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OBJECTIVE: Reoperative surgery for isolated tricuspid valve (TV) pathology has been associated with high morbidity and mortality rates; however, the current guidelines recommend intervention for severe, symptomatic TV regurgitation or mild to moderate symptoms with progressive right ventricular dysfunction. There are minimal data regarding reoperative intervention for TV disease. Similarly, there are no large series describing robot-assisted reoperative TV surgery. METHODS: Institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database data were used to identify patients with previous cardiac surgery undergoing robot-assisted TV surgery from 2017 to 2022 from 2 tertiary referral hospitals. Patient demographics, preoperative characteristics, disease progression, operative details, and outcomes were analyzed. The primary outcome was 30-day mortality. Secondary outcomes were 30-day readmission, length of stay, and adverse events. Descriptive and summative statistics were used to describe clinical data and examine differences in outcomes of patients with primary versus secondary etiology using bivariate analyses. RESULTS: Twenty-four patients were divided into 2 arms, primary TV pathology and secondary dysfunction due to comorbid cardiac conditions. The overall mortality was 8.3%. Major complications, including respiratory failure, renal failure, and reoperation were 12.5%, 8.3%, and 8.3%, respectively. No permanent pacemakers were required, and the 30-day readmission rate was 4.5%. CONCLUSIONS: Reoperative robotic TV surgery is a safe and viable alternative to traditional sternotomy for both primary and secondary TV pathology. TV repair and replacement are possible using the minimally invasive technique. The morbidity and mortality rates are acceptable when compared with traditional approaches with decreased need for pacemaker placement in the minimally invasive approach.
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Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) devices are well-established adjunctive treatment measures for patients with heart failure. ECMO can serve as a bridge to transplant in a chronic setting or as a salvage therapy for patients who are unable to be weaned from bypass following cardiac surgery. However, the role of ECMO as a bridge to definitive therapy in a setting of acute heart failure is less established. Similarly, the treatment of patients using combined ECMO and ECLS devices has been, at times, shown to show some benefit; however, these benefits have not been widely studied. In this study, we present the case of a patient who was diagnosed with severe acute onset heart failure secondary to torrential mitral regurgitation following COVID-19 pneumonia. The patient was emergently placed on venoarterial (VA) ECMO with an indwelling centrifugal pump device in the left ventricle. This combination of ECMO and ECLS served as a bridge to open mitral valve replacement 6 days after presentation. Following successful mitral valve replacement, the patient had persistent right ventricular failure, and therefore, a decision was made to incorporate venovenous (VV) ECMO into the VA ECMO circuit. This technique resulted in a VV-VA or VPa-VA configuration, as oxygenated blood was being returned to the pulmonary artery as well as the descending aorta. VA ECMO was discontinued after 4 days of therapy, and the patient was extubated 3 days later. VV ECMO was weaned over the following week, and the patient was decannulated after a total 23 days of ECMO. The patient was then transitioned to inpatient rehabilitation and ultimately discharged home after 18 days. At the 6-month follow-up, the patient was doing well, and objective cardiopulmonary testing revealed normal function. This case is an excellent demonstration of how advanced ECMO and ECLS devices can be used in unique ways through multiple configurations to rescue and optimize patients in the perioperative period.
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In patients with chronic renal failure progressing toward the need for renal replacement therapy, establishment of permanent dialysis access is paramount to long-term survival. Prior studies have demonstrated the importance of creation of a direct arteriovenous fistula (AVF) in patients with adequate vasculature, beginning in the nondominant upper extremity. The standard outflow veins are the forearm cephalic vein, upper arm cephalic vein, and upper arm basilic vein. Some investigators have successfully used the transposed brachial vein in select patients. For patients with insufficient native vasculature in the nondominant upper extremity, the use of either synthetic arteriovenous grafts in the nondominant upper extremity or the use of the dominant upper extremity is required. An arteriovenous graft poses a higher risk of infection and thrombosis compared with an AVF. We present a case in which a transposed distal radial artery to radial vein AVF was created as an alternative to graft or brachial vein use due to insufficient standard outflow veins. The AVF remains patent 2 years after creation and is being successfully used for hemodialysis. This novel strategy represents a creative autologous alternative to synthetic grafts for patients who require permanent hemodialysis access but lack superficial venous anatomy for traditional AVF creation.
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BACKGROUND: The role of extracorporeal membrane oxygenation (ECMO) for patients with refractory respiratory failure due to coronavirus 2019 (COVID-19) is still unclear even now over a year into the pandemic. ECMO is becoming more commonplace even at smaller community hospitals. While the advantages of venovenous (VV) ECMO in acute respiratory distress syndrome (ARDS) from COVID-19 have not been fully determined, we believe the benefits outweighed the risks in our patient population. Here we describe all patients who underwent VV ECMO at our center. METHODS: All patients placed on ECMO at our center since the beginning of the pandemic, May 5, 2020, until February 20, 2021 were included in our study. All patients placed on ECMO during the time period described above were followed until discharge or death. The primary endpoint was in-hospital death. Secondary outcomes included discharge disposition, that is, whether patients were sent to a long-term acute care center (LTAC), inpatient rehabilitation, or went directly home. RESULTS: A total of 41 patients were placed on VV ECMO for refractory acute respiratory failure. Survival to discharge, the primary end point, was 63.4% (26/41). Inpatient mortality was 36.6% (15/41). CONCLUSIONS: We show here that a successful high-volume VV ECMO program for ARDS is achievable at even a medium-size community hospital. We think our success can be replicated by most small- and medium-size community hospitals with cardiothoracic surgery programs and intensivist teams.