Management of Severe Bilateral Symptomatic Internal Carotid Artery Stenosis: Case Report and Literature Review.

Multiple strategies for tandem severe carotid artery stenosis are reported: bilateral carotid artery endarterectomy (CEA), bilateral carotid artery stenting (CAS), and hybrid procedures (CEA and CAS). The management is controversial, considering the reported high risk of periprocedural stroke, hemodynamic distress, and cerebral hyperperfusion syndrome. We present the case of a 64-year-old patient with severe symptomatic bilateral internal carotid artery stenosis (95% stenosis on the left internal carotid artery with recent ipsilateral watershed anterior cerebral artery-medial cerebral artery (ACA-MCA) and medial cerebral artery-posterior cerebral artery (MCA-PCA) ischemic strokes and 90% stenosis on the right internal carotid artery with chronic ipsilateral frontal ischemic stroke) managed successfully with staged CEA within a 3-day interval. The patient had a history of coronary angioplasty and stenting. Strategies for brain protection included shunt placement after the evaluation of carotid stump pressure, internal carotid backflow, and near-infrared spectroscopy. A collagen and silver-coated polyester patch was used to complete the endarterectomy using a 6.0 polypropylene continuous suture in both instances. Management also included neurological consults after extubation, dual antiplatelet therapy, head CT between the two surgeries, myocardial ischemia monitoring, and general anesthesia. Staged CEA with a small time interval between surgeries can be an option to treat tandem symptomatic carotid artery stenosis in highly selected patients. The decision should be tailored according to the patient's characteristics and should also be made by a cardiology specialist, a neurology specialist, and an anesthesia and intensive care physician.

Investigation of the Association between Bilateral Selective Anterograde Cerebral Perfusion and Postoperative Ischemic Stroke in Obese Patients with Emergency Surgery for Acute Type A Aortic Dissection.

Background and objectives: The relationship between cerebral perfusion and new postoperative ischemic stroke in obese patients is not well defined. The aim of this study was to investigate the association between selective bilateral anterograde cerebral perfusion and new postoperative ischemic stroke in obese patients with emergency surgery for acute type A aortic dissection. Materials and methods: A total of 292 patients with emergency surgery for acute type A aortic dissection were included in this study. Patients with hemorrhagic stroke or ischemic stroke with severe neurological dysfunction at admission that were not candidates for surgery; patients who died in the first 48 h after intensive care admission and patients with incomplete medical records were excluded. Results: The mean age was 59.42 ± 10.68 years and the mean Euroscore was 9.12 ± 1.63. Obesity was present in 76.4%, the incidence of new postoperative ischemic stroke was 27.5%, and the postoperative mortality rate was 26.7%. The mean cardiopulmonary bypass time was 206.81 ± 75.48 min, the aortic cross-clamp time was 118.2 ± 46.42 min, and 90% of cases required cerebral perfusion. The mean cerebral perfusion time was 30.8 ± 24.41 min. Obese patients had a higher frequency of in-hospital death (p = 0.009), smoking (p = 0.036), hypertension (p = 0.023), left common carotid artery dissection (p < 0.001), right common carotid artery dissection (p = 0.029), femoral artery cannulation (p = 0.026), aortic root replacement (p = 0.009), aortic valve replacement (p = 0.005) and early reintervention for bleeding (p = 0.004). Using logistic regression, selective bilateral anterograde cerebral perfusion over 40 min in obese patients was independently associated with new postoperative ischemic stroke (OR = 2.35; 95%CI = 1.36-4.86; p = 0.021). Conclusions: A patient-tailored strategy for cerebral perfusion should be considered in obese patients, considering the high atheromatous burden of the supra-aortic vessels in these patients and the potential risk of atheromatous embolization associated with this technique.

Management of a Rare Case of Multiple Coronary Artery Fistulas Associated with Ascending Aortic and Root Aneurysm: Case Report and Review of Literature.

