A Propensity Score Analysis of Early and Long-Term Outcomes of Retrograde Arterial Perfusion for Endoscopic and Minimally Invasive Heart Valve Surgery in Both Young and Elderly Patients.

(1) Background: Minimal invasive cardiac surgery via right anterolateral thoracotomy for heart valve surgery and other intracardiac procedures proven to have lower postoperative complications. We aim to compare the neurological complications and post-operative outcomes in two cohort groups as well as survival rates up to 5 years postoperatively; (2) Methodology: Retrospective observational study for patients who had minimally invasive cardiac valve surgery with retrograde femoral arterial perfusion between 2007 and 2021 (n = 596) and the categorized patients into two groups based on their age (≥70 years old and below 70). Propensity match analysis was conducted. The primary endpoint consisted of major postoperative complications and the secondary endpoint was the long-term survival rate. (3) Results: There was no difference between the two groups in terms of postoperative outcomes. Patients ≥ 70 years old had no increased risk for neurological complications (p = 0.75) compared with those below 70 years old. The mortality rate was also not significant between the two groups (p = 0.37) as well as the crude survival rates. (4) Conclusions: The use of retrograde femoral arterial perfusion in elderly patients is not associated with increased risk compared to the younger patients' group for a spectrum of primary cardiac valve procedures. Hence, minimally invasive approaches could be offered to elderly patients who might benefit from it.

Endoscopic Tricuspid Valve Surgery is a Safe and Effective Option.

OBJECTIVE: Isolated tricuspid surgery through median sternotomy can be associated with a high morbidity and mortality. Reports of minimally invasive isolated tricuspid valve operations are rare, but the outcomes are encouraging. We present our experience of endoscopic isolated tricuspid valve surgery. METHODS: In our institution, 452 patients underwent endoscopic minimal access cardiac surgery between August 2008 and December 2018. A total of 90 patients underwent tricuspid valve surgery whether isolated or with other cardiac procedure. We further selected patients who had isolated tricuspid valve surgery (n = 24). Of these patients, 13 (54%) had more than one previous sternotomy. RESULTS: Tricuspid repair was performed in 18 patients (75%) with the remaining 6 (25%) having bioprosthetic tricuspid replacement. Three (12.5%) were performed with a beating heart, the remaining with endoaortic clamping and cardioplegia. There were no conversions to sternotomy. None of the patients had reoperation for bleeding, tamponade, or valve issues. Three patients (12.5%) required blood transfusion, 3 patients (12.5%) required renal dialysis, and 7 patients (29%) had respiratory complications such as chest infection, requiring continuous positive airway pressure (CPAP) with 2 being re-intubated. One patient (4.1%) died within 30 days from chest sepsis leading to multi-organ failure. Mean hospital stay was 11.1 ± 8.9 days (median of 8). All patients had mild or less regurgitation on follow-up echo at 6 months. CONCLUSIONS: Isolated tricuspid valve surgery can be performed through an endoscopic minimally access approach, with good results. It appears to provide better results than a sternotomy approach. A high repair rate can be achieved, and the procedure is particularly valuable in redo-surgery with low mortality and morbidity compared to historical sternotomy case series.

Duplicated common femoral artery can be safely cannulated for femorofemoral cardiopulmonary bypass.

The duplicated common femoral artery can be safely cannulated for femorofemoral bypass, but we recommend postoperative imaging to identify potential complications. We found no previous reports of duplicated common femoral artery.

Successful on-pump coronary artery bypass without using protamine.

A 48-year-old woman presented with a history of angina and breathlessness on exertion. She was diagnosed to have critical left main stem coronary artery disease along with a blocked right coronary artery. She was also allergic to protamine. After multidisciplinary consultation, it was decided to use heparin without protamine for reversal. She underwent successful on-pump coronary artery bypass grafting (CABG) without excessive blood loss. The disadvantages were a longer total operating time and the use of blood products to achieve normal coagulation. This case report describes the successful management of this complex problem.

