Case report: Eighteen nails gun shots in the head, thorax and abdomen but still conscious at admission: A challenging patient for the cardiac surgeon!

We report an unusual case of multiple penetrating cerebral, cardiac and abdominal injuries following a suicidal attempt using a nail gun. Successful treatment required several emergency procedures and resulted from a wise interdisciplinary management and timing of surgery.

Intracardiac bone cement embolism resulting in ventricular perforation: an unusual cause of sudden chest pain.

Leakage of bone cement is a known complication after percutaneous kyphoplasty. In rare cases, bone cement can reach the venous system and cause life-threatening embolism. We present the case of a 73-year-old male, who was admitted to our hospital with new-onset chest pain and dyspnoea. He had a history of percutaneous kyphoplasty. Multimodal imaging showed intracardiac cement embolism in the right ventricle with penetration of the interventricular septum and perforation of the apex. The bone cement was successfully removed during open cardiac surgery.

Aortic wrapping is life-saving in high-risk acute aortic dissection and intramural haematoma.

Aortic wrapping is a controversial repair in patients presenting with acute type A aortic dissection or intramural haematoma, but this method may be a potential alternative to medical treatment or conventional repair in patients aged >80 years and in those presenting with prohibitive co-morbidities such as stroke, circulatory collapse, full oral anticoagulation with the last generation drugs. We report on 5 high-risk and/or patients over 80 years who received external aortic wrapping with or without cardiopulmonary bypass during the last 18 months. All survived the procedure and could be extubated early postoperatively. No patient remained on the intensive care longer than 2 days and all were discharged without additional complications. Postoperative radiological control was acceptable and no patient had any new aortic event up to 18 months postoperatively.

Corrigendum: Robotic Cardiac Surgery in Europe: Status 2020.

[This corrects the article DOI: 10.3389/fcvm.2021.827515.].

Sexual Quality of Life in Men <60 Years Old after Coronary Bypass Surgery.

PURPOSE: To explore the effect of undergoing coronary artery bypass grafting on sexual quality of life as an integral part of patients' health-related quality of life. METHODS: This cross-sectional study included 265 men ages 18 to 60 years (median age, 55) who underwent coronary artery bypass grafting 1 to 5 years before the study. Standardized questionnaires were implemented to evaluate participant pre- and postoperative sexual quality of life and the quality of counseling provided to patients. RESULTS: Among the patients, 77% were in a steady relationship. The general health score was 5.5 ± 2.8 (mean ± standard deviation) preoperatively and 6 ± 2.2 at follow-up (P = .01). No sexual counseling was given to 83% and 77% of the patients pre- and postoperatively, respectively. The mean sexual satisfaction score dropped from 6.5 ± 2.6 preoperatively to 4.7 ± 3 postoperatively (P < .001). The decline in sexual intercourse frequency and masturbation frequency was significant (P < .001 and P = .006, respectively). Linear regression analysis showed that general health status (P = .008), higher-quality counseling (P = .027), and preoperative sexual quality of life (P < .001) correlated positively with sexual quality of life, whereas sternal pain (P < .001), erectile dysfunction (P < .001), and fear of excessive cardiac burden (P < .001) correlated negatively. CONCLUSIONS: Middle-aged men experience decreased sexual quality of life after coronary artery bypass grafting. Preoperative sexual quality of life, general health, and higher-quality counseling positively affect postoperative sexual quality of life, whereas sternal pain, fear, and erectile dysfunction play a negative role. Pre- and postoperative care guidelines should be improved. Further prospective large cohort studies for males and females are required.

The effect of hemoadsorption on rivaroxaban blood plasma concentration in emergency cardiac surgery.

