Analysis of racial disparities in acute type A aortic dissection repair at a rural tertiary academic medical center.

BACKGROUND: To determine if racial disparities exist between African Americans (AA) and Non-Hispanic Whites (NHW) for patients undergoing repair of acute type A aortic dissection (ATAAD) at a rural tertiary academic medical center. METHODS: There were 215 consecutive AA and NHW patients who underwent ATAAD repair at our institution from 1999 to 2019 included in a retrospective analysis of our Society of Thoracic Surgeons Adult Cardiac Surgery Database. Statistical analysis was performed with a p value of less than .05 considered statistically significant. RESULTS: Patients undergoing ATAAD repair were 47% AA despite comprising only 27% of the total population in our region. AAs were significantly younger (54.0 vs. 61.2 years), were more likely to be hypertensive (94.1% vs. 79.7%), had higher creatinine levels (1.7 vs. 1.1 mg/dL), and higher body mass index (30.8 vs. 28.1 kg/m2 ) (all p values < .006). There were no significant differences in type of repair or intraoperative variables. A logistic regression analysis showed AAs had an increased rate of postoperative acute renal failure not requiring hemodialysis when compared to NHWs (20.8% vs. 10.6%, p value = .042). Thirty-day mortality was not significantly different (15.7% vs. 13.4%) nor was 1-year survival (78% vs. 79%) in AAs and NHWs, respectively. CONCLUSIONS: Despite AAs having more medical comorbidities at presentation, there were no differences in short- and intermediate-term survival. In our catchment of 1.8 million people, AAs appear to undergo ATAAD repair at a disproportionate rate versus NHWs. These findings may alter strategies for surveillance and prevention of aortic disease in this high-risk population.

Recommendation by a law body to ban infant male circumcision has serious worldwide implications for pediatric practice and human rights.

BACKGROUND: Recent attempts in the USA and Europe to ban the circumcision of male children have been unsuccessful. Of current concern is a report by the Tasmanian Law Reform Institute (TLRI) recommending that non-therapeutic circumcision be prohibited, with parents and doctors risking criminal sanctions except where the parents have strong religious and ethnic ties to circumcision. The acceptance of this recommendation would create a precedent for legislation elsewhere in the world, thereby posing a threat to pediatric practice, parental responsibilities and freedoms, and public health. DISCUSSION: The TLRI report ignores the scientific consensus within medical literature about circumcision. It contains legal and ethical arguments that are seriously flawed. Dispassionate ethical arguments and the United Nations Convention on the Rights of the Child are consistent with parents being permitted to authorize circumcision for their male child. Uncritical acceptance of the TLRI report's recommendations would strengthen and legitimize efforts to ban childhood male circumcision not just in Australia, but in other countries as well. The medical profession should be concerned about any attempt to criminalize a well-accepted and evidence-based medical procedure. The recommendations are illogical, pose potential dangers and seem unworkable in practice. There is no explanation of how the State could impose criminal charges against doctors and parents, nor of how such a punitive apparatus could be structured, nor how strength of ethnic or religious ties could be determined. The proposal could easily be used inappropriately, and discriminates against parents not tied to the religions specified. With time, religious exemptions could subsequently be overturned. The law, governments and the medical profession should reject the TLRI recommendations, especially since the recent affirmative infant male circumcision policy statement by the American Academy of Pediatrics attests to the significant individual and public health benefits and low risk of infant male circumcision. SUMMARY: Doctors should be allowed to perform medical procedures based on sound evidence of effectiveness and safety with guaranteed protection. Parents should be free to act in the best interests of the health of their infant son by having him circumcised should they choose.

Pulmonary valve infective endocarditis caused by Mycobacterium abscessus.

Infective endocarditis caused by Mycobacterium abscessus is an uncommon event that, when it does occur, usually requires surgical valve replacement. The pulmonary valve is the least common heart valve involved in infective endocarditis. We present a rare case of isolated pulmonary valve endocarditis with Mycobacterium abscessus in a patient with recurrent sternal infections following repeated coronary artery bypass.

Surgical management of a type A aortic dissection in a pregnant patient.

Despite emphasis for emergent surgical treatment of Stanford type A aortic dissections, pregnant patients that are clinically stable may safely receive a staged approach instead, with delivery followed by delayed dissection repair.

Second-generation extracellular matrix patch for epicardial infarct repair.

Current myocardial infarction treatments focus on improving hemodynamics rather than addressing the problem of lost myocardium impairing left ventricular function. Epicardial infarct repair with a bioactive patch placed on the ischemic area is an emerging approach to promote endogenous myocardial repair. We report the use of a second-generation CorMatrix-extracellular matrix (ECM) patch as an adjunct to surgical revascularization in treating a young patient with diffuse, multivessel coronary artery disease unamenable to PCI and a large anterior myocardial infarction. The progressive myocardial scar shrinkage and increase in left ventricular ejection fraction from 10 to 51% are generally not observed with surgical revascularization therapy alone, suggesting this new patch has adjunctive potential to current revascularization therapy.

