Minimally invasive periareolar approach to repair sinus venosus atrial septal defect with partial anomalous pulmonary venous connection.

BACKGROUND AND AIM: Atrial septal defects with anomalous venous connections are commonly repaired via sternotomy, requiring careful baffle reconstruction to redirect pulmonary venous return and ensure a durable result. The cosmetically appealing periareolar incision may provide an esthetically superior alternative to the anterolateral minithoracotomy incision used in minimally invasive cardiac surgery. METHODS: We describe a patient with a sinus venosus atrial septal defect and partial anomalous pulmonary venous connection who underwent successful minimally invasive, endoscopic repair with apical vein translocation and autologous pericardial baffle reconstruction through a periareolar approach. RESULTS: Post-operative echocardiography demonstrated excellent results with no residual shunt and a widely patent baffle and preserved biventricular function. At 1-year post-op, our patient has had a greatly improved quality of life and an excellent cosmetic result with normal nipple-areolar sensation. CONCLUSIONS: We believe that periareolar approaches should be considered for all adult patients with simple and complex atrial septal defects.

[Strategy of transfusion in cardiac and aortic surgery].

Current trend in transfusion is a decreasing of the donor's blood use due to possible complications. The article deals with analysis of intraoperative blood loss in different surgeries on the heart and aorta and of a role of blood-saving factors in decreasing of the donor's blood transfusion. We found a correlation between the blood components need and type of surgery and assessed a preoperative provision of autoplasma and intraoperative autohemotransfusion with a blood sampling from the right atrium before the beginning of artificial circulation (Complex use of the blood-saving methods with a prophylactics and treatment of hemostasis disturbances allowed the significantly decreasing of the donor's blood use. 50-70% of patients did not receive components of the donor's blood during cardiac surgery.

Surgical ablation of refractory ventricular tachycardia in patients with nonischemic cardiomyopathy.

BACKGROUND: The surgical approach for the treatment of ventricular tachycardia (VT) has been largely replaced by percutaneous, catheter-based techniques. However, some VT circuits, particularly in patients with nonischemic cardiomyopathy, remain inaccessible to percutaneous ablation. Surgical therapy of these VTs is an alternative approach; however, its methodology has not been well defined. The purpose of this study was to evaluate the efficacy of preoperative electroanatomic and electrophysiological characterization of the VT substrate and circuit to guide surgical ablation. METHODS AND RESULTS: Eight patients with recurrent sustained VT refractory to antiarrhythmic drugs underwent endocardial and/or epicardial ablation procedures. Electroanatomic mapping was performed, and the VT substrate and circuit(s) were defined using voltage, activation, entrainment, and pace mapping. All 8 patients underwent detailed endocardial mapping; 6 patients also underwent epicardial mapping. Radiofrequency ablation was performed with the use of an open-irrigation catheter. After the unsuccessful percutaneous approach, surgical cryoablation was applied to the sites previously identified and targeted during the percutaneous procedure. There were no significant perioperative complications. During a mean follow-up period of 23 ± 6 months (range, 15 to 34 months), 6 patients had significant reduction in VT burden as evident by a reduced number of implantable cardioverter-defibrillator shocks after ablation (6.6 to 0.6 shocks per patient; P = 0.026). Two patients died, one of progressive heart failure and one of sepsis. CONCLUSIONS: VT circuits inaccessible to percutaneous ablation techniques are rare but can be encountered in patients with nonischemic cardiomyopathy. These VTs can be successfully targeted by surgical cryoablation guided by preoperative electroanatomic and electrophysiological mapping.

Recent advances in perioperative medicine: highlights from the literature for the cardiothoracic and vascular anesthesiologist.

There have been major advances in perioperative cardiothoracic and vascular medicine. Because of promising data, steroids, statins, and endothelin antagonists are being clinically tested in randomized trials with adult cardiac surgical patients. In vascular surgical patients, recent meta-analysis has revealed that interventions such as beta-blockade or endovascular stenting for peripheral vascular lesions may not improve outcome overall. Furthermore, a landmark trial has shown that anesthetic technique does not affect outcome after carotid endarterectomy. The surgical Apgar score may become part of routine clinical care of the vascular surgical patient because it predicts outcome and can be calculated at the bedside. Recent studies confirm that the serious perioperative risks of hyperglycemia also apply to nondiabetic and pediatric cardiac surgical patients. This has been highlighted in the new guidelines from the Society of Thoracic Surgeons. Perioperative myocardial protection is possible with ischemic preconditioning and omega-3 fatty acids. Pneumonia after lung resection may be reduced significantly by broadening antibiotic prophylaxis. Transfusion-related acute lung injury has immediate and delayed presentations that highlight the dangers of blood transfusion. Perioperative renal dysfunction after adult cardiac surgery is significantly reduced by the infusion of sodium bicarbonate. Although promising, further trials are required. Taken together, these recent advances will have significant influence on the future practice of cardiovascular and thoracic anesthesia as the ongoing search for perioperative outcome improvement achieves results.