Hemoadsorption was used in a 59-year-old patient with an acute type A aortic dissection, who was on rivaroxaban and dual antiplatelet therapy with clopidogrel and acetylsalicylic acid. Our aim was to expeditiously remove rivaroxaban preoperatively. After 8 h of hemoadsorption, the rivaroxaban blood plasma concentration (RBPC) did not decrease below 42.1 µg/l. Intraoperatively, hemoadsorption was repeated during extracorporeal circulation. Sixteen hours after surgery and a total of 13 h of hemoadsorption, the RBPC was 40.1 µg/l. Thereafter, the RBPC spontaneously decreased to 24.7 µg/l within 14 h. In our patient, hemoadsorption may have enhanced rivaroxaban removal at higher RBPC (cutoff value 40-50 µg/l). At lower RBPC, the removal of rivaroxaban may depend solely on the natural drug elimination process. The evolution of the RBPC under hemoadsorption in vivo warrants a thorough investigation. Further clinical studies are required to assess the effectiveness and limitations of hemoadsorption to preclude a fatal bleeding event in patients with rivaroxaban in need of major emergency surgery.

Robotic Cardiac Surgery in Europe: Status 2020.

BACKGROUND: European surgeons were the first worldwide to use robotic techniques in cardiac surgery and major steps in procedure development were taken in Europe. After a hype in the early 2000s case numbers decreased but due to technological improvements renewed interest can be noted. We assessed the current activities and outcomes in robotically assisted cardiac surgery on the European continent. METHODS: Data were collected in an international anonymized registry of 26 European centers with a robotic cardiac surgery program. RESULTS: During a 4-year period (2016-2019), 2,563 procedures were carried out [30.0% female, 58.5 (15.4) years old, EuroSCORE II 1.56 (1.74)], including robotically assisted coronary bypass grafting (n = 1266, 49.4%), robotic mitral or tricuspid valve surgery (n = 945, 36.9%), isolated atrial septal defect closure (n = 225, 8.8%), left atrial myxoma resection (n = 54, 2.1%), and other procedures (n = 73, 2.8%). The number of procedures doubled during the study period (from n = 435 in 2016 to n = 923 in 2019). The mean cardiopulmonary bypass time in pump assisted cases was 148.6 (63.5) min and the myocardial ischemic time was 88.7 (46.1) min. Conversion to larger thoracic incisions was required in 56 cases (2.2%). Perioperative rates of revision for bleeding, stroke, and mortality were 56 (2.2%), 6 (0.2 %), and 27 (1.1%), respectively. Median postoperative hospital length of stay was 6.6 (6.6) days. CONCLUSION: Robotic cardiac surgery case numbers in Europe are growing fast, including a large spectrum of procedures. Conversion rates are low and clinical outcomes are favorable, indicating safe conduct of these high-tech minimally invasive procedures.

Conservative Treatment of Unicuspid Aortic Valve with Newly Diagnosed Type A Aortic Dissection.

We present a case of a 36-year-old male patient with known arthrogryposis multiplex congenita and an associated unicuspid aortic valve. The patient later developed a significant aneurysm of the ascending aorta, however refused surgical intervention and missed follow-up appointments for 5 years. During an urgent, general practitioner-initiated transthoracic echocardiography follow-up, a chronic type A aortic dissection was diagnosed as a result of progressive aortic dilatation. Due to the stationary pressure gradients and non-progressive leaflet fibrosis, a conservative approach for to the unicuspid aortic valve was chosen, combined with replacement of the ascending aorta and partial replacement of the aortic arch.

Conservative treatment of unicuspid aortic valve with newly diagnosed type a aortic dissection

Abstract We present a case of a 36-year-old male patient with known arthrogryposis multiplex congenita and an associated unicuspid aortic valve. The patient later developed a significant aneurysm of the ascending aorta, however refused surgical intervention and missed follow-up appointments for 5 years. During an urgent, general practitioner-initiated transthoracic echocardiography follow-up, a chronic type A aortic dissection was diagnosed as a result of progressive aortic dilatation. Due to the stationary pressure gradients and non-progressive leaflet fibrosis, a conservative approach for to the unicuspid aortic valve was chosen, combined with replacement of the ascending aorta and partial replacement of the aortic arch.

