weakness of the skeletal muscles, with remissions and exacerbations due to antibodies acting on the acetylcholine receptors. This leads to the characteristic defect transmission in the neuromuscular junction. Treatment includes anticholinesterase agents, thymectomy, and immunosuppression. Surgical thymectomy can induce remission or improvement, allowing for reduction in the immunosuppressive treatment. The case of an 84-year-old female patient with myasthenia gravis, aortic valve stenosis, mitral valve regurgitation and myocarditis is described. The development of myocarditis was related to inflammatory cell infiltration, and progressive and additive focal cellular necrosis associated with reactive myocardial fibrosis. After replacement of the mitral valve, complications arose whereby a rupture of the left ventricular posterior wall occurred, which caused massive bleeding and sudden death on the operating table.

Off pump repair of left ventricular rupture following mitral valve replacement: The crucial assistance of the IntraAortic Balloon Pump.

INTRODUCTION: Left ventricular (LV) rupture is a not as frequent, but potentially lethal complication of mitral valve replacement or repair. PRESENTATION OF CASE: We report a case of a 67-year-old man who underwent mitral valve replacement and Cox Maze IV procedure. A massive bleed from the LV rupture was noted postoperatively while the patient was extubated. The control of bleeding was impossible until an IntraAortic Balloon Pump (IABP) was inserted. A bovine pericardial patch was applied, overlapping an extensive epicardial area, perimetrically of the hematoma. Between the epicardium and the pericardial patch we applied an autologous fibrin sealant. DISCUSSION: The off-pump technique used to repair the LV rupture after a MVR, is more feasible when the patient is supported by an IABP that subsequently decreases the tension of the myocardial suture site. CONCLUSION: The IABP, is a necessary device, that decreases the tension along the suture site post a left ventricular rupture following a MVR.

Microcirculation and macrocirculation in cardiac surgical patients.

Background. The aim of our study was to investigate the relationship between microcirculatory alterations after open cardiac surgery, macrohemodynamics, and global indices of organ perfusion. Methods. Patients' microcirculation was assessed with near-infrared spectroscopy (NIRS) and the vascular occlusion technique (VOT). Results. 23 patients undergoing open cardiac surgery (11 male/12 female, median age 68 (range 28-82) years, EuroSCORE 6 (1-12)) were enrolled in the study. For pooled data, CI correlated with the tissue oxygen consumption rate as well as the reperfusion rate (r = 0.56, P < 0.001 and r = 0.58, P < 0.001, resp.). In addition, both total oxygen delivery (DO(2), mL/min per m(2)) and total oxygen consumption (VO(2), mL/min per m(2)) also correlated with the tissue oxygen consumption rate and the reperfusion rate. The tissue oxygen saturation of the thenar postoperatively correlated with the peak lactate levels during the six hour monitoring period (r = 0.50, P < 0.05). The tissue oxygen consumption rate (%/min) and the reperfusion rate (%/min), as derived from the VOT, were higher in survivors compared to nonsurvivors for pooled data [23 (4-54) versus 20 (8-38) P < 0.05] and [424 (27-1215) versus 197 (57-632) P < 0.01], respectively. Conclusion. Microcirculatory alterations after open cardiac surgery are related to macrohemodynamics and global indices of organ perfusion.