Accidental fracture of the tip of the Coopdech bronchial blocker during insertion for one lung ventilation.

PURPOSE: The distal tip of a Coopdech bronchial blocker has a preformed angulation to aid placement in the desired bronchus. We report two cases wherein this design may have resulted in distal tip fracture due to entanglement at the level of the Murphy's eye of the endotracheal tube or at the carina. CLINICAL FEATURES: A 49-yr-old female had a Coopdech bronchial blocker inserted into her right main bronchus for video-assisted thoracoscopic (VAT) lung biopsy. Resistance was encountered on its insertion, followed by confirmation of its position by fibreoptic bronchoscopy. As lung isolation was inadequate, bronchoscopy was repeated during surgery. This showed fracture of the blocker tip that required patient repositioning and insertion of another blocker. In a second incident, a bronchial blocker was inserted into the right main bronchus of a 19-yr-old male for VAT bullectomy. This procedure was performed under continuous fibreoptic guidance. Nevertheless, it was difficult to pass the blocker tip beyond the Murphy's eye of the endotracheal tube, as repeated attempts resulted in its entanglement and fracture. Another blocker was inserted by maneuvering the tip beyond the Murphy's eye. CONCLUSION: The preformed tip of the Coopdech bronchial blocker can be damaged at the Murphy's eye of the endotracheal tube or at the carina. This can result in tip fracture, especially during insertion into the right main bronchus. Maneuvering the tip away from the Murphy's eye can circumvent this problem. Continuous bronchoscopic guidance should be used as recommended by the manufacturer.

The impact of administration of tranexamic acid in reducing the use of red blood cells and other blood products in cardiac surgery.

BACKGROUND: To study the effect of administration of tranexamic acid on the use of blood and blood products, return to theatre for post-operative bleeding and the length of intensive care stay after primary cardiac surgery, data for 4191 patients, of all priorities, who underwent primary cardiac operation during the period between 30/10/00 and 21/09/04 were analysed. METHODS: Retrospective analysis of data collected prospectively during the study period. The main outcome measures were whether or not patients were transfused with red blood cells, fresh frozen plasma or any blood product, the proportion of patients returned to theatre for investigation for post-operative bleeding and length of stay in the intensive care unit. We performed univariate analysis to identify the factors influencing the outcome measures and multivariate analysis to identify the effect of administration of tranexamic acid on the outcome measures. RESULTS: Administration of tranexamic acid was an independent factor affecting the transfusion of red blood cells, fresh frozen plasma or any blood product. It was also an independent factor influencing the rate of return to theatre for exploration of bleeding. The odds of receiving a transfusion or returning to theatre for bleeding were significantly lower in patients receiving tranexamic acid. The administration of tranexamic acid also significantly decreased blood loss. We did not find any association between the administration of tranexamic acid and the length of intensive care stay. CONCLUSION: Based on the analysis of 4191 patients who underwent a primary cardiac operation, administration of tranexamic acid decreased the number of patients exposed to a transfusion or returned to theatre for bleeding in our institute.

Extubation of the surgically resected airway--a role for remifentanil and propofol infusions.

PURPOSE: To report the use of propofol and remifentanil infusions to facilitate smooth extubation of a surgically resected airway. CLINICAL FEATURES: A 19-yr-old man weighing 85 kg was scheduled for tracheal resection surgery following postintubation tracheal stenosis. He had a relatively long segment (4 cm) of his trachea resected and anastomosed. Postoperatively, he was sedated and electively ventilated for four days in a chin to chest position by stay sutures. In order to reduce any risk of traumatic disruption to the tracheal anastomosis, we planned to extubate his trachea under light general anesthesia. Attempts to extubate his trachea using propofol and alfentanil infusions failed. We used propofol and remifentanil infusions to achieve a state of sedate cooperation and extubated his trachea with fibreoptic bronchoscope guidance. CONCLUSION: Propofol and remifentanil infusions in combination can facilitate successful extubation of the surgically resected airway with high risk of disruption.