A System for Accurate Deployment of Unconstrained Triple-Fenestrated Aortic Arch Endografts.

PURPOSE: To achieve accurate rotational orientation and the axial position of unconstrained triple-fenestrated physician-modified endografts upon deployment in the aortic arch during total arch thoracic endovascular aortic repair (TA-TEVAR). MATERIALS AND METHODS: Following a detailed study of reconstructed computerized tomography angiography images of patients' arch anatomy, customized, sealable fenestrations with radio-opaque margins are created onsite on Valiant Captivia (Medtronic) endografts, transposing the arch branch ostial anatomic interrelationship onto the endograft precisely. Radio-opaque figure-of-8 markers, indicating the 12 o'clock (superior) position, are attached to the endograft on the surface and brought up to the surface under the endograft cover during resheathing. Resheathing without any twist in the endograft is achieved by lining up the welds in each endograft stent segment in a straight line. The fluoroscopic working view for arch endograft delivery and deployment is the left anterior oblique view that is orthogonal to the plane of the arch, which, in turn, is the right anterior oblique view in which parts of a stiff indwelling guidewire in the ascending and descending aorta precisely overlap. During introduction in the working view, the endograft delivery system is rotated in the descending thoracic aorta so that the 12 o'clock figure-of-8 markers are viewed on the edge and situated at the outer aortic curvature; continued advancement into the arch without any further rotation will ensure superior orientation of the figure-of-8 markers and, consequently, correct endograft rotational orientation. Proper axial endograft positioning requires locating the left common carotid artery (LCCA) fenestration just proximal to a taut externalized LCCA-femoral guidewire loop marking the posterior limit of the LCCA ostium. After endograft deployment during rapid cardiac pacing, the target arch branches are cannulated through their respective fenestrations using hydrophilic 0.035-inch guidewires that are externalized via distal sheaths to create femoral-arch branch (through-and-through) loops over which covered fenestrated stents are introduced and deployed. RESULTS: This technique was used successfully in 31 consecutive patients undergoing TA-TEVAR; systemic blood pressure was obtained in all arch branches immediately after endograft deployment, indicating adequate blood flow. All arch branches were successfully cannulated and stented. CONCLUSION: This system enables accurate deployment of unconstrained triple-fenestrated arch endografts simply and reliably during TA-TEVAR.

Laboratory and clinical comparison of the efficacy of prestorage leukoreduction of red cells at cold versus room temperature.

BACKGROUND: The temperature at which filtration takes place has been reported to influence the efficacy of leukoreduction. We aimed to compare the residual leukocyte count (RLC) in red cell units (RCUs) filtered at cold (CT) versus room temperature (RT) and to assess whether this correlates clinically with a difference in the incidence of acute transfusion reactions (ATRs). METHODS AND MATERIALS: In the first part of the study, whole blood units collected were randomly allocated for subsequent filtration at CT and RT, respectively. RLC postfiltration was assessed using flow cytometry. The second part of the study was a nonrandomized clinical trial in which incidence of ATR was compared between RCUs filtered at RT and CT for 6 months each. RESULTS: Thirty-five RCUs each underwent leukofiltration at CT and RT, respectively. The median RLCs in the filtered units at CT and RT were 0.02 × 106 and 0.1 × 106 leukocytes/unit, respectively (p = .0001), with no difference in red blood cell (RBC) recovery (p = .41). During the second part, 3455 RCUs filtered at RT and 3539 RCUs filtered at CT were transfused to patients. The rate of febrile non-hemolytic transfusion reaction (FNHTR) among transfused patients was less with units filtered at CT (1 per 2000 transfusions) in comparison to RT (1 per 588 transfusions). The difference was, however, not significant (p = .14). CONCLUSION: If change in temperature alone can cause significant reduction in leukocytes, then it is a simple way to curtail the rate of this common yet unpleasant reaction and reduce the reaction rate at minimal cost.

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta.

Purpose: To report a technique of global cerebral embolic protection (CEP) designed for use during thoracic endovascular aortic repair (TEVAR). Technique: Arterial cannulas are inserted percutaneously in the right axillary artery (12-F) and left common carotid artery (LCCA; 10-F) to provide normothermic antegrade cerebral perfusion during TEVAR with neuromonitoring. Inferior vena cava blood is drawn using a 19-F femoral cannula, filtered, oxygenated, and delivered through independent roller pumps to the arterial cannulas. Static CEP is obtained by balloon occlusion of the 3 aortic arch branches proximally, resulting in complete separation of aortic and cerebral blood flow; static CEP is used during aortic endograft delivery and deployment. Dynamic CEP, obtained by creating flow reversal in the innominate artery and proximal LCCA, is used at all other times. Successful use of this CEP technique is illustrated in a patient with shaggy aorta undergoing fenestrated total arch TEVAR. Conclusion: Percutaneous normothermic bilateral antegrade cerebral perfusion provides effective CEP during TEVAR.