Coronary artery fistulas draining into the left ventricle is a rare finding. They can be associated with other congenital cardiac anomalies like ventricular septal defect or tetralogy of Fallot. While most of them are asymptomatic, they can lead to severe cardiac complications like infective endocarditis, heart failure, or myocardial ischemia. Symptomatic coronary artery fistulas can be managed surgically or percutaneously. We present a case of a 61-year-old male patient with both left anterior descending artery and right coronary artery fistulas draining into the left ventricle associated with ascending aorta and root aneurysm. Preoperative assessment for myocardial ischemia and the size and location of the fistulas was performed. The echocardiography stress test was negative. Surgery consisted of replacement of the ascending aorta and reconstruction of the noncoronary sinus with a Dacron patch with aortic valve preservation and no intervention for the coronary artery fistulas. The surgical strategy was adapted for cardioplegia administration to compensate for the volume of coronary blood drained into the left ventricle and for better protection of the distal myocardium.

Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries.

BACKGROUND: Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event". METHODS: We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy. RESULTS: This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis. CONCLUSIONS: We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.

Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection-Single Centre Experience.

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1-2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25-28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/- 56.874 min, the mean aortic cross-clamp time was 114.775 +/- 34.602 min, and the mean cerebral perfusion time was 37.837 +/- 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418-9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25-28 °C.

Telemedicine for Optimizing Secondary Prevention in Coronary Artery Bypass Grafting Patients during COVID-19 Pandemic.

(1) Background: The COVID-19 pandemic has introduced a major disruption to the delivery of secondary prevention measures in patients with established atherosclerotic cardiovascular disease (CVD). It required a rapid and widespread adoption of new medical services, including the use of telemedicine. This study aimed to examine the impact of COVID-19 on secondary prevention in patients with coronary artery bypass grafting (CABG) and to evaluate the effectiveness of the telemedicine application for the implementation of lifestyle change measures, remote monitoring, and treatment regimen adjustment; (2) Methods: This prospective study on 194 CABG patients evaluated three consecutive years between 2019 and 2022 in the pre-pandemic period by face-to-face visits and during the pandemic by teleconsultations or hybrid follow-up. Variables of interest were compared between four periods: pre-pandemic-pre-P (1 March 2019-29 February 2020), lockdown-Lock (1 March-31 August 2020), restrictive-pandemic-Restr-P (1 September 2020-28 February 2021), and relaxed-pandemic-Rel-P (1 March 2021-1 March 2022). (3) Results: The average values of the lipidogram, blood sugar, and uric acid increased during Lock and Restr-P, but, through the use of teleprevention, they returned to the pre-pandemic level or even below this level. The exception was blood sugar, which remained high in Rel-P. The number of newly diagnosed patients with diabetes also increased, with most of them having moderate forms of COVID. During Lock and Res-P, the percentage of obese, smoking, or hypertensive patients increased, but, through the use of teleprevention, we managed to reduce it, although it remained slightly higher than the pre-pandemic level. Physical activity decreased in the first year of the pandemic, but, in Rel-P, CABG patients became more active than before the pandemic (4) Conclusions: The use of telemedicine for cardiovascular secondary prevention allowed us to not only continue seeing CABG patients but, also, to adjust their medication and to expand cardiovascular preventive counseling and testing with favorable results, especially during the second year of the pandemic.

Spontaneous Pulmonary Hematoma: Case Report of a Giant Post-COVID-19 Hematoma and Literature Review.

Pulmonary hematomas are a rare pathology. Although they are usually reported post-traumatically, there are also spontaneous forms in pulmonary pathologies or during drug therapy. In these spontaneous entities, primitive forms are rarely described, although the contributory local pulmonary pathological terrain or a specific associated medication has not yet been identified. We present the case of a patient who developed a giant pulmonary hematoma that appeared spontaneously during recovery from COVID-19 infection. It appeared in one of the two bullae-like cystic lung lesions developed during secondary COVID-19 infection. The clinical impact was major, with hypotension and anemia being observed, requiring hemodynamic support and the adjustment of drug therapy. The clinical course was favorable, with a quasi-complete resolution of both the hematoma and a second cystic lesion being observable at 8 months by pulmonary remodeling. Spontaneous pulmonary hematomas may constitute a pathological entity associated with a post-COVID-19 remodeling process of the lung and the related anticoagulant treatment, which should be recognized, especially in the actual COVID-19 pandemic or in the widespread use of anticoagulant treatment. Conservative treatment is the method of choice, even in giant lung forms.

Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection.

Background and Objectives: Postoperative neurological complications (NCs) are an important cause of mortality in patients with acute type A aortic dissection (ATAAD). The aim of the study was to determine the association between intraoperative risk factors and newly developed postoperative NCs in patients after emergency surgery for ATAAD. Materials and Methods: A total of 203 patients requiring emergency surgery were included in the study. Patients with preoperative neurological dysfunction, deceased on the operating table or within the first 48 h after intensive care admission, with uncertain postoperative neurologic status or with incomplete records were excluded. Results: Mean age was 57.61 ± 12.27 years. Hyperlipidemia was the most frequent comorbidity (69%). A bicuspid aortic valve was present in 12.8% of cases, severe acute aortic regurgitation was present in 29.1% of patients, and cardiac tamponade was present in 27.1% of cases. The innominate artery was the most frequently dissected supra-aortic artery in 27.1% of cases. In 65% of cases, the primary entry tear was at the level of the ascending aorta. The incidence of newly developed postoperative NCs was 39.4%. The most common surgical technique performed was supra-coronary ascending aorta and hemiarch replacement, in 53.2% of patients. Using logistic regression, cardiopulmonary bypass time (OR = 1.01; 95% CI = 1.01-1.02; p < 0.001), aortic cross-clamp time over 3 h (OR = 2.71, 95% CI = 1.43-5.14, p = 0.002) and cerebral perfusion time (OR = 1.02; 95% CI = 1.002-1.03; p = 0.027) were independently associated with newly developed postoperative NCs. Conclusions: Based on the results of the study, all efforts should be made to reduce operative times. Using a simple surgical technique, like the supra-coronary ascending aorta and hemiarch technique, whenever possible, and using a simpler technique for cerebral perfusion like unilateral cerebral perfusion via the right axillary artery, could reduce operating times.

Delayed Surgical Management of Acute Type A Aortic Dissection in a Patient with Recent COVID-19 Infection and Post-COVID-19 Bronchopneumonia-Case Report and Review of Literature.

Ever since it was first described in 1760, acute type A aortic dissection has created difficulties in its management. The recent COVID-19 pandemic revealed that extrapulmonary manifestations of this condition may occur, and recent reports suggested that aortic dissection may be amongst them since it shares a common physiopathology, that is, hyper-inflammatory syndrome. Cardiac surgery with cardiopulmonary bypass in the setting of COVID-19-positive patients carries a high risk of postoperative respiratory failure. While the vast majority accept that management of type A aortic dissection requires urgent surgery and central aortic therapy, there are some reports that advocate for delaying surgery. In this situation, the risk of aortic rupture must be balanced with the possible benefits of delaying urgent surgery. We present a case of acute type A dissection with COVID-19-associated bronchopneumonia successfully managed after delaying surgery for 6 days.

Chain pain following cardiac surgery in a 35-year-old man.

CLINICAL INTRODUCTION: A 35-year-old man with multiple cardiovascular risk factors presented with a recent history of fever and acute heart failure. His initial echocardiogram showed evidence of severe aortic regurgitation due to ongoing infective endocarditis. Preoperative coronary angiography revealed no coronary abnormalities. Urgent aortic valve replacement was performed and a 29 mm St Jude mechanical valve was implanted. While blood and resected valvular tissue cultures were negative for bacteria, a PCR-based analysis revealed the presence of penicillin-sensitive Streptococcus pneumoniae. Echocardiographic follow-up study at day 3 showed excellent mechanical valve function with no persistent signs of endocarditis. Eight days after surgery, our patient presented with severe chest pain. The ECG is shown in figure 1A and coronary angiography was performed for diagnostic confirmation (figure 1B-D and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313577.supp1Supplementary file 1 heartjnl;105/3/234/F1F1F1Figure 1(A) 12-lead ECG. (B, C) Selective angiogram of the left main, left anterior descending artery and circumflex artery. (D) Aortic root angiography. QUESTION: Which of the following is most likely the diagnostic?Occlusion of the left anterior descending coronary arteryDissection of the left anterior descending coronary arteryValsalva aneurysm presenting as an acute coronary syndromeLeft anterior descending coronary artery spasmLeft main coronary aneurysm.

