Retrospective study assessing outcomes in cardiac surgery after implementation of Quantra.

BACKGROUND: The Quantra QPlus System is a cartridge-based device with a unique ultrasound technology that can measure the viscoelastic properties of whole blood during coagulation. These viscoelastic properties correlate directly with hemostatic function. The primary objective of this study was to assess blood product utilization in cardiac surgery patients before and after the implementation of the Quantra QPlus System. METHODS: Yavapai Regional Medical Center implemented the Quantra QPlus System to aid in their efforts to reduce the transfusion of allogenic blood products and improve outcomes in patients undergoing cardiac surgery. A total of 64 patients were enrolled prior to the utilization of the Quantra (pre-Quantra cohort), and 64 patients were enrolled after (post-Quantra cohort). The pre-Quantra cohort had been managed via standard laboratory assays along with physician discretion for transfusion decisions. The utilization of blood products and frequency of transfusions were compared and analyzed between the two cohorts. (using the Student's t-test) RESULTS: The implementation of the Quantra resulted in a change in the pattern of blood product utilization leading to a demonstrated decrease in the amount of blood products transfused and the associated costs. The amount of FFP transfused was significantly decreased by 97% (P = 0.0004), whereas cryoprecipitate decreased by 67% (P = 0.3134), platelets decreased by 26% (P = 0.4879), and packed red blood cells decreased by 10% (P = 0.8027) however these trends did not reach statistical significance. The acquisition cost of blood products decreased by 41% for total savings of roughly $40,682. CONCLUSIONS: Use of the Quantra QPlus System has the potential to improve patient blood management and decrease costs. STUDY REGISTERED AT CLINICALTRIALS.GOV: NCT05501730.

Transcatheter Aortic Valve Replacement in Patients With Symptomatic Severe Aortic Stenosis and Prior External Chest Radiation.

BACKGROUND/PURPOSE: Surgical aortic valve replacement (SAVR) in patients with symptomatic severe aortic stenosis (AS) and prior chest radiation is associated with poor outcomes in comparison with patients without prior radiation. Our objective was to compare clinical outcomes of patients with and without prior chest radiation undergoing transcatheter aortic valve replacement (TAVR) for symptomatic severe AS. METHODS/MATERIALS: Between January 2003 and January 2017, 1150 patients underwent TAVR at our institution. Of these, 44 had prior chest radiation. Baseline demographic and clinical characteristics, procedural details, and clinical outcomes were prospectively collected. RESULTS: Patients with prior chest radiation were younger, 76 ±â€¯13 years, compared with those without prior chest radiation, 82 ±â€¯8 years (p = 0.002). Median Society of Thoracic Surgeons score for chest radiation patients was 7 ±â€¯4, compared to 8 ±â€¯5 in those without prior radiation. Despite higher prevalence of complete heart block, there was no significant difference between the 2 groups with regard to the need for permanent pacemaker implantation. There was a trend toward longer length of intensive care unit stay in chest radiation patients, but there was no significant difference in 30-day or 1-year mortality. CONCLUSIONS: Thus, TAVR appears to be a safe treatment option in the short and medium term for patients with symptomatic severe AS and prior chest radiation.

Right Coronary Artery and Left Anterior Descending Artery Occlusion after Aortic Valve Replacement.

Coronary artery stenosis is a potentially life-threatening complication after heart valve surgery. The details are presented of a patient with unobstructed coronary arteries, who underwent routine aortic valve replacement and developed dissection of the right coronary artery (RCA) on the third postoperative day, and occlusion of the left anterior descending (LAD) artery one month after surgery. This complication required prompt clinical recognition and diagnosis by repeat coronary angiography, and a rapid intervention with coronary artery bypass grafting or with angioplasty and stenting.

Complete Resolution of Wegener's Granulomatosis Lung Granuloma After Aortic Root Replacement.

Wegner's granulomatosis (WG) is an autoimmune systemic vasculitis that results in necrotizing granulomas. We report a WG patient with a lung granuloma and aortic root dilatation, who underwent aortic root replacement on cardiopulmonary bypass (CPB). Intraoperatively, the patient suffered an aortic dissection, which was repaired immediately under deep hypothermic circulatory arrest (DHCA). Follow-up imaging showed complete granuloma resolution, despite absence of immunosuppressive therapy. Immune stimulation following CPB is well described; here, the opposite was observed and DHCA effects are discussed.