Coronary computed tomography angiography for heart team decision-making in multivessel coronary artery disease.

Aims: Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography. Methods and results: Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen's kappa 0.82, 95% confidence interval 0.74-0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients. Conclusion: In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information. Trial registration number: NCT02813473.

Anastomotic leak after surgical repair of type A aortic dissection - prevalence and consequences in midterm follow-up.

BACKGROUND: This study reports the mid-term prevalence and therapeutic consequences of anastomotic leaks after surgery for Stanford type A aortic dissections. PATIENTS AND METHODS: From July 2007 to July 2013, 93 patients survived surgery for acute type A dissections at our center and underwent a standardized follow-up. The pre-, peri-, and postoperative as well as the midterm results were collected prospectively. Follow-up computed tomography (CT) imaging was performed 7 days, 3, and 12 months after surgery, and yearly thereafter, to assess the presence or progression of anastomotic leaks at the aorto-prosthesis anastomotic sites. RESULTS: The mean follow-up was 4 years (1534 ± 724 days). Follow-up CT revealed anastomotic leaks in 4 patients (4.3 %). All leaks developed during midterm follow-up and half of them did not increase with time. Two patients required redo surgery for an increase in periaortic extravasation and compression of neighboring structures. Further analysis was not able to reveal independent risk factors for development or deterioration of leaks. CONCLUSIONS: Anastomotic leaks after surgery for Stanford Type A aortic dissection can develop in midterm follow-up, even after initially excellent results. Meticulous follow-up is mandatory to detect possible deterioration and a need for redo surgery.

Transapical aortic stenting: an initial case series.

AIMS: The standard approach for thoracic endovascular aortic repair (TEVAR) is transfemoral; however, calcifications and tortuosity of the access vessels might be so extensive as to increase the operative risk markedly or preclude the procedure. This study evaluates the transapical approach as an alternative route for TEVAR in such patients. METHODS AND RESULTS: From June 2011 to July 2013, the institution's interdisciplinary board for aortic diseases initially denied TEVAR for eight patients with thoracic aortic pathology due to extensive calcification and tortuosity of the distal vessels. The transapical approach was suggested and approved by the board. All procedures were performed in a hybrid operating room through a left mini-thoracotomy. The stent grafts were implanted in either the proximal descending or the ascending aorta. The deployment was performed under rapid ventricular pacing. Procedural success was 100%. There were no intraoperative complications. One patient needed re-exploration. There was no 30-day mortality. In follow-up, one patient suffered type 1B endoleak, which required surgery after one year. CONCLUSIONS: The transapical approach for TEVAR (TaTEVAR) is a feasible option for patients with distal aorta/iliac vessels unsuitable for transfemoral access. It might be even more beneficial for TEVAR of the ascending aorta.

Off-Pump Debranching and Thoracic Endovascular Aortic Repair for Aortic Arch Pathology.

OBJECTIVE: This study aimed to simplify an until-now complex procedure for the treatment of proximal aortic arch pathology (zones 0 and 1), where a deep hypothermic circulatory arrest even with selective cerebral perfusion is still a high-risk procedure with accompanying splanchnic and spinal cord ischemia. METHODS: From June 2012 until March 2013, 106 patients underwent aortic surgery in our institution, of whom, 20 patients underwent aortic arch surgery. Of the 20 patients, 7 with multiple comorbidities and a high operative risk and no other indication for a cardiopulmonary bypass were selected to undergo an off-pump aortic arch debranching and thoracic endovascular aortic repair: 4 patients had chronic dissections, and 3 patients had arch aneurysms. The procedure was performed through median sternotomy. The supraaortic branches were rerouted to the ascending aorta, and this process was followed by thoracic endovascular aortic repair of the aortic arch and proximal descending aorta. Transaortic antegrade stenting was performed in 5 cases. Cerebral protection and perfusion monitoring were achieved by biradial pressure monitoring, electroencephalogram, and online transcranial duplex sonography. The preoperative, operative, and postoperative data were collected and analyzed retrospectively. RESULTS: All procedures were successful. There were no conversions to cardiopulmonary bypass support. The mean operative time was 184 ± 24 minutes. Postoperatively, there was 1 rethoracotomy for bleeding and 1 cerebrovascular insult. The 30-day mortality was 1 patient. CONCLUSIONS: Off-pump aortic debranching with arch stenting is a reproducible procedure that could be favorable in certain situations, such as in patients with a higher operative risk profile, thereby reducing the risks associated with deep hypothermic circulatory arrest and also yielding favorable outcomes, even in an older patient cohort with more comorbidities.