Imaging and histology in the diagnosis of multiple papillary fibroelastomas in a patient with hypertrophic obstructive cardiomyopathy. Case report.

Papillary fibroelastomas (PFEs) are one of the most frequent primary cardiac tumors and occur more often in patients with hypertrophic obstructive cardiomyopathy (HOCM). PFEs have been linked to an increased risk of neurological events. We report a case of a 59-year-old woman with HOCM in whom echocardiography (transthoracic and transesophageal, using 2D and 3D techniques) revealed multiple masses in various locations in the left cardiac chambers. Surgical excision of the cardiac tumors and aortic valve replacement was performed and the pathologic report confirmed the diagnosis of PFEs. Patient followup using ultrasonography is crucial since recurrence is a possibility. Current cardiac ultrasound techniques are essential for diagnosing and for guiding the management of these conditions.

The extent of P2Y12 inhibition by clopidogrel in diabetes mellitus patients with acute coronary syndrome is not related to glycaemic control: roles of white blood cell count and body weight.

It was the study objective to determine whether glycaemic control affects the extent of platelet inhibition by thienopyridines as assessed by vasodilator-stimulated phosphoprotein flow cytometry (VASP-FCT) in patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) during acute coronary syndrome (ACS). Although the proportion of high on-treatment residual platelet reactivity is higher in DM, the contributions of glycaemic control and other factors associated with DM, such as excess body weight and inflammation, to this impaired platelet inhibition by thienopyridines have not yet been fully characterised. In this study, the extent of P2Y12 ADP receptor pathway inhibition was evaluated by the VASP-FCT. Platelet activation was expressed as the platelet reactivity index (PRI). Low response to clopidogrel (LR) was defined as a PRI of >61%. Four hundred forty-five consecutive ACS patients (DM = 160, NDM = 285) were enrolled. The proportion of LR was higher in DM patients (50 vs. 37.5%). In DM, PRI was not correlated with glycosylated haemoglobin (HbA1c) or glycaemia. In a univariate analysis, LR was associated with age, male sex, overweight, and white blood cell count (WBC). In a multivariate analysis, WBC >10,000 and body weight >80 kg were the sole independent predictors of LR to clopidogrel (hazard ratio (HR) 3.02 [1.36-6.68], p=0.006 and HR 2.47 [1.14-5.35], p = 0.021, respectively). Conversely, in non-DM patients, ST-elevation myocardial infarction was the sole independent predictor of LR. In conclusion, in ACS DM patients undergoing PCI, the extent of P2Y12 inhibition by clopidogrel is not related to glycaemic control but is related to body weight and inflammatory status as assessed by the WBC.

Cardiovascular mortality in chronic kidney disease patients undergoing percutaneous coronary intervention is mainly related to impaired P2Y12 inhibition by clopidogrel.

OBJECTIVES: We sought to determine whether low platelet response to the P2Y(12) receptor antagonist clopidogrel as assessed by vasodilator-stimulated phosphoprotein flow cytometry test (VASP-FCT) differentially affects outcomes in patients with or without chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI). BACKGROUND: Although both CKD and impaired platelet responsiveness to clopidogrel are strong predictors of unfavorable outcome after PCI, the impact of their association is unknown. The platelet VASP-FCT assay is specific for the P2Y(12) ADP receptor pathway. In this test, platelet activation is expressed as the platelet reactivity index (PRI). METHODS: Four-hundred forty unselected patients (CKD: 126, estimated glomerular filtration rate [eGFR] <60 ml/min/1.73 m(2)), no-CKD: 314 eGFR >60 ml/min/1.73 m(2)) undergoing urgent (n = 336) or planned (n = 104) PCI were prospectively enrolled. In each subgroup, patients were classified as low-responders (LR: PRI ≥ 61%) or responders (R: PRI <61%) to clopidogrel. RESULTS: At a mean follow-up of 9 ± 2 months, all-cause mortality, cardiac death, and possible stent thrombosis were higher in CKD than in no-CKD patients. Within the CKD group, the LR status was associated with higher rates of all-cause mortality (25.5% vs. 2.8%, p < 0.001), cardiac death (23.5% vs. 2.8%, p < 0.001), all stent thrombosis (19.6% vs. 2.7%, p = 0.003), and MACE (33.3% vs. 12.3%, p = 0.007). Conversely, in no-CKD patients, the LR status did not affect outcomes. Multivariate analysis identified Killip class ≥ 3, drug-eluting stent implantation, and the interaction between LR and CKD (hazard ratio: 11.96, 95% confidence interval: 1.22 to 116.82; p = 0.033) as independent predictors of cardiac death. CONCLUSIONS: In CKD patients, the presence of low platelet response to clopidogrel is associated with worse outcomes after PCI.