Tetralogy of Fallot with absent pulmonary valve in an adult.

Absent pulmonary valve syndrome (APVS) is seen in around 3 to 6% of tetralogy of Fallot (TOF) patients. They present in the neonatal or infantile period with respiratory compromise, cardiac failure, or cyanosis. They rarely survive into adulthood with only few reports published in literature so far. In this report, we present an adult patient with TOF and APVS, who underwent a successful repair with prosthetic valve implantation.

A natural systemic to pulmonary artery shunt.

Isolation of the left subclavian artery is a rare anomaly associated with right aortic arch. We report a case in which this subclavian artery was supplying the pulmonary circulation in a patient with tetralogy of Fallot (TOF) which effectively acted as a natural systemic to pulmonary artery shunt. The patient had good room air saturation and no features of vertebrobasilar insufficiency or left upper limb ischemia. She underwent a total correction of TOF and ligation of the aberrant left subclavian artery.

Comparison of Point-of-Care PT-INR by Hand-Held Device with Conventional PT-INR Testing in Anti-phospholipid Antibody Syndrome Patients on Oral Anticoagulation.

Evidence on agreement of point-of-care (POC) INR testing with laboratory testing in APS patients on oral anticoagulation (OAC), is scarce. This study assessed agreement of paired PT INR testing by a POC device vs. conventional platform-based laboratory test, in APS patients on OAC using a pre-determined definition of agreement. Simultaneous paired PT INR estimation in 92 APS patients was carried out, during October 2020-September 2021. POC INR was performed on capillary blood (pin prick) using the qLabs® PT-INR hand-held device, while laboratory INR estimation was performed using citrated blood (venepuncture) on STA-R Max Analyzer® using STA-NeoPTimal thromboplastin reagent®. Concordance was defined no greater than ± 30% (as per international standards ISO 17593:2007 guidelines) for each paired INR estimation. Agreement between the two was defined as ≥ 90% of paired INR measurements being concordant. 211 paired estimations were performed, within which 190 (90%) were concordant. Good correlation was seen between the 2 methods of INR estimation on Bland Altman plot analysis with an Intra-class correlation coefficient (95% CI) of 0.91(0.882, 0.932). Lab INR range > 4 (P = 0.001) was a significant predictor of higher variability between both methods of INR estimation. Lupus anti-coagulant, other anti-phospholipid antibodies (APL) or triple APL positivity did not result in any statistically significant variation in paired measurements. This study demonstrated good correlation between POC INR measurement and Lab INR estimation and agreement was ascertained between the 2 methods in APS patients on OAC.

Does tuberculosis affect surgical outcomes following pericardiectomy for chronic constrictive pericarditis? Twelve years' experience from a tertiary care center in India.

Introduction and purpose: Tuberculosis (TB) is the commonest cause of chronic constrictive pericarditis (CCP) in India, unlike in the western countries. Pericardiectomy is the treatment of choice for CCP. Surgery in TB CCP is considerably more difficult than it is for other etiologies. The role of TB as an independent predictor for adverse surgical outcomes had not been properly evaluated in the Indian scenario. Hence, the aim of this study was to retrospectively analyze our results of surgery for CCP and the pre-operative factors that influenced post-operative outcomes. Methods: The data of all adult patients who underwent pericardiectomy for CCP, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analyzed. Results: There were 124 patients in the study. The average age was 32 years. The male to female ratio was 3:1. TB was the commonest cause of CCP, identified in 64 (51.6%) patients. Complete anterior pericardiectomy (CAP) was possible in 122 (98.3%) patients. All the patients had significant drop in their central venous pressure (CVP) (10.25 ± 3.47 mmHg) after surgery. The operative time (p = 0.008), intra-operative blood loss (p = 0.02), intensive care unit (ICU) stay (p = 0.03), and hospital stay (p = 0.028) were significantly higher in the TB group. Apart from TB, the other pre-operative variables that predicted adverse outcomes were male sex, presence of pleural effusion or ascites, and advanced New York Heart Association (NYHA) class. There were 7 (5.6%) post-operative complications and 3 (2.4%) in-hospital deaths. Conclusion: The high incidence of TB CCP makes a pericardiectomy in developing countries technically more challenging resulting in increased operative time, more blood loss, and prolonged ICU and hospital stay, but did not affect in-hospital mortality or morbidity.