Heparin-Induced Thrombocytopenia After Mitral Valve Replacement.

Background: Heparin-induced thrombocytopenia (HIT) is a rare autoimmune reaction that involves a decrease in platelet count following heparin exposure and can be associated with life-threatening thrombosis. Because of their prolonged heparin exposure, patients undergoing cardiac surgery are at risk of HIT, with an incidence of 0.1% to 3%. Case Report: A 65-year-old male with severe mitral regurgitation and preoperative ejection fraction of 20% to 25% underwent mitral valve bioprosthetic replacement with coronary artery bypass graft surgery. Heparin anticoagulation was started on postoperative day (POD) 1. Respiratory failure resulted in prolonged mechanical ventilation and heparinization without the ability to initiate warfarin. While the patient was on heparin, his platelet count declined on POD 2 and then steadily increased to above the preoperative level on POD 7. On POD 10, the patient's platelet count dramatically decreased, and on POD 13 he developed acute common femoral artery occlusion necessitating embolectomy. Intraoperative transesophageal echocardiography revealed heavy thrombus burden across the mitral bioprosthesis. HIT was confirmed with a positive heparin-induced platelet antibody and serotonin release assay. Heparin was stopped and argatroban initiated. The patient underwent reoperative bioprosthetic mitral valve replacement on POD 18 using bivalirudin intraoperatively. Despite resolution of HIT, the patient developed sepsis and died on POD 59. Conclusion: The diagnosis of HIT is challenging in patients who undergo cardiopulmonary bypass. Platelet counts often decrease 40% to 60% during the first 72 hours postoperatively, and the frequency of nonspecific anti-platelet factor 4/heparin antibody formation is high. These findings can mask early signs of HIT and delay diagnosis.

Does Elective Sternal Plating in Morbidly Obese Patients Reduce Sternal Complication Rates?

BACKGROUND: Although the literature shows rigid plate fixation has superior outcomes over wire cerclage techniques, a patient population clearly benefitting from initial sternal plating over standard closure has not been identified. Data on plating as primary sternal closure in the morbidly obese patient remains sparse. METHODS: A single-center retrospective study was performed on 564 consecutive patients undergoing complete median sternotomy from July 2014 to July 2017. Postoperative outcomes of patients with a body mass index of 35 kg/m2 or more were compared between sternotomies with standard wire cerclage closure and those with sternal plate reinforcement. The primary endpoint was postoperative sternal complication defined as deep sternal wound infection, acute sternal dehiscence, chronic sternal disunion, or noninfectious sternal wound complication requiring operative intervention. RESULTS: In all, 32.6% of sternotomies (184 of 564) were performed on patients with a body mass index of 35 kg/m2 or greater. Of this group, 31.5% (58 of 184) underwent sternal closure with titanium plate reinforcement and 68.5% (126 of 184) underwent traditional chest closure. The overall sternal complication rate was 4.9% (9 of 184), consisting of 6 of 126 nonplated patients and 3 of 58 plated patients (4.8% vs 5.2%, P = .80). CONCLUSIONS: Sternal plate reinforcement for sternotomy closure of patients with a body mass index 35 kg/m2 or greater produced no difference in postoperative sternal complication rates.

Fortification of Preservation Solution With Nitroprusside Does Not Alter Lung Allograft Survival in Clinical Human Lung Transplantation.

Background: Nitric oxide improves gas exchange following primary lung allograft dysfunction. Nitroprusside, a potent nitric oxide donor, has reduced reperfusion injury and improved oxygenation in experimental lung transplantation. Methods: We sought to study the effect on lung allograft outcomes of fortifying the preservation solution with nitroprusside. We conducted a single-center clinical study of 46 consecutive lung recipients between 1998 and 2000: 24 patients received donor organs preserved in modified Euro-Collins solution with prostaglandin E1 (PGE1) (control group), and 22 patients received organs preserved in modified Euro-Collins with PGE1 and nitroprusside (NP group). The primary endpoint was overall survival. Results: Baseline characteristics were similar between the groups except for a significantly longer graft ischemic time in the NP group vs the control group (253.3 ± 52 vs 225.3 ± 41 minutes, respectively, P=0.04). No significant differences were found in partial pressure arterial oxygen to fraction inspired oxygen ratio at ≤48 hours, primary graft dysfunction, or bronchiolitis obliterans-free days. Overall survival at 1, 3, and 5 years was 89%, 73%, and 63% in the control group and 76%, 38%, and 23% in the NP group. Log-rank survival analysis showed that the NP group had a significantly increased risk of mortality (P=0.034) compared to the control group. Conclusion: The addition of nitroprusside to the lung transplant perfusate in this clinical trial did not improve survival; however, a large randomized trial would likely reduce confounding ischemia times and increase the power of the study.