Impact of P2Y12 inhibition by clopidogrel on cardiovascular mortality in unselected patients treated by percutaneous coronary angioplasty: a prospective registry.

OBJECTIVES: The aim of this study was to determine whether low platelet response to the P2Y(12) receptor antagonist clopidogrel as assessed by Vasodilator-stimulated phosphoprotein flow cytometry test (VASP- FCT) predicts cardiovascular events in a high-risk population undergoing percutaneous coronary intervention (PCI). BACKGROUND: Impaired platelet responsiveness to clopidogrel is thought to be a determinant of cardiovascular events after PCI. The platelet VASP-FCT is a new assay specific to the P2Y(12) adenosine diphosphate receptor-pathway. In this test, platelet activation is expressed as platelet reactivity index (PRI). METHODS: Four-hundred sixty-one unselected patients undergoing urgent (n = 346) or planned (n = 115) PCI were prospectively enrolled. Patients were classified as low-response (LR) and response (R) to clopidogrel, depending on their PRI. Optimal PRI cutoff was determined by receiver-operator characteristic curve analysis to 61% (LR: PRI > or =61% and R: PRI <61%). Follow-up was obtained at a mean of 9 +/- 2 months in 453 patients (98.3%). RESULTS: At follow-up, total cardiac mortality rates and possible and total stent thrombosis were higher in LR patients. Multivariate analysis identified creatinine clearance (hazard ratio [HR]: 0.95; 95% confidence interval [CI]: 0.93 to 0.98, p < 0.001), drug-eluting stent (HR: 5.73; 95% CI: 1.40 to 23.43, p = 0.015), C-reactive protein (HR: 1.01; 95% CI: 1.001 to 1.019, p = 0.024), and LR to clopidogrel (HR: 4.00; 95% CI: 1.08 to 14.80, p = 0.037) as independent predictors of cardiac death. The deleterious impact of LR to clopidogrel on cardiovascular death was significantly higher in patients implanted with drug-eluting stent. CONCLUSIONS: In patients undergoing PCI, LR to clopidogrel assessed by VASP-FCT is an independent predictor of cardiovascular death at the PRI cutoff value of > or =61%. The LR clinical impact seems to be dependent on the type of stent implanted.

Prevention of perioperative atrial fibrillation with betablockers in coronary surgery: betaxolol versus metoprolol.

In this study, we tried to compare the efficacy and safety of betaxolol vs. metoprolol immediately postoperatively in coronary artery bypass grafting (CABG) patients and to determine whether prophylaxy for atrial fibrillation (AF) with betaxolol could reduce hospitalization and economic costs after cardiac surgery. Our trial was open-label, randomized, multicentric enrolling 1352 coronary surgery patients randomized to receive betaxolol or metoprolol. The primary endpoints were the composites of 30-day mortality, in-hospital AF (safety endpoints), duration of hospitalization and immobilization, quality of life, and the above endpoint plus in-hospital embolic event, bradycardia, gastrointestinal symptoms, sleep disturbances, cold extremities (efficacy plus safety endpoint). At the end of the study the incidence and probability of early postoperative AF with betaxolol was lower than with metoprolol in coronary surgery (P<0.0001). In the two study groups minor side effects were similar and no major complication was reported (P<0.001). Patient compliance was good and the general condition improved due to shortened hospitalization and immobilization with subsequent improvement in the psychological status, less arrhythmias and lack of significant side effects. In conclusion, because of its efficacy and safety, betaxolol was superior to metoprolol for the prevention of the early postoperative AF in coronary surgery.