Complications of trans-catheter closure of atrial septal defects.

Trans-catheter device closure of atrial septal defects (ASD) is considered to be safe with minimal complications. But, there are certain complications that arise after these device closures which might require urgent or late surgical intervention. We have retrospectively analysed our experience. Out of 780 patients who underwent device closure, 11 (1.4%) patients required urgent surgical intervention to retrieve the embolized device. The size of the ASD, expertise of the cardiologist and the type of the device directly impacted the rate of device embolization. Early diagnosis and prompt surgical retrieval is paramount before any life threatening complications arise due to the embolized device. One patient developed infective endocarditis later, which required surgery. Regular long term follow up is needed after these procedures to diagnose the complications earlier so that prompt surgical intervention could be done.

Efficacy of paravertebral block in "Fast-tracking" pediatric cardiac surgery - Experiences from a tertiary care center.

Introduction: Fast tracking plays a crucial role in reducing perioperative morbidity and financial burden by facilitating early extubation and discharge from hospital. Paravertebral block (PVB) is becoming more popular in paediatric surgeries as an alternative to epidural and caudal analgesia. There is scarcity of data regarding the efficacy and safety of PVB in paediatric cardiac surgery. Methods: We performed a review of records of paediatric cardiac patients who underwent cardiac surgery under general anaesthesia with single shot PVB and compared the analgesia and postoperative outcomes with matched historical controls who underwent cardiac surgery with same anaesthesia protocol without PVB. Results: The data from 200 children were analysed. 100 children who received paravertebral block were compared with a matched historical controls. The median time to extubation was shorter in the PVB group (0 hr, IQR 0-3 hrs) compared to the control group (16 hrs, IQR 4-20 hrs) (P value 0.017*). Intraoperative and postoperative fentanyl requirement was much lower in the PVB group (3.49 (0.91)) compared to the control group (9.86 (1.37)) P value <0.01*. Time to first rescue dose of analgesic was longer (7 hrs vs 5 hrs, P 0.01*), while time to extubation and duration of ICU stay were significantly less in PVB group . Mean postoperative pain scores were significantly lower in the PVB group at the time of ICU admission (0.85 vs 3.12, P 0.001*) till 4 hours (2.11 vs 3.32, P 0.001*). Conclusion: PVB provides an effective and safe anaesthetic approach which can form an important component of "fast-track" care in paediatric cardiac surgery.

Combined mitral and aortic valve replacement for rheumatic heart disease: fifteen-year follow up and long-term results.

BACKGROUND AND AIM OF THE STUDY: Rheumatic heart disease is the most common cause of multivalvular disease in developing countries. Unless aggressive and timely intervention in the form of valve replacement is pursued, the condition progresses rapidly to disability and death. Combined mitral-aortic valve replacement represents a major technical challenge, and carries high early and late mortality rates. METHODS: The course of 382 consecutive hospital survivors of combined mitral-aortic valve replacement, operated on between January 1992 and December 2006, was reviewed. The valve of choice for the mitral position was the Starr-Edwards (98%), while Medtronic-Hall and St. Jude Medical valves were favored for the aortic position (81%). RESULTS: The mean postoperative follow up was 64.8 +/- 53.9 months, with a total cumulative follow up of 1,792 patient-years (pt-yr); the follow up was 87% complete (n=332). Late death occurred in 29 patients (8.7%). Long-term survival at five, 10 and 15 years was 92%, 78% and 45%, respectively, with a mean survival of 153 months. The linearized rates of thromboembolism, anticoagulation-related hemorrhage and prosthetic valve endocarditis were 1.06, 2.41 and 0.334% per pt-yr, respectively. CONCLUSION: Among the rheumatic population, double valve replacement offers excellent symptomatic improvement and favorable late survival. Hemodynamic superiority and thromboresistance are the normal selection criteria for these prostheses, although the surgeon's experience, and the ease of insertion, availability and cost of the valve also play important roles. A strict adherence to optimal anticoagulation levels optimizes protection against thromboembolism and anticoagulation-related hemorrhage, and helps to provide the patient with a good quality life.

Unruptured aneurysm of the sinus of Valsalva presenting with right ventricular outflow obstruction.

Sinus of Valsalva aneurysms rarely present until rupture occurs. We describe the case of a patient who presented with acute right heart failure and upon investigation was found to have an unruptured sinus of Valsalva aneurysm causing right ventricular outflow obstruction; there was an associated subaortic ventricular septal defect. To the best of our knowledge, only 1 other case with these features has been reported in the medical literature. The diagnosis was made by transthoracic echocardiography and cardiac catheterization. Through an aortic and right ventricular approach, we successfully excised the aneurysmal right coronary sinus, closed the ventricular septal defect, and replaced the aortic valve.