Use of HeartWare Ventricular Assist System for systemic ventricular support of a pediatric patient after Mustard procedure.

BACKGROUND: The HeartWare Ventricular Assist System is indicated to provide mechanical circulatory support of patients with intractable heart failure as a bridge to cardiac transplantation. We describe the use of this device to support the systemic right ventricle (RV) of a pediatric patient with New York Heart Association class IIIC congestive heart failure who had undergone Mustard procedure for D-transposition of the great vessels as an infant. CASE REPORT: A HeartWare ventricular assist device was implanted in the left chest of a 16-year-old female patient (body surface area 1.43 m(2)) who presented with edema and later deteriorated, developing acute kidney injury, dysrhythmia, and pulmonary edema. RESULTS: The patient's edema and acute kidney injury resolved after device placement. She was discharged home and successfully underwent device removal with heart transplant five months later. CONCLUSION: The HeartWare device may be used for extended support as a systemic RV in a pediatric patient. It is feasible to consider using the device in this patient population.

A minimally invasive, algorithm-based approach for anomalous aortic origin of a coronary artery.

OBJECTIVE: Operative repair for anomalous aortic origin of a coronary artery (AAOCA) has been described using various innovative techniques. Common to each series is the use of a full sternotomy. As demand for minimally invasive approaches to adult cardiac surgery has increased, the upper hemisternotomy has emerged as a safe and effective technique for aortic valve and root replacement. This report reviews our results and describes the application of an upper hemisternotomy to an algorithm-based surgical approach for AAOCA. METHODS: From January 2012 to March 2013, the aortic root was approached via a 7-cm skin incision and upper hemisternotomy for all patients undergoing repair of an AAOCA. The type of repair performed was in accordance with a predefined surgical algorithm. The anomalous vessel had a slit-like ostium and followed a supracommissural intramural course in three patients with symptomatic anomalous right coronary artery. These patients underwent coronary unroofing. In contrast, a patient with an anomalous left coronary artery presented without an intramural segment and underwent vessel translocation and reimplantation. RESULTS: All patients underwent AAOCA repair according to our surgical algorithm and via an upper hemisternotomy. The median length of stay was 4 days. All patients had resolution of symptoms, and there were no reported complications at a median follow-up of 16.5 months. CONCLUSIONS: This series describes a minimally invasive approach to AAOCA repair. When used in conjunction with a defined surgical algorithm, this technique enables a safe and effective repair in all forms of AAOCA without concomitant coronary artery disease.

Exposure of difficult left hilum in bilateral sequential lung transplantation.

Left hilar exposure can be challenging during bilateral sequential lung transplantation, particularly in patients with idiopathic pulmonary fibrosis due to the overlying heart and limited space. We describe a cost-effective technique that has been used in off-pump cardiopulmonary bypass to retract the heart away from the left hilum, without causing hemodynamic instability, thereby allowing implantation of the left lung without the use of cardiopulmonary bypass.

Alternative technique for salvage of donor lungs with insufficient atrial cuffs.

Inadequate left atrial cuff surrounding donor pulmonary veins may present a technical challenge for successful lung transplantation. A simple technique for construction of venous anastomoses during lung transplantation when donor atrial cuff is lacking involves circumferential incorporation of surrounding donor pericardium into the anastomosis without directly suturing or augmenting donor venous structures.

Pulmonary resection of metastatic hepatocellular carcinoma after liver transplantation.

BACKGROUND: The primary limitation to long-term survival after liver transplantation for hepatocellular carcinoma (HCC) is tumor recurrence. Pulmonary resection for metastatic HCC prolongs survival in patients after liver resection; this success may be extrapolated to the transplant population in the treatment of pulmonary recurrence of HCC after liver transplantation. METHODS: Between January 2000 and January 2006, five patients who underwent orthotopic liver transplantation for HCC were identified on routine follow-up with pulmonary metastases. They all underwent resection of the pulmonary recurrence of HCC and were studied retrospectively. RESULTS: The time from transplant to diagnosis of pulmonary recurrence ranged from 150 days to 880 days, with a mean of 500 days. All of the recurrences were amenable to complete resection. Two patients developed a second tumor. One patient had a new primary of squamous cell carcinoma. Another patient had a bony recurrence of HCC in the ninth rib. Four of the patients are still alive, and the fifth died from hepatic failure. The stage of the tumor in the explanted liver ranged from II to IVb. The average time for survival from transplant was 44 months, and the average time from pulmonary resection was 27.5 months. CONCLUSIONS: The patients in this study demonstrate survival times similar to patients with HCC treated with liver resection. Although the size of the study population is small, the long survival times in the patients is encouraging. The advanced stage and histologically invasive nature of the primary tumors may predispose to subsequent pulmonary recurrence.