A systematic review of the safety and efficacy of distal coronary artery anastomotic devices in MIDCAB and TECAB surgery.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) techniques may improve recovery and reduce hospital stay following coronary artery bypass surgery (CABG). However, working in a limited space with indirect visualisation would greatly benefit from a simple, high-quality and reproducible automated distal anastomotic method. Several devices have been developed; however, their uptake has been limited due to uncertainty around their impact on patient outcomes. METHODS: A systematic review of the literature identified six studies, incorporating 139 subjects undergoing MIDCAB or TECAB surgery using a distal anastomotic device. RESULTS: The overall 30-day mortality was 0.7% (1/137). No cardiac specific mortality was observed. For each outcome of perioperative myocardial infarction (MI), postoperative stroke and haemorrhage, only a single event was observed for each (n=1/136, 1/138 and 1/136, respectively). The overall device failure rates were low, with the use of additional sutures only reported in a single case with the Magnetic Vascular Port (MVP) device. Anastomotic time ranged from a mean of 3.32 minutes with the MVP device to 20 minutes with the C-Port device. CONCLUSIONS: These results demonstrate the overall acceptable early outcomes of distal anastomotic devices for use in minimally invasive coronary bypass surgery. Future research should focus on designing adequately powered, comparative, randomised trials, focusing on major adverse cardiac and cerebrovascular events (MACCE) outcomes in both the short and long-term, with clear case-by-case reasons for device failure and a comparison of anastomotic times. In this way, we may determine whether such devices will facilitate the minimal access and robotic coronary procedures of the future.

Management of a left atrial intramural hematoma after percutaneous intervention.

Left atrial intramural hematoma is a rare complication of percutaneous intervention. We report the case of a 69-year-old man with recurrent angina after CABG 19 years ago who was admitted for percutaneous intervention. After an attempt to recanalize the native circumflex artery and the vein graft, he had a cardiac arrest and was resuscitated successfully. Transesophageal echocardiography showed a large expanding hematoma within the left atrial wall causing obstruction of the mitral valve and compressing the right atrium from across the septum. An emergency thoracotomy was performed and with transesophageal echocardiography guidance and left atrial intramural hematoma was drained successfully.

Surgical revascularisation of the acute coronary artery syndrome.

Although the European Society of Cardiology and American Heart Association/American College of Cardiology guidelines provide some suggestions regarding coronary artery bypass grafting (CABG) in the acute coronary syndrome (ACS), the exact indications for surgery in this diverse spectrum of disease requires further clarification. ACS may present with different scenarios, from NSTEMI to cardiogenic shock. Primary percutaneous coronary intervention is the first-line treatment in most cases; however, there may be a subgroup of ACS patients in whom CABG may be preferred over percutaneous coronary intervention, particularly in the setting of triple vessel disease. CABG can be performed with reasonably low mortality and excellent outcome, particularly in the case of NSTEMI. Furthermore, off-pump or on-pump beating heart techniques may further improve the feasibility and outcomes of CABG. Where possible every patient should be immediately referred to a tertiary centre and evaluated by the 'heart team'. Here risk stratification and intervention according to the expert consensus may be rapidly implemented in order to improve both morbidity and mortality.

Contained rupture of the sinus of valsalva associated with infective endocarditis and untreated congenital ventricular septal defect.

Isolated sinus of Valsalva (SV) aneurysm is a rare condition that may arise in patients with congenital ventricular septal defects (VSD). Small VSDs are often left untreated because of high rate of spontaneous closure. However, complications such as aortic regurgitation and infective endocarditis may occur as complications of small VSDs. We present the case of a 19-year-old man with a history of VSD, who presented with Staphylococcus aureus endocarditis and a contained rupture of the SV into the right ventricle, which was successfully treated. In the light of this case, we believe that even small VSDs should be assessed regularly and treated before such drastic complications occur.

Does coronary artery bypass grafting improve quality of life in elderly patients?

Traditional outcome measures such as long-term mortality may be of less value than symptomatic improvement in elderly patients undergoing coronary artery bypass grafting (CABG). In this systematic review, we analyse health-related quality of life (HRQOL) as a marker of outcome after CABG. We aimed to assess the role of HRQOL tools in making recommendations for elderly patients undergoing surgery, where symptomatic and quality-of-life improvement may often be the key indications for intervention. Twenty-three studies, encompassing 4793 patients were included. Overall, elderly patients underwent CABG at reasonably low risk. Our findings, therefore, support the conclusion that performing CABG in the elderly may be associated with significant improvements in HRQOL. In order to overcome previous methodological limitations, future work must clearly define and stringently follow-up this elderly population, to develop a more robust, sensitive and specialty-specific HRQOL tool.

Can lungs be taken for transplantation from donors with a significant smoking history?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Can lungs be taken for transplantation from donors with a significant smoking history?'. Five papers were found using the reported search that represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These studies compared the outcome and survival between patients who receive lungs from smokers with those receiving non-smoker lungs. None of these studies were randomized controlled trials. They retrospectively analysed a cohort of patients undergoing lung transplantation for the past 10 years. These studies showed worse outcomes in the early postoperative period, such as longer intensive care unit stay, longer ventilation time and higher early postoperative mortality, with lungs harvested from smokers. Two studies also demonstrated a worse long-term outcome in recipients of lungs from smokers, whereas the other two showed worse results during the early postoperative period only. These latter two studies reported similar survival rates after 3 months and up to 3 years in recipients receiving smoker vs non-smoker lungs. One study, however, showed a better 5-year survival with smoker lungs compared with non-smokers, although in this study, lungs from heavy smokers showed the worse outcome. Despite the difference in long-term results and outcome reported by these authors, all of these studies unanimously indicate that lungs from smokers should not be rejected, as survival in these patients receiving smoker lungs is still significantly higher in 3 and 5 years compared with that in those who remain on the transplant waiting list. In conclusion, the current evidence in the literature suggests that lungs from smokers can be used for transplantation. Patients should, however, be fully informed of the risks involved with these lungs and the worse outcome compared with those receiving non-smoker lungs.