The efficacy and safety of extending the ischemic time with a modified cardioplegic technique for coronary artery surgery.

BACKGROUND AND AIM: The need to intermittently discontinue the administration of cardioplegia in order to complete the surgical procedure is a major drawback of antegrade warm blood cardioplegia. An ischemic time of 15 minutes is generally considered safe based on empirical observation. The aim of this study was the evaluation of the efficacy and safety of an intermittent warm blood cardioplegia with intervals between administrations prolonged to 25 minutes. METHODS: Ninety-seven patients undergoing primary elective coronary artery revascularization were prospectively randomized into two groups. The first, Intermittent Antegrade Warm Blood Cardioplegia (IAWBC) group, comprising 49 patients, received standard intermittent antegrade warm blood cardioplegia repeated every 15 minutes. The second, Modified Intermittent Antegrade Warm Blood Cardioplegia (M-IAWBC) group, comprising 48 patients, received intermittent antegrade warm blood cardioplegia supplemented with magnesium sulfate (MgSO(4)), delivered in volumes proportional to the ventricular mass and repeated every 25 minutes. The clinical outcomes were evaluated. The levels of creatine kinase-MB (CK-MB) isoenzyme, in addition to the echocardiographic assessment of septal dyskinesia and tricuspid annulus plane systolic excursion (TAPSE), have been used as markers of myocardial damage. RESULTS: There were no statistically significant differences in clinical outcomes, need for inotropes and vasodilators, length of stay in the intensive care unit, and postoperative levels of CK-MB between the two groups. Likewise, postoperative echocardiographic assessment showed no relevant differences. CONCLUSIONS: Administration of warm antegrade cardioplegic solution supplemented with MgSO(4), delivered in volumes proportional to ventricular mass every 25 minutes, provides adequate myocardial protection for coronary artery surgery.

Method of propulsion of a ferromagnetic core in the cardiovascular system through magnetic gradients generated by an MRI system.

This paper reports the use of a magnetic resonance imaging (MRI) system to propel a ferromagnetic core. The concept was studied for future development of microdevices designed to perform minimally invasive interventions in remote sites accessible through the human cardiovascular system. A mathematical model is described taking into account various parameters such as the size of blood vessels, the velocities and viscous properties of blood, the magnetic properties of the materials, the characteristics of MRI gradient coils, as well as the ratio between the diameter of a spherical core and the diameter of the blood vessels. The concept of magnetic propulsion by MRI is validated experimentally by measuring the flow velocities that magnetized spheres (carbon steel 1010/1020) can withstand inside cylindrical tubes under the different magnetic forces created with a Siemens Magnetom Vision 1.5 T MRI system. The differences between the velocities predicted by the theoretical model and the experiments are approximately 10%. The results indicate that with the technology available today for gradient coils used in clinical MRI systems, it is possible to generate sufficient gradients to propel a ferromagnetic sphere in the larger sections of the arterial system. In other words, the results show that in the larger blood vessels where the diameter of the microdevices could be as large as a couple a millimeters, the few tens of mT/m of gradients required for displacement against the relatively high blood flow rate is well within the limits of clinical MRI systems. On the other hand, although propulsion of a ferromagnetic core with diameter of approximately 600 microm may be possible with existing clinical MRI systems, gradient amplitudes of several T/m would be required to propel a much smaller ferromagnetic core in small vessels such as capillaries and additional gradient coils would be required to upgrade existing MRI systems for operations at such a scale.

A modified combined approach to operative carotid and coronary artery disease: 82 cases in 8 years.

BACKGROUND: A significant number of patients undergoing coronary artery surgery have severe carotid artery disease. It is also true that up to half of the patients undergoing carotid endarterectomy (CEA) have severe treatable coronary lesions. This study aims to review data regarding 82 patients of combined approach in 8 years; the second half consists of 44 patients whose CEA was performed under local anesthesia. It compares results of the conventional and the modified approaches to simultaneous surgery. METHODS: All 82 patients who planned to have a concomitant procedure were recorded prospectively between 1995 and 2003. From 1998, the surgical technique has been modified to switch to local anesthesia for CEA, rather than perform under a single general anesthetic period. All pre-and perioperative data as well as in-hospital and outpatient control (mid- to long-term) data were recorded. A P-value of less than .05 was considered as significant. Analysis of survival was performed by using the Kaplan-Meier method and the log-rank test. RESULTS: The 30-day follow-up was 100% complete for all patients. All patients were followed for 59.59 to 114 months) months postoperatively. Three patients (6.8%) in the modified and 2 (5.2%) in the standard group had intraluminal shunting (P > .05). In the standard group, 3 patients expired and 3 had perioperative stroke; only 1 patient had a stroke in the modified group and two expired (P > .05). Mean survival time according to Kaplan-Meier test was 109.97, SE 2.84, 95% CI (104.41-115.52) months for the former group, whereas it was 62.79, SE 1.20, 95% CI (60.4565.13) months for the latter. Actuarial estimates of survival during ten-year follow up were 94.44% SE 3.83 in ten-year follow-ups and 97.67% SE 2.30 in 5-year follow-ups for the modified group (P > .05). CONCLUSIONS: Avoidance from extended periods of general anesthesia and cardiopulmonary bypass periods as well as immediate recognition of impaired cerebral flow during CEA and the time it provides to take preventive measures are the most important benefits of the modified technique without significantly changing hospital and long-term mortality and stroke. It may also reduce the cost and the waiting period for the suffering patient.

[Preoperative autologous blood donation in elderly patients with cardiovascular surgery].

BACKGROUND: During the cardiovascular surgeries in elderly people, only a few cases can avoid the homologous blood transfusion, because of their preoperative anemic tendency and low hemopoietic abilities. We examined the capability to avoid the homologous blood transfusion in over 75 year old patients by the preoperative autologous blood collection. Sixty-six patients underwent scheduled cardiovascular surgery between January 1996 and December 1999. The groups were divided into three categories of preoperatively collected autologous blood amounts: high-amount (800-1,200 ml), medium-amount (200-800 ml), and low-amount (0 ml). Each group was divided into two subgroups in according to the use of cardiopulmonary bypass (CPB). There were no differences among the each group in age, body weight, or preoperative and postoperative day-7 hematocrit values. RESULTS: Only 21.2% of patients could donate the expected blood amounts preoperatively. Mean volume was 641 ml. In groups used CPB, no patient was transfused homologous blood in high-amount group. On the contrary, 100% patients were donated in medium and low amount groups. In groups operated without CPB, homologous blood transfusion was required 14.3% in high-amount group, 25.0% in medium-amount group, and 83.3% in low-amount group. CONCLUSION: It seems that predonation of more than 800 ml may be sufficient to avoid the homologous blood transfusion in using CPB operation and more than 400 ml in non using CPB operation.

Tissue engineering in cardiovascular surgery: new approach to develop completely human autologous tissue.

OBJECTIVE: In cardiovascular tissue engineering, three-dimensional scaffolds serve as physical supports and templates for cell attachment and tissue development. Currently used scaffolds are still far from ideal, they are potentially immunogenic and they show toxic degradation and inflammatory reactions. The aim of this study is to develop a new method for a three-dimensional completely autologous human tissue without using any scaffold materials. METHODS: Human aortic tissue is harvested from the ascending aorta in the operation room and worked up to pure human myofibroblasts cultures. These human aortic myofibroblasts cultures (1.5x10(6) cells, passage 3) were seeded into 15-cm culture dishes. Cells were cultured with Dulbecco' s modified Eagle's medium supplemented with 1 mM L-ascorbic acid 2-phosphate for 4 weeks to form myofibroblast sheets. The harvested cell sheets were folded to form four-layer sheets. The folded sheets were then framed up and cultured for another 4 weeks. Tissue development was evaluated by biochemical assay and light and electron microscopy. RESULTS: After 4 weeks of culture in ascorbic acid supplemented medium, myofibroblasts formed thin cell sheets in culture dishes. The cell sheets presented in a multi-layered pattern surrounded by extracellular matrices. Cultured for additional 4 weeks on the frames, the folded sheets further developed into more solid and flexible tissues. Light microscopy documented a structure resembling to a native tissue with confluent extracellular matrix. Under transmission electron microscope, viable cells and confluent bundles of striated mature collagen fibers were observed. Hydroxyproline assays showed significant increase of collagen content after culturing on the frames and were 80.5% of that of natural human pericardium. CONCLUSIONS: Improved cell culture technique may render human aortic myofibroblasts to a native tissue-like structure. A three-dimensional completely autologous human tissue may be further developed on the base of this structure with no show toxic degradation or inflammatory reactions.

Blood transfusion support in pediatric cardiovascular surgery.

The majority of children who undergo open-heart surgery with cardiopulmonary bypass (CPB) require perioperative blood transfusion. Blood product requirements are affected by factors such as patient age, underlying cardiac disease, complexity of the surgical procedure, and hemostatic alterations induced by CPB. Transfusion support may include the use of whole blood and/or individual blood components with transfusion practices varying widely based on individual preferences and blood product availability. Approaches to limit allogeneic blood exposure include the use of modified ultrafiltration and smaller bypass circuits, preoperative autologous blood donation and intraoperative blood salvage, and adjunctive antifibrinolytic agents. Potential advantages and disadvantages of the different blood products and pharmacological agents must be considered in managing the pediatric cardiac surgery patient.