Retrospective record review on timing of COVID-19 vaccination and cardiac surgery.

BACKGROUND: Novel clinical challenges are faced by cardiac surgeons under the coronavirus disease 2019 (COVID-19) pandemic. Amidst the uncertainties faced due to the socioeconomic and public health impact, there is little evidence surrounding COVID-19 vaccination in patients undergoing cardiac surgery. Timing of vaccination and postvaccination adverse effects are required parameters to discuss with cardiac surgical patients. METHODS: This is a single-center, retrospective observational study. All patients who underwent adult cardiac surgery at the Prince of Wales Hospital, Hong Kong from January 2021 to December 2021 were included. Postoperative clinical outcomes, COVID-19 vaccination status, and vaccination-related adverse effects were collected. RESULTS: A total of 426 patients; 117 (27%) underwent isolated coronary artery bypass grafting, 111 (26%) underwent valvular surgery, and 97 (23%) underwent aortic surgery. Patients received either Sinovac CoronaVac or Pfizer BNT162b2 vaccine. Overall vaccination rate with at least 1 dose was 52% (n = 212), 15% (n = 63) received the first dose before surgery, 36% (n = 149) received the first dose vaccination after surgery. Rate of completion with second and third doses of vaccination were 22% (n = 89) and 4.9% (n = 20), respectively. The mean timing of first dose of vaccine after surgery was 216 ± 84 days from operation. Three (1.4%) patients recorded vaccination-related complications. CONCLUSIONS: COVID-19 vaccination is safe in patients who received major cardiac surgery, with low adverse effects recorded and no vaccine-related mortality observed. A time frame of 3-6 months after cardiac surgery receiving COVID-19 vaccination is reasonable and could serve as a guidance for future COVID-19 vaccination booster programs.

Initial Asian experience of the branched E-vita open NEO in complex aortic pathologies.

Background: Aortic arch pathology often requires staged segmental repairs. Total aortic arch replacement with frozen elephant trunk (FET) offers surgical options for these pathologies. The Jotec E-vita Open NEO™ branched prosthesis was introduced in 2020; we sought to share our initial experience focusing on the prosthesis selection strategies, surgical techniques, anastomosis-bleeding and graft-oozing control methods, and early clinical outcomes from two Asian centers. Methods: We performed a retrospective cohort study in patients with aortic arch pathologies who underwent total arch replacement using the FET procedure with Jotec E-vita Open NEO™ branched prosthesis from two Asian centers between October 2020 and August 2021. The primary outcome was overall 30-day mortality, and the secondary outcomes were operative complications. Results: Twenty-five consecutive patients underwent total arch replacement with FET with the novel hybrid prosthesis. Overall 30-day mortality from both centers was 0%. Overall mean operative, cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion times were 353.4±80.5, 183.2±39.6, 57.2±14.7, and 138.2±28.6 minutes, respectively. No patient developed stroke. Permanent spinal cord injury (SCI) was recorded in one patient (4%) and one (4%) had transient lower limb weakness that resolved after spinal drainage. There was no requirement of re-sternotomy for hemostasis. Conclusions: We reported a multicenter Asian case series with the novel FET hybrid prosthesis demonstrating the feasibility and safety of promising initial clinical outcomes. The technique of circumferential reinforcement of vascular anastomosis for hemostasis may be one of the methods for lowering the rates of re-sternotomy for hemostasis, and proper surgical or transfusion strategies would overcome the excessive oozing of the prosthesis. Long-term follow-up is required for further evaluation of aortic pathology progression and device-related outcomes.

Coronary endarterectomy in coronary artery disease: Factors affecting graft patency and survival.