Sutureless Aortic Valve Replacement International Registry (SU-AVR-IR): design and rationale from the International Valvular Surgery Study Group (IVSSG).

BACKGROUND: Sutureless aortic valve replacement (SU-AVR) is an innovative approach which shortens cardiopulmonary bypass and cross-clamp durations and may facilitate minimally invasive approach. Evidence outlining its safety, efficacy, hemodynamic profile and potential complications is replete with small-volume observational studies and few comparative publications. METHODS: Minimally invasive aortic valve surgery and high-volume SU-AVR replacement centers were contacted for recruitment into a global collaborative coalition dedicated to sutureless valve research. A Research Steering Committee was formulated to direct research and support the mission of providing registry evidence warranted for SU-AVR. RESULTS: The International Valvular Surgery Study Group (IVSSG) was formed under the auspices of the Research Steering Committee, comprised of 36 expert valvular surgeons from 27 major centers across the globe. IVSSG Sutureless Projects currently proceeding include the Retrospective and Prospective Phases of the SU-AVR International Registry (SU-AVR-IR). CONCLUSIONS: The global pooling of data by the IVSSG Sutureless Projects will provide required robust clinical evidence on the safety, efficacy and hemodynamic outcomes of SU-AVR.

Transapical endovascular stenting of penetrating atherosclerotic ulcer of ascending aorta.

A 71-year-old woman presented with acute chest pain and was admitted at our institution. Computed tomography revealed a penetrating atherosclerotic ulcer in the ascending aorta with extensive intramural hematoma. A transapical endovascular stenting was successfully performed. Computed tomography at a 6-month follow-up visit revealed a type I endoleak, which was restented through the same approach. Despite initial satisfactory results, follow-up revealed a persistent endoleak, so that a high-risk open surgical repair was required. Surgical replacement of the ascending aorta was successfully performed without postoperative neurologic deficit.

Protective effect of previous cardiac operation: survival of contained right ventricular rupture.

Although cardiac contusions are common, cardiac rupture is an uncommon sequela of blunt chest trauma. The mortality rate associated with cardiac rupture is very high, and patients usually do not survive long enough to reach the hospital. We report a 66-year-old man with a history of coronary artery bypass grafting 15 years previously, who was involved in a traffic accident and experienced multiple trauma, including a small contained rupture of the right ventricular outflow tract. He survived, and a false aneurysm developed at the site of the rupture within the next 6 months. The patient then underwent a cardiac operation, and the aneurysm was successfully resected. The intraoperative and postoperative courses were uneventful. In this case, the previous cardiac operation with the resulting pericardial adhesions proved to be lifesaving.

Transapical endovascular deployment of a stent-graft in the thoracic descending aorta.

We report the case of a 74-year-old man with a large aneurysm (60 mm) of the descending thoracic aorta. Because of severe calcification and kinking of the iliac vessels, the expected access-related complication during the endovascular repair urged us to search for an alternative strategy. Having good experience with transcatheter aortic valve implantation, we thought that the transapical approach may be the best option in this case. The stent-graft was successfully deployed through the heart apex without any complications. The postoperative imaging showed an excellent result.