Are frozen sections of mediastinoscopy samples as effective as formal paraffin assessment of mediastinoscopy samples for a decision on a combined mediastinoscopy plus lobectomy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Are frozen sections of mediastinoscopy samples as effective as formal paraffin assessment of mediastinoscopy samples for a decision on a same-day lobectomy?'. Five papers were found using the reported search that represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These studies compared the efficacy and accuracy of frozen sections (FSs) from mediastinal lymph nodes for staging of patients with lung cancer to determine whether a combined procedure can be planned based on these results and to proceed to thoracotomy and lung resection in cases of negative mediastinal nodes diagnosed by FS. These studies unanimously showed that FS of mediastinal nodes are as accurate as permanent section results and definite histology diagnosis with a sensitivity of >94% and specificity of 100% with no false-positive results. They also confirmed that even in benign lung conditions and other malignancies of the mediastinum, the results of FS are compared with the histology of the node. Based on the current reports, a combined procedure (staging mediastinal nodes by FS and planning for thoracotomy or abandoning thoracotomy) is a safe approach to treat non-small-cell lung cancer (NSCLC). From the patients' point of view, this approach is superior to the staged procedure (mediastinoscopy followed by lung resection at a later date based on the histology of mediastinal nodes) due to single hospitalization and anaesthesia, however whether it is cost effective or not is debatable. It is also labour-intensive and operator-dependent. In conclusion, the current evidence in the literature suggests that a combined procedure of mediastinal node FS followed by lung resection can be a safe alternative to a staged approach to this disease.

Videothoracoscopic repair of diaphragm and pleurectomy/abrasion in patients with catamenial pneumothorax: a 9-year experience.

BACKGROUND: Catamenial pneumothorax (CP) is a cause of recurrent pneumothorax in women of child-bearing age. Surgical treatment has been associated with high recurrence rates. We report our experience with a totally videothoracoscopic approach involving diaphragmatic repair, pleurectomy/abrasion, and hormonal treatment in patients with proven CP. METHODS: This was a retrospective study of all patients with proven CP operated on by a single surgeon using a videothoracoscopic approach, diaphragmatic repair, and pleurectomy/pleural abrasion. A polytetrafluoroethylene mesh was used to cover the diaphragm in patients with pores or fenestrations. All patients received hormone therapy for 6 to 12 months postoperatively and were followed up to assess complications and recurrence. RESULTS: Twelve patients were identified as having CP. All patients except one had suffered right sided pneumothorax only. One patient also had a history of left-sided pneumothorax managed conservatively at another institution. All cases except one underwent a primary operation. One patient had previously had videothoracoscopic pleurodesis without diaphragm repair at another center. In all cases, findings typical of CP were identified within the pleural cavity, mainly on the diaphragm. In three patients, no diaphragmatic pores or fenestrations were noted. There were no postoperative complications and no mortality. Median follow-up was 45.8 28.6 months. One patient suffered a single episode of recurrence before starting hormonal therapy, treated conservatively. CONCLUSIONS: A totally videothoracoscopic approach to CP including diaphragmatic cover with a mesh and pleurectomy/pleural abrasion is feasible, safe, and highly effective. Routine hormonal treatment (gonadotropin-releasing hormone analog) may also help reduce recurrences.

Is coronary artery bypass grafting an acceptable alternative to myotomy for the treatment of myocardial bridging?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Is CABG an effective alternative for the treatment of myocardial bridging?' Altogether, only six papers were identified using the reported search that represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers are tabulated; these studies reported the outcome of myotomy and coronary artery bypass grafting (CABG) for myocardial bridging. All of these studies were retrospective reports of the results of surgical intervention in patients with myocardial bridging. They showed that the incidence of myocardial bridging was less than 1-1.5% in patients with angina requiring angiography, and 7-9% of these patients had refractory angina despite medical treatment and required surgery. The evidence on the treatment of this congenital condition that mainly affects the middle segment of left anterior descending artery is limited, and there are no treatment guidelines currently available. Stenting of the tunnelled segment has shown high failure rates in approximately half of the cases. Current evidence in the literature suggests that surgery is the mainstay treatment for myocardial bridging. Surgery is performed either as supra-arterial myotomy and de-roofing of the muscle bands on- or off-pump, or as coronary artery bypass grafting of the affected coronary artery beyond the tunnelled segment. Although no mortality was reported with either of these operations, surgical myotomy on deep and extensive myocardial bridges carries the risk of entering the right ventricle, bleeding and aneurysm formation. In addition, in a small percentage of the patients undergoing myotomy, angina recurred. Despite the possibility of competitive flow in the native coronary artery after CABG for myocardial bridging, we did not identify any evidence demonstrating graft occlusion after CABG for myocardial bridging. In conclusion, in extensive and deep myocardial bridgings, CABG may be the treatment of choice that carries low risk, limited complications and excellent symptomatic relief.