Aortic and mitral valve replacement in a patient with hemophilia B.

A 25-year-old man with factor IX deficiency had an aortic and mitral valve replacement using a 2M Starr Edwards valve in the mitral position and a 22 Medtronic valve in the aortic position under cover of factor IX concentrate. The surgical procedure and the immediate postoperative period were uneventful except for a pericardial effusion which required a pericardiostomy. He was anticoagulated with heparin in the immediate postoperative period while the factor IX concentrate was being administered. Oral anticoagulation with acenocoumarol (Acitrom) was started, maintaining the international normalized ratio between 1.5 and 2. He was doing well at follow-up 9 months later.

Surgical results in bronchiectasis: analysis of 149 patients.

Bronchiectasis remains a serious problem in developing countries. We reviewed the morbidity, mortality, and functional outcome of surgical treatment for bronchiectasis in our institution. Between 1992 and 2003, 149 patients (105 males, 44 females) underwent pulmonary resection for bronchiectasis. Their mean age was 33.7 years (range, 5-66 years). The indications for surgery were failure of conservative treatment in 59 (40%) patients, recurrent hemoptysis in 53 (36%), bronchial obstruction by a tumor in 9 (6%), and destroyed lung in 28 (19%). Bilateral disease was seen in 24 (16%) patients. Surgical treatment included pneumonectomy in 55 (37%) patients, lobectomy in 55 (37%), bilobectomy in 37 (25%), and lobectomy and/or segmentectomy in 2 (1%). There was one operative death (mortality, 0.67%) and morbidity occurred in 22 (14.8%) patients. Follow-up was complete in 94 patients, for a mean of 4.8 years (range, 3 months to 12 years). After surgery, 51 (34%) patients were asymptomatic. Surgical treatment for bronchiectasis can achieve good results with acceptable morbidity and mortality, not only in localized disease but also in extensive disease, if complete resection can be achieved.

Bronchovenous fistula - leading to fatal massive systemic air embolism during cardiopulmonary bypass.

OBJECTIVES: We report a case of a bronchovenous fistula in an adult who could not be resuscitated following a mitral valve replacement. METHODS: A 39-year-old man underwent a mitral valve replacement for severe mitral stenosis and regurgitation. Following uneventful valve replacement surgery, and while attempting to wean the patient off bypass, we encounted a bronchovenous fistula following mechanical ventilation. RESULTS: This patient could not be resuscitated following surgery because of persistent air embolism in the patient. CONCLUSION: Systemic air embolism has been reported to occur following penetrating chest injury. Especially, when the entry and the exit sites have been over sewn and either a marked Valsalva maneuver by the patient (such as coughing or straining) or forced positive pressure ventilation in excess of 60 torr occurs, systemic air embolism can be created from bronchiolar-alveolar to pulmonary venous fistula. It has also been described in blunt thoracic trauma. Bronchovenous fistula is occasionally encountered in neonates due to ventilation injuries with high ventilatory pressures, especially with underlying lung pathology like respiratory distress syndrome, necessitating such high ventilatory pressures. To our knowledge, this is the first such case reported in the literature.

Pseudoaneurysm of ascending aorta after aortic valve replacement.

A pseudoaneurysm of the ascending aorta is an unusual and potentially fatal complication after aortic surgical procedures. A contrast computed tomographic scan is the investigation of choice. Surgical treatment is mandatory. We describe the successful management of a pseudoaneurysm of the ascending aorta by instituting femorofemoral bypass and achieving hypothermic circulatory arrest, which provided safe reentry and prevented an impending rupture.

Inflammatory pseudotumour of the lung.

Inflammatory pseudotumours of the lungs have rarely been reported. These have been described as a benign entity of unknown origin and are often locally invasive requiring extensive pulmonary resection. We present a 12-year-old boy with fever and massive haemoptysis who was found to have a well defined left-sided paracardiac mass lesion on chest X-ray and CT scan thorax. A CT-guided fine needle aspiration cytology was reported as inflammatory pseudotumour. As a result of recurrent episodes of massive haemoptysis during admission the child underwent an emergency left posterolateral thoracotomy and excision of the mass along with a left pneumonectomy. The biopsy of the mass was conclusive. Postoperatively the child was ventilated over night and was extubated the next day. He has been doing well on follow-up. Based on our case report and on other similar reports it would appear that the primary treatment of inflammatory pseudotumors of the lung is surgical. Complete resection is the key to prevent recurrence and the prognosis is excellent following surgery.