BACKGROUND: Coronary endarterectomy aims to improve completeness of revascularization in patients with occluded coronary vessels. The benefits of coronary endarterectomy remain uncertain. The aim of this study was to evaluate short-term surgical outcomes and factors affecting graft patency post-coronary endarterectomy. METHODS: Between 2009 and 2019, 81 consecutive patients who had coronary endarterectomy done were evaluated for their perioperative and early results. A total of 36 patients with follow-up coronary studies were included in patency analysis. Mortality rates, major adverse cardiac and cerebrovascular events, and graft patency were outcomes of interest. Survival and risk factor analysis were performed with Kaplan-Meier and logistic regression analysis. RESULTS: The average age of the cohort was 61.9 ± 9.29 years. Complete revascularization rate was 95.4% post-coronary endarterectomy. The 30-day and 1-year mortality was 2.5 and 6.2%, respectively. One-year major adverse cardiac and cerebrovascular events rate was 11.1%. Periprocedural myocardial infarction rate was 7.4%. Three patients required repeat revascularization within a mean follow-up duration of 49.6 ± 36.5 months. Overall graft patency was 89.2% at 20.2 months and graft patency post-coronary endarterectomy was 85.4%. Arterial grafts showed 100% patency. Vein grafts to endarterectomized obtuse marginal branch had patency rates of 33.3%. Multiple endarterectomies were associated with worse one-year major adverse cardiac and cerebrovascular events (OR: 28.6 ± 1.16; P = 0.003). CONCLUSIONS: Coronary endarterectomy facilitates completeness of revascularization and does not increase early mortality. Graft patency post-coronary endarterectomy on obtuse marginal artery was suboptimal. Judicious use of coronary endarterectomy should be practiced to balance the need of completeness of revascularization against the risk of myocardial infarction.

Total Aortic Arch Replacement and Frozen Elephant Trunk.

Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement and frozen elephant trunk had evolved over last decades with promising mid-term outcomes. We evaluate our mid-term outcomes on total arch replacement with frozen elephant trunk and the role of timely second staged interventions. Between August 2014 and April 2020, 41 patients with aortic arch pathologies underwent total arch replacement with frozen elephant trunk with Thoraflex-Hybrid-Plexus device (Vascutek, Inchinnan, Scotland). Patients' perioperative, clinical and radiological outcomes were reviewed. Post discharge survival (n = 37) at 3 year was 100%. Overall survival of 85.3% over a median follow up of 3.3 years, inpatient mortality of 9.8%. Distribution of aortic pathologies with acute type A dissection or intramural hematoma (n = 15, 36.6%), thoracic aortic aneurysm, including arch and descending aortic aneurysm (n = 9, 22%) and chronic aortic dissection including chronic type A and type B dissections (n = 13, 31.7%). Mean operative, circulatory arrest, and antegrade cerebral perfusion time were 417 ± 121 minutes, 89 ± 28 minutes, and 154 ± 43 minutes, respectively. Second stage procedures were performed in 32% and distal stent graft induced new entry was observed in 19% of patients. We reported an Asian series of Thoraflex with outstanding midterm clinical outcomes, given descending aortic pathologies were tackled with a timely second stage interventions. The observation of aortic remodeling and distal stent graft induced new entry requires further investigations.

Open descending aortic replacement after Thoraflex hybrid graft implantation.

The Thoraflex hybrid graft has been widely used around the world to allow a single-stage treatment for multi-segment aortic pathologies. The distal stent graft component of the Thoraflex has made it exceptionally easy for endovascular second-stage procedures when compared with the floating elephant trunk. However, published reports on operative techniques for open second-stage procedures after Thoraflex are limited. In this video tutorial we describe our open second-stage after Thoraflex with special focus on the ideal anastomosis technique to achieve good hemostasis and an optimal surgical outcome.

10-year outcomes post coronary artery bypass grafting in Asian patients with ischemic cardiomyopathy: a comprehensive analysis of survival and cardiac performance.

BACKGROUND: Coronary artery bypass grafting (CABG) is the standard of care for patients with ischemic cardiomyopathy (ICM). Despite recent evidence supporting the role of CABG, long term outcomes for patients with ICM remain poor and 10-year results post CABG in ICM patients are under-reported, especially among Asians. Uncertainty on whether CABG improves cardiac performance and survival in the long term remains. In this study, we aim to analyze 10-year results concerning cardiac performance and survival post CABG in Asian patients with left ventricular ejection fraction (LVEF) ≤35% and predominant heart failure symptoms, and identify perioperative risk factors affecting long term survival and cardiac function. METHODS: Thirty-six patients with LVEF <35% who had CABG performed between the year 2006-2009 were selected from local hospital records for retrospective analysis. Outcomes of interest included post-operative cardiac symptoms, LVEF & 10-year all-cause and cardiac-event free survival. Survival analysis was performed using Kaplan Meier analysis, and predictive factors were identified with log- rank test and logistic regression analysis. RESULTS: The mean age of the cohort was 62.9±9.9 years. Operative mortality within 30 days was 5.6%. The 10-year all-cause mortality rate was 55.6%. The mean duration of survival was 105.9±8.3 months. Of the patients who did not survive till 10 years, 65.0% died of cardiac-related causes, with non-ST elevation myocardial infarction being the commonest cause. CABG improved LVEF (24.9% to 32.2%; P<0.001) and 66.7% of patients remained with impaired LVEF ≤35% post CABG. Post op NYHA class 3-4 symptoms (OR: 6.3; P=0.012) was the only predictive factor for 10 year all-cause mortality and post op LVEF improvement ≥5% (OR: 5.8; 95% CI, 1.1-29.9; P=0.036) was associated with improvement in NYHA class. Completeness of revascularization and viability of myocardium were not predictive of survival or changes in LVEF or NYHA class. CONCLUSIONS: The 10-year survival rates of Asian patients with ICM were similarly disappointing as its counterparts in the west. A majority of patients still suffered from cardiac-event related deaths. Post CABG NYHA class was found to be important in determining success and adequacy of treatment in patients with ICM and improvement in LVEF ≥5% was predictive of improvement of symptoms. Neither completeness of revascularization or presence of myocardial viability had any impact on survival in our patient cohort.

Application of Cerebral Protection System in Open Mitral Replacement with Extensive Calcified Left Atrial Thrombus.

Neurological complications remain a major burden in cardiac surgery, despite various intraoperative measures attempting to reduce its occurrence. Advancement of percutaneous approach in valve replacement has brought focus to the use of cerebral protection system (CPS). We reported a novel application of percutaneous CPS in open heart surgery for a patient with an extensive calcified left atrial thrombus to reduce risk of embolic stroke. Although, there is no evidence to advocate routine use of CPS in all open cardiac surgical patients, we believe it is a technically feasible and probably safe approach for neurological protection in high-risk patients.

Epithelioid haemangioendothelioma of the anterior skull base: what is the optimal treatment?

We report an unusual malignant tumour affecting an unusual site. Epithelioid haemangioendothelioma was formerly considered a tumour of intermediate malignancy but has been reclassified as fully malignant. It is important to be aware of this clinical entity as the best hope of cure is timely radical resection. There is a paucity of evidence concerning the efficacy of alternative treatments because the tumour is very rare.

Endovascular Fenestration for Distal Aortic Sealing After Frozen Elephant Trunk With Thoraflex.

We describe a case of total arch replacement with frozen elephant trunk for chronic type B aortic dissecting aneurysm, which resulted in inadvertent landing of the frozen elephant trunk into the false lumen. A radiofrequency puncture system-assisted controlled endovascular fenestration of the dissection flap was performed at the upper abdominal aorta and subsequent thoracic endovascular stenting, successfully redirecting the blood flow from the false to the true lumen. Our case illustrated a possible way to seal distal reentry in chronic type B aortic dissection.

Transcatheter aortic valve implantation: the transaortic approach.

Background Transcatheter aortic valve implantation has been established as a safe and effective treatment option for patients at high or prohibitive surgical risk. However, some patients may not be suitable for the transfemoral approach due to severe iliofemoral disease or aneurysmal disease of the thoracoabdominal aorta. The aim of this case series was to evaluate the feasibility and clinical outcomes of the transaortic approach. Methods From May 2015 to June 2016, 5 patients (mean age 78.4 ± 3.9 years) with severe symptomatic aortic stenosis underwent transaortic transcatheter aortic valve implantation after a heart team discussion. They were considered to be at high surgical risk and ineligible for the transfemoral approach due to iliofemoral or thoracoabdominal aortic disease. Results A CoreValve Evolut R was successfully deployed in all 5 patients. We performed 4 right mini-parasternal incisions and one J-incision partial sternotomy. None of the patients required permanent pacemaker implantation, one required reopening of the mini-parasternal incision for postoperative bleeding. Follow-up echocardiography one month after the procedure showed improvement in the mean aortic gradient (from 63.2 to 8.3 mm Hg) and aortic valve area (from 0.62 to 2.2 cm2). None of the patients had more than mild paravalvular leakage. There was no intraoperative or 30-day mortality. Conclusion Transaortic transcatheter aortic valve implantation is a safe and feasible option for patients with severe aortic stenosis who are considered unsuitable for transfemoral aortic valve implantation.

Mycotic aortic arch aneurysm coexistent with constrictive pericarditis: is surgery a dangerous resort?

An elderly man presented with fever and evidence of Salmonella infection, and was diagnosed to have coexisting constrictive pericarditis and mycotic aneurysm of the aortic arch. Pericardiectomy was performed under cardiopulmonary bypass with good result. To avoid deep hypothermic circulatory arrest, an aorto-brachiocephalic bypass, instead of total arch replacement, was performed. This was followed by a staged carotid-carotid bypass, thoracic endovascular stent graft placement. He was subsequently treated with prolonged antibiotics, and inflammatory marker normalized afterwards. He was last seen well 2 years after the operation. Follow-up computer tomography (CT) scan at 18 months post-op showed no evidence of endoleak or fistulation. Our case demonstrated that a hybrid treatment of open pericardiectomy and aortic debranching followed by thoracic endovascular stent graft placement is feasible and associated with satisfactory mid-term outcome.

Hypoxemia associated with right-side cardiac tumor: right atrial lymphoma with patent foramen ovale.

A 66-year-old man presented with acute type I respiratory failure, and was diagnosed to have a huge mass occupying the right atrium (RA) of the heart, with no evidence of pulmonary embolism. Intra-operative transesophageal echocardiogram identified a patent foramen ovale (PFO) with right-to-left shunt apart from a huge right atrial tumor arising from the atrioventricular groove. The tumor was debulked, and the patent foramen was closed. Patient had an uneventful recovery and WAS discharged on post-operative day 7. Pathology revealed diffuse large B-cell lymphoma (DLBCL). The patient was further treated with adjuvant chemotherapy and remained well 1 year after surgery. This case illustrates the importance of meticulous echocardiographic examination to look for any intracardiac shunts in the case of hypoxemia associated with a right-sided cardiac tumor. We advocate surgery as the most important initial management to maximize survival, as it allows correction of any hemodynamic sequelae, and simultaneous attainment of definite histological diagnosis for guidance of adjuvant therapy.

Preemptive Aneurysm Sac Embolization for Thoracic Endovascular Aortic Repair With Inadequate Proximal Landing Zone.

Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment for aortic arch aneurysms. Clinical challenges arise when there is inadequate proximal landing for zone 1 TEVAR, such that a median sternotomy with total aortic debranching is required before stent deployment. The chimney technique was reported as an alternative approach to stent the arch branches and avoid sternotomy, but it was still associated with considerable chance of a type IA endoleak. We report a case of aortic arch aneurysm with an inadequate proximal landing for zone 1 TEVAR that was treated with debranching of head and neck vessels followed by TEVAR and preemptive and targeted coil embolization of the arch aneurysmal sac. Postoperative computed tomography showed no significant endoleak, and the patient had an unremarkable recovery.

Coil Embolization of Diverticulum of Kommerell: A Targeted Hybrid Endovascular Technique.

A 57-year-old man was incidentally found to have a dissected diverticulum of Kommerell originating from aberrant origin of right subclavian artery during follow-up for treated colon cancer. A right carotid-axillary bypass was followed by embolization of aberrant artery and the diverticulum by deployment of multiple detachable coils using the Penumbra Ruby System (Penumbra, Alameda, CA). Angiography after embolization showed exclusion of flow to the aberrant artery and a patent right carotid-axillary bypass. The patient recovered uneventfully and remained well for 12 weeks after the operation, without any complications. We believe this targeted endovascular approach can avoid complications related to the coverage of thoracic aorta and reduce the risk of access vessel trauma.

Mitral valve repair using a semirigid ring: patient selection and early outcomes.

BACKGROUND: Commonly used complete mitral annuloplastic rings include saddle-shaped and semirigid rings, with no clear indication for either type. A semirigid ring may be preferred in patients whose native mitral saddle shape is well maintained. We present our experience of using semirigid rings for mitral valve repair. METHODS: We routinely measured the annular height-to-commissural width ratio by 3-dimensional transesophageal echocardiography prior to mitral repair. We generally chose a semirigid (Memo 3D) ring in patients whose annular height-to-commissural width ratio was normal (≥ 15%). The same semirigid ring with an additional chordal guiding system (Memo 3D ReChord) was selected for patients with anterior leaflet or bileaflet pathology. Over an 18-month period, 66 patients with severe degenerative (n = 60) or functional (n = 6) mitral regurgitation had Memo 3D (n = 32) or Memo 3D ReChord (n = 34) rings implanted. RESULTS: Postoperative 3-dimensional transesophageal echocardiography was completed in all patients (mean follow-up 7 ± 5 months). The majority of patients had no or mild residual mitral regurgitation; only two had moderate (2+) mitral regurgitation. There was no mortality at 30-days or on midterm follow-up. CONCLUSIONS: Our series represents the first Asian clinical experience using the Memo 3D ReChord ring. Although the long-term durability of mitral repair with this type of semirigid annuloplastic ring warrants further validation, our current clinical data are encouraging.

Hybrid DynaCT scan-guided localization single-port lobectomy. [corrected].

Small pulmonary lesions can be difficult to locate intraoperatively. Preoperative CT scan-guided localization, for example with hookwire, is a popular method to help localize such lesions. However, the delay between CT scan localization with hookwire and surgery can lead to risks of pneumothorax and wire dislodgement. We describe a 56-year-old woman who underwent DynaCT-guided hookwire localization of a ground-glass opacity in the hybrid operating room followed immediately by single-port video-assisted thoracic surgery lobectomy. The advantages, disadvantages, and special considerations in adopting this approach are discussed.

Delayed fracture of MatrixRIB precontoured plate system.

OBJECTIVES: Use of titanium prostheses for reconstructing chest wall defects following major chest wall resections is rapidly increasing in popularity. Previously, complications including prosthesis fracture have been reported for the system secured to the rib ends using clips following chest wall reconstruction and pectus excavatum repair. By contrast, fracture failure in titanium systems fastening the plate to the rib with locking screws through predrilled holes has not been previously reported, possibly owing to differences in the design and material of the system. METHODS: We report an index case of plate fracture in the latter design following rib reconstruction and discuss the pathophysiology and relative risks behind such fractures. RESULTS: Fracture of titanium plate occurred after chest impact during sport at 25 months following initial plate implantation. Surgical excision was performed because of persistent pain and cough. CONCLUSIONS: Fracture failure can occur in those systems fastening the plate to the rib with locking-screws, and patients, particularly those engaged in contact sports or occupations with chest impact risks, should be informed of this possibility during consent, as surgical removal is most likely required following implant fracture failur.

Bone morphogenic protein-4 contributes to venous endothelial dysfunction in patients with diabetes undergoing coronary revascularization.

BACKGROUND: Hyperglycemia-induced venous endothelial dysfunction accelerates the progression of vein graft failure in patients with diabetes undergoing surgical coronary revascularization. Recent studies suggest the importance of bone morphogenic protein-4 (BMP4)-induced arterial endothelial dysfunction in the development of hypertension and atherosclerosis. The present study investigated the potential role of BMP4 in the pathogenesis of venous endothelial dysfunction in the setting of diabetes. METHODS: Segments of saphenous vein from pigs and from patients with diabetes or patients without diabetes, as well as human umbilical venous endothelial cells (HUVECs), were used. The changes of BMP4 expression in veins from patients and in HUVECs cultured under hyperglycemic conditions were evaluated by Western blot assay. The effects of BMP4 on the production of reactive oxygen species (ROS) and endothelium-dependent venous relaxation were assessed by using dihydroethidium fluorescence and isometric tension measurements, respectively. RESULTS: The impaired venous endothelium-dependent relaxations (2.9%±4.8% versus control group 74.1%±10%; p<0.01) accompanied by markedly increased BMP4 expression were observed in the diabetic group. The level of BMP4 expression in HUVECs treated with high levels of glucose were elevated in a glucose concentration-dependent manner. Ex vivo treatment with the BMP4 antagonist noggin significantly improved endothelium-dependent relaxations and inhibited accumulation of ROS in saphenous veins from patients with diabetes. Noggin treatment had no effect on the venous endothelium-dependent relaxations in individuals without diabetes. Meanwhile, BMP4 inhibited acetylcholine-induced relaxation (control group, 90%±7.1% versus BMP4-treated group, 52%±12.6%; p<0.05) and enhanced ROS production in porcine saphenous veins. Such harmful effects were again reversed by noggin. CONCLUSIONS: The increased BMP4 expression and related ROS overproduction may play an important role in the development of hyperglycemia-induced venous endothelial